Does public reporting of the detection of fetal growth restriction improve clinical outcomes: a retrospective cohort study.

OBJECTIVE: To assess the impact of publicly reporting a statewide fetal growth restriction (FGR) performance indicator. DESIGN: Retrospective cohort study from 2000 to 2017. SETTING: All maternity services in Victoria, Australia. POPULATION: A total of 1 231 415 singleton births at ≥32 weeks of gestation. METHODS: We performed an interrupted time-series analysis to assess the impact of publicly reporting an FGR performance indicator on the rate of detection for severe cases of small for gestational age (SGA). Rates of perinatal mortality and morbidity and obstetric intervention were assessed for severe SGA pregnancies and pregnancies delivered for suspected SGA. MAIN OUTCOME MEASURES: Gestation at delivery, obstetric management and perinatal outcome. RESULTS: The public reporting of a statewide FGR performance indicator was associated with a steeper reduction per quarter in the percentage of severe SGA undelivered by 40 weeks of gestation, from 0.13 to 0.51% (P = 0.001), and a decrease in the stillbirth rate by 3.3 per 1000 births among those babies (P = 0.01). Of babies delivered for suspected SGA, the percentage with birthweights ≥ 10th centile increased from 41.4% (n = 307) in 2000 to 53.3% (n = 1597) in 2017 (P < 0.001). Admissions to a neonatal intensive care unit for babies delivered for suspected SGA but with a birthweight ≥ 10th centile increased from 0.8 to 2.0% (P < 0.001). CONCLUSIONS: The public reporting of an FGR performance indicator has been associated with the improved detection of severe SGA and a decrease in the rate of stillbirth among those babies, but with an increase in the rate of iatrogenic birth for babies with normal growth. TWEETABLE ABSTRACT: The public reporting of hospital performance is associated with a reduction in stillbirth, but also with unintended interventions.

Review of external referrals to a regional stroke centre: it is not just about thrombectomy.

AIMS: To determine the experience of a regional stroke referral centre of external referrals for endovascular thrombectomy (EVT) in patients with symptoms of acute ischaemic stroke (AIS) and large vessel occlusion (LVO). MATERIALS AND METHODS: Data were collected prospectively over two 4-month periods (2017-2018) on consecutive external referrals for EVT. Baseline demographics, imaging findings, and key time parameters were recorded. Reasons for not transferring patients and for not performing EVT were recorded. Key time intervals were calculated and compared between the transferred and non-transferred group with and without intracranial occlusion and between the transferred patients who underwent thrombectomy and those who did not. RESULTS: Two hundred and sixty-two patients were referred. Sixty-one percent (n=159) were accepted and transferred for treatment. Of those transferred, 86% (n=136) had EVT. Fourteen percent (n=23) were unsuitable for EVT on arrival due to no vessel occlusion (48% n=11), poor Alberta Stroke Program Early CT Score (ASPECTS)/established infarct (30%, n=7) haemorrhage (9%, n=2), and clinical recovery (13% n=3). One hundred and three patients (39%) were ineligible for EVT following phone discussion due to absence of intracranial occlusion (59%, n=61), low ASPECTS (22%, n=23), distal occlusion (4%, n=4), low/improving National Institutes of Health Stroke Scale (NIHSS; 10.7%, n=11), and poor modified Rankin Scale (mRS) at baseline (3%, n=3). Patients with LVO but not transferred had longer onset to hospital arrival time compared with those transferred 151.5 versus 91 minutes (p<0.005), with a trend also toward a longer door to CT/CTA 40 minutes versus 30 minutes (p=0.142). CONCLUSION: These data provide valuable insights into the service provision of a comprehensive stroke network. The present rates of EVT and futile transfers are modest compared to published data. Access to neuroradiology and specialised stroke assessment is crucial to optimise time to treatment.

An Unusual Case of a Facial Guard Causing Penetrating Soft Tissue Injury in the Game of Hurling

Aim To highlight the dangers of hurling helmet modification. Methods A case report highlighting the consequences of modifying a hurling helmet from factory settings. Results Photographic evidence of a penetrating injury from helmet modification. Conclusion Rule changes to allow referees to inspect helmets before games take place.

Neuroimaging of central diabetes insipidus-when, how and findings.

Central or neurogenic diabetes insipidus (CDI) is due to deficient synthesis or secretion of antidiuretic hormone (ADH), also known as arginine vasopressin peptide (AVP). It is clinically characterised by polydipsia and polyuria (urine output > 30 mL/kg/day) of dilute urine (< 250 mOsm/L). It is the result of a defect in one of more sites involving the hypothalamic osmoreceptors, supraoptic or paraventricular nuclei of the hypothalamus, median eminence of the hypothalamus, infundibulum or the posterior pituitary gland. A focused MRI pituitary gland or sella protocol is essential. There are several neuroimaging correlates and causes of CDI, illustrated in this review. The most common causes are benign or malignant neoplasms of the hypothalamic-pituitary axis (25%), surgery (20%), head trauma (16%) or familial causes (10%). No cause is identified in up to 30% of cases. Knowledge of the anatomy and physiology of the hypothalamo-neurohypophyseal axis is crucial when evaluating a patient with CDI. Establishing the aetiology of CDI with MRI in combination with clinical and biochemical assessment facilitates appropriate targeted treatment. The aim of the pictorial review is to illustrate the wide variety of causes of CDI on neuroimaging, highlight the optimal MRI protocol and to revise the detailed neuroanatomy and neurophysiology required to interpret these studies.

Role of Musculoskeletal Radiology in Modern Sports Medicine.

Musculoskeletal radiology's role in the recent and continued evolution of sports medicine is an exciting and expanding one. In this article we explore a variety of the ways that musculoskeletal radiology contributes to current practices in modern sports medicine, discussing advances across a variety of imaging modalities in the care of both elite athletes and so-called weekend warriors. We describe the technical and ethical factors pertaining to image-guided therapeutic intervention in athletes and speculate on the potential for future developments in the role of imaging in deciding when an athlete may return to participation. We also explore the recent shift to the delivery of imaging facilities at sporting events and in stadiums.

Are adult carpal angle measurements applicable to the pediatric population in the trauma setting?

OBJECTIVE: The aim of this study is to assess the applicability of standard adult carpal angle measurements, specifically the scapholunate and capitolunate angles, in the assessment of the pediatric wrist. MATERIALS AND METHODS: The study cohort comprised male and female children who underwent a wrist radiograph for the evaluation of suspected wrist injuries following trauma. A gender- and indication-matched adult cohort was also assessed. To ensure an accurate carpal angle measurement, only individuals with a sufficiently ossified carpus and an adequately positioned lateral wrist radiograph were included. RESULTS: Carpal angle measurements were performed on the lateral wrist radiographs of 256 individuals between the ages of 5 and 17 years (mean 11.2 years, SD ± 2.5 years) and 256 individuals between the ages of 18 and 40 years (mean 28.8 years, SD ± 6.2 years). The mean pediatric scapholunate angle was 47° (SD ± 8) and the mean pediatric capitolunate angle was 11° (SD ± 7). The mean adult scapholunate and capitolunate angles were 48° (SD ± 8°) and 10° (SD ± 6°) respectively. No statistically significant difference was observed between the scapholunate or capitolunate angle measurements in the two groups (p = 0.26 and p = 0.36). CONCLUSION: The study data supports the applicability of standard adult carpal angle values to the pediatric population provided the carpus is sufficiently ossified.

The effect of primary midwife-led care on women's experience of childbirth: results from the COSMOS randomised controlled trial.

OBJECTIVE: To determine the effect of primary midwife-led care ('caseload midwifery') on women's experiences of childbirth. DESIGN: Randomised controlled trial. SETTING: Tertiary care women's hospital in Melbourne, Australia. POPULATION: A total of 2314 low-risk pregnant women. METHODS: Women randomised to caseload care received antenatal, intrapartum and postpartum care from a primary midwife, with some care provided by a 'back-up' midwife. Women in standard care received midwifery-led care with varying levels of continuity, junior obstetric care or community-based medical care. MAIN OUTCOME MEASURES: The primary outcome of the study was caesarean section. This paper presents a secondary outcome, women's experience of childbirth. Women's views and experiences were sought using seven-point rating scales via postal questionnaires 2 months after the birth. RESULTS: A total of 2314 women were randomised between September 2007 and June 2010; 1156 to caseload and 1158 to standard care. Response rates to the follow-up questionnaire were 88 and 74%, respectively. Women in the caseload group were more positive about their overall birth experience than women in the standard care group (adjusted odds ratio 1.50, 95% CI 1.22-1.84). They also felt more in control during labour, were more proud of themselves, less anxious, and more likely to have a positive experience of pain. CONCLUSIONS: Compared with standard maternity care, caseload midwifery may improve women's experiences of childbirth. TWEETABLE ABSTRACT: Primary midwife-led care ('caseload midwifery') improves women's experiences of childbirth.

Thermal territories of the abdomen after caesarean section birth: infrared thermography and analysis.

OBJECTIVE: To develop and refine qualitative mapping and quantitative analysis techniques to define 'thermal territories' of the post-partum abdomen, the caesarean section site and the infected surgical wound. In addition, to explore women's perspectives on thermal imaging and acceptability as a method for infection screening. METHOD: Prospective feasibility study undertaken at a large University teaching hospital, Sheffield UK. Infrared thermal imaging of the abdomen was undertaken at the bedside on the first two days after elective caesarean section. Target recruitment: six women in each of three body mass index (BMI) categories (normal, 18.5-24.9 kg/m²; overweight 25-29.9 kg/m²; obese ≥30 kg/m²). Additionally, women presenting to the ward with wound infection were eligible for inclusion in the study. Perspectives on the use of thermal imaging and its practicality were also explored via semi-structured interviews and analysed using thematic content analysis. RESULTS: We recruited 20 women who had all undergone caesarean section. From the booking BMI, eight women were obese (including two women with infected wounds), seven women were overweight and five women had a normal BMI. Temperature (ºC) profiling and pixel clustering segmentation (hierarchical clustering-based segmentation, HCS) revealed characteristic features of thermal territories between scar and adjacent regions. Differences in scar thermal intensity profiles exist between healthy scars and infected wounds; features that have potential for wound surveillance. The maximum temperature differences (∆T) between healthy skin and the wound site exceed 2º C in women with established wound infection. At day two, two women had a scar thermogram with features observed in the 'infected' wound thermogram. CONCLUSION: Thermal imaging at early and later times after caesarean birth is feasible and acceptable. Women reported potential benefits of the technique for future wound infection screening. Thermal intensity profiling and HCS for pixel cluster dissimilarity between scar and adjacent healthy skin has potential as a method for the development of techniques targeted to early infection surveillance in women after caesarean section.

The Z0011 Trial: Is this the end of axillary ultrasound in the pre-operative assessment of breast cancer patients?

OBJECTIVES: The Z0011 trial questioned the role of axillary ultrasound (AxUS) in preoperative staging of breast cancer in patients with ≤2 positive sentinel lymph nodes (SLN). The purpose of this study was to correlate the number of abnormal nodes on AxUS with final nodal burden and determine the utility of AxUS with sampling (AxUS + S) in preoperative staging. METHODS: Six hundred and seventy-nine patients underwent pre-operative AxUS. Suspicious nodes were sampled. Negative axillae proceeded to SLN biopsy. The number of abnormal nodes identified on ultrasound and final histology as well as sensitivity and specificity for AxUS + S were calculated. Subgroup analysis was performed on Z0011 eligible patients. RESULTS: Two hundred and ninety-six patients had positive axillary nodes on final histology with 169 detected by AxUS + S (sensitivity 86.2%, specificity 100%, PPV 100 %, NPV 71.9%). Patients with nodal metastases identified by AxUS had a mean burden of 7.3 nodes on histology (1 node on AxUS = 5.2 nodes on histology, 2 nodes on AxUS = 7.5 nodes, >2 nodes = 10.1 nodes). Patients diagnosed on SLNB had a mean burden of 2.2 nodes. CONCLUSION: A single nodal metastasis detected on AxUS + S correlated with a mean of 5.2 nodes on final histology highlighting that AxUS remains essential in guiding appropriate management of the axilla in breast cancer. KEY POINTS: • Axillary ultrasound +/- sampling is an essential technique in preoperative axillary staging. • Axillary ultrasound findings correlate with final histological axillary node disease burden. • Axillary ultrasound can help triage patients who require axillary lymph node dissection. • The role of axillary ultrasound in breast cancer staging continues to evolve.

A retrospective observational study examining the characteristics and outcomes of tumours diagnosed within and without of the English NHS Bowel Cancer Screening Programme.

BACKGROUND: Colorectal cancer is common in England and, with long-term survival relatively poor, improving outcomes is a priority. A major initiative to reduce mortality from the disease has been the introduction of the National Health Service (NHS) Bowel Cancer Screening Programme (BCSP). Combining data from the BCSP with that in the National Cancer Data Repository (NCDR) allows all tumours diagnosed in England to be categorised according to their involvement with the BCSP. This study sought to quantify the characteristics of the tumours diagnosed within and outside the BCSP and investigate its impact on outcomes. METHODS: Linkage of the NCDR and BCSP data allowed all tumours diagnosed between July 2006 and December 2008 to be categorised into four groups; screen-detected tumours, screening-interval tumours, tumours diagnosed in non-participating invitees and tumours diagnosed in those never invited to participate. The characteristics, management and outcome of tumours in each category were compared. RESULTS: In all, 76 943 individuals were diagnosed with their first primary colorectal cancer during the study period. Of these 2213 (2.9%) were screen-detected, 623 (0.8%) were screening-interval cancers, 1760 (2.3%) were diagnosed in individuals in non-participating invitees and 72 437 (94.1%) were diagnosed in individuals not invited to participate in the programme due to its ongoing roll-out over the time period studied. Screen-detected tumours were identified at earlier Dukes' stages, were more likely to be managed with curative intent and had significantly better outcomes than tumours in other categories. CONCLUSION: Screen-detected cancers had a significantly better prognosis than other tumours and this would suggest that the BCSP should reduce mortality from colorectal cancer in England.

Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.

OBJECTIVE: To determine whether primary midwife care (caseload midwifery) decreases the caesarean section rate compared with standard maternity care. DESIGN: Randomised controlled trial. SETTING: Tertiary-care women's hospital in Melbourne, Australia. POPULATION: A total of 2314 low-risk pregnant women. METHODS: Women randomised to caseload received antenatal, intrapartum and postpartum care from a primary midwife with some care by 'back-up' midwives. Women randomised to standard care received either midwifery or obstetric-trainee care with varying levels of continuity, or community-based general practitioner care. PRIMARY OUTCOME: caesarean birth. Secondary outcomes included instrumental vaginal births, analgesia, perineal trauma, induction of labour, infant admission to special/neonatal intensive care, gestational age, Apgar scores and birthweight. RESULTS: In total 2314 women were randomised-1156 to caseload and 1158 to standard care. Women allocated to caseload were less likely to have a caesarean section (19.4% versus 24.9%; risk ratio [RR] 0.78; 95% CI 0.67-0.91; P = 0.001); more likely to have a spontaneous vaginal birth (63.0% versus 55.7%; RR 1.13; 95% CI 1.06-1.21; P < 0.001); less likely to have epidural analgesia (30.5% versus 34.6%; RR 0.88; 95% CI 0.79-0.996; P = 0.04) and less likely to have an episiotomy (23.1% versus 29.4%; RR 0.79; 95% CI 0.67-0.92; P = 0.003). Infants of women allocated to caseload were less likely to be admitted to special or neonatal intensive care (4.0% versus 6.4%; RR 0.63; 95% CI 0.44-0.90; P = 0.01). No infant outcomes favoured standard care. CONCLUSION: In settings with a relatively high baseline caesarean section rate, caseload midwifery for women at low obstetric risk in early pregnancy shows promise for reducing caesarean births.

Translating obstetrics and gynaecology undergraduate experience into career aspiration: an audit of Royal College of Obstetricians and Gynaecologists (RCOG) medical student placement standards.

In 2006, the Royal College of Obstetricians and Gynaecologists (RCOG) published a list of undergraduate placement standards in an effort to improve the obstetrics and gynaecology (O&G) undergraduate experience and reverse declining interest in the specialty among UK graduates. We surveyed 3rd-year medical students undertaking O&G placements to investigate how appropriate they felt the RCOG placement standards were. We present the first evaluation of these standards and discuss their potential role in improving the undergraduate O&G experience. We also sought to examine the influence of undergraduate O&G exposure on interest in entering the specialty and the effect of gender on perceived learning experience. Students rated the RCOG standards as highly appropriate, and significant differences in clinical exposure and career intentions were seen between genders. Overall, students demonstrated greater interest in pursuing O&G than has previously been documented, which may represent a wider upturn in interest in the speciality.

Making a difference in the real world. User-centred impact evaluation of an eight-country, community-based early childhood programme.

This paper presents a unique approach to the Impact Evaluation of a project that focused on low-threshold intergenerational play-based interactions in order to support young children from marginalised communities in eight European countries. The approach builds upon the work of Fetterman's Empowerment Evaluation and Patton's Utilization Focused Evaluation and brings them together to form an adapted model of evaluation. We outline in this paper how these two well developed methods of evaluation have been applied to a real world context, that is, the impact evaluation of a complex international project. Our approach highlights the complexities of differing contexts and allows for surprising and unintended consequences to emerge. It results, through double loop learning, a type of feedback loop with the internal stakeholders and implementers that is useful to the project coordination team, with a view to further upscaling of the initiative. Recommendations for policy at local, national and European Union levels were provided to the project and potential external users. However, the predominant feedback was provided at two crucial points along the way; during a stakeholder mapping exercise and during the further development of monitoring data tools.

A nurse-led palpitations clinic: a 2-year experience.

OBJECTIVE: To investigate the role of a nurse-led clinic in the assessment of patients with palpitations. DESIGN: Prospective descriptive study. SETTING: Nurse-led palpitations clinic in a UK district general hospital. PARTICIPANTS: Patients referred from primary care or the emergency department with palpitations. METHODS: Referral letters were screened, and only patients without high-risk features or a documented arrhythmia were diverted to the palpitations clinic. Patients were evaluated using a protocol. All patients had an ECG and ambulatory ECG monitoring and were discussed with a cardiologist. RESULTS: Over 15 months, 389 patients were seen. The mean time from referral to assessment was 38 days (range 3-142). The most common diagnoses were symptomatic extrasystoles (42%) and sinus rhythm (22%). Significant arrhythmias were diagnosed in 15% (atrial fibrillation/flutter, 8%; supraventricular arrhythmias, 6%). Only 52 (13%) were subsequently referred to a cardiologist, including 20 with high-risk features. These 20 patients waited on average an additional 70 days to be seen by a cardiologist compared with patients who were seen directly by a cardiologist after referral by primary care or the emergency department. CONCLUSIONS: For low-risk patients, a nurse-led palpitations clinic may provide a viable alternative to the traditional cardiology outpatient service. Despite attempts to exclude them, some high-risk patients were seen. This was unforeseen and led to a clinically important delay in their appropriate assessment. Hence, before adopting a nurse-led palpitations service, a rigorous pathway for the early assessment of high-risk patients needs to be agreed.

Unity Makes Strength: Exploring Intraspecies and Interspecies Toxin Synergism between Phospholipases A2 and Cytotoxins.

Toxin synergism is a complex biochemical phenomenon, where different animal venom proteins interact either directly or indirectly to potentiate toxicity to a level that is above the sum of the toxicities of the individual toxins. This provides the animals possessing venoms with synergistically enhanced toxicity with a metabolic advantage, since less venom is needed to inflict potent toxic effects in prey and predators. Among the toxins that are known for interacting synergistically are cytotoxins from snake venoms, phospholipases A2 from snake and bee venoms, and melittin from bee venom. These toxins may derive a synergistically enhanced toxicity via formation of toxin complexes by hetero-oligomerization. Using a human keratinocyte assay mimicking human epidermis in vitro, we demonstrate and quantify the level of synergistically enhanced toxicity for 12 cytotoxin/melittin-PLA2 combinations using toxins from elapids, vipers, and bees. Moreover, by utilizing an interaction-based assay and by including a wealth of information obtained via a thorough literature review, we speculate and propose a mechanistic model for how toxin synergism in relation to cytotoxicity may be mediated by cytotoxin/melittin and PLA2 complex formation.

Radiation effects in free-ranging pocket mice, Perognathus parvus, during the breeding season.

Captive and free-ranging Great Basin pocket mice, Perognathus parvus, were exposed to ionizing radiation during the breeding season, April-June, in 1971. The values for the median lethal dose (LD(50)) at 30 days plus or minus the standard deviation were 880 +/- 14 rads and 780 +/- 27 rads, respectively, and the slopes of the survivorship curves were significantly different. These differences suggested that there was a synergism between radiation-induced and environmental sources of mortality, since the field data were corrected for natural mortality (5 percent) in the controls.

All "chick-a-dee" calls are not created equally. Part II. Mechanisms for discrimination by sympatric and allopatric chickadees.

The 'chick-a-dee' call, common to all members of the genus Poecile, is used by both sexes throughout the year to putatively co-ordinate flock movements and register alarm. In some regions, two or more chickadee species occupy overlapping territories, and therefore it is essential that these sympatric species learn to discriminate between the acoustically similar calls of the species. Previous work from our laboratory has shown that black-capped (P. atricapillus) and mountain chickadees (P. gambeli) discriminate between the species' calls and treat each species' calls as belonging to separate open-ended categories. In the current set of experiments we use an operant conditioning paradigm to gain an understanding of (1) how the birds perform this discrimination and (2) whether birds with different levels of experience with heterospecific calls perform this task differently. We use natural recordings of chick-a-dee calls and perform several manipulations to test the importance of the introductory 'chick-a' portion and the terminal 'dee' portion for discriminating among the calls of the two species. Evidence suggests that birds mainly use the terminal 'dee' portion, as all groups of birds responded similarly to these probe stimuli and control chick-a-dee calls. We propose that the terminal 'dee' portion, consisting of lower frequency notes, is more likely to be resistant to degradation, and therefore a more reliable species-specific marker.

Mathematical Modeling of Diffusion of a Hydrophilic Ionic Fertilizer in Plant Cuticles: Surfactant and Hygroscopic Effects.

The agricultural industry requires improved efficacy of sprays being applied to crops and weeds to reduce their environmental impact and increase financial returns. One way to improve efficacy is by enhancing foliar penetration. The plant leaf cuticle is the most significant barrier to agrochemical diffusion within the leaf. The importance of a mechanistic mathematical model has been noted previously in the literature, as each penetration experiment is dictated by its specific parameters, namely plant species, environmental conditions such as relative humidity and spray formulation including adjuvant addition. A mechanistic mathematical model has been previously developed by the authors, focusing on plant cuticle diffusion of calcium chloride through tomato fruit cuticles including pore swelling, ion binding and evaporation, along with the ability to vary the active ingredient concentration and type, relative humidity and plant species. Here we further develop this model to include adjuvant effects as well as the hygroscopic nature of deliquescent ionic solutions with evaporation on the cuticle surface. These modifications to a penetration and evaporation model provide a novel addition to the literature and allow the model to be applied to many types of evaporating ionic hygroscopic solutions on many types of substrates, not just plant cuticles. We validate our theoretical model results against appropriate experimental data, discuss key sensitivities and relate theoretical predictions to physical mechanisms. The important governing mechanisms influencing surfactant enhanced penetration of ionic active through plant cuticles were found to be aqueous pore radius, pore density, cuticle thickness and initial contact angle of the applied droplet; ion binding, relative humidity and evaporation including hygroscopic water absorption parameters for point of deliquescence. The sensitivity analysis indicated surfactants increase penetration by changing the point of deliquescence of a solution, which alters the water absorption and the initial contact angle, which alters the number of pores under the droplet. The results of the validation and sensitivity analysis imply that this model accounts for many of the mechanisms governing penetration in plant cuticles.

Bioluminescence imaging of point sources implanted in small animals post mortem: evaluation of a method for estimating source strength and depth.

The performance of a simple approach for the in vivo reconstruction of bioluminescent point sources in small animals was evaluated. The method uses the diffusion approximation as a forward model of light propagation from a point source in a homogeneous tissue to find the source depth and power. The optical properties of the tissue are estimated from reflectance images obtained at the same location on the animal. It was possible to localize point sources implanted in mice, 2-8 mm deep, to within 1 mm. The same performance was achieved for sources implanted in rat abdomens when the effects of tissue surface curvature were eliminated. The source power was reconstructed within a factor of 2 of the true power for the given range of depths, even though the apparent brightness of the source varied by several orders of magnitude. The study also showed that reconstructions using optical properties measured in situ were superior to those based on data in the literature.

Fetal size and growth velocity in the prediction of the large for gestational age (LGA) infant in a glucose impaired population.

OBJECTIVES: To evaluate the performances of estimated fetal weight (EFW) and fetal growth velocity (FGV) in the prediction of birth weight>95th centile amongst women with impaired glucose tolerance (IGT); the prediction of neonatal hypoglycaemia was a secondary endpoint. STUDY DESIGN: Two hundred and forty-two consecutive women (61 type 1 diabetes mellitus, 14 type 2 diabetes mellitus, 49 gestational diabetics and 118 with impaired glucose tolerance) receiving routine care at the combined diabetes/antenatal clinic, Jessop Hospital for Women, Sheffield. EFW was routinely calculated at approximately two-week intervals in the third trimester with the last EFW prior to delivery used in the analysis. FGV was calculated from two estimates of fetal weight between 21 and 35 days apart. EFW and FGV were both expressed as standard deviation (Z) scores. RESULTS: The mean gestational age at delivery was 37 weeks (range 26-40 weeks). Sixty-five (27%) infants were of birth weight>95th centile. Mean EFW Z scores were 2.7 and 0.99 for >95th and <95th centile, respectively (p<0.001). Receiver operator characteristics (ROC) curve analysis gave area under the curve 0.8; using a cut-off Z score of 1.7 (=95.5 centile), EFW has sensitivity 80% and specificity 72% in predicting an LGA neonate (likelihood ratios 2.8 and 0.27 for positive and negative test). Mean FGV Z scores were 0.85 and 0.4 for >95th and <95th centile, respectively (p>0.05); ROC curve analysis indicated no discriminatory capacity. Estimates of fetal size and growth performed poorly in the prediction of neonatal hypoglycaemia. CONCLUSION: In routine clinical practice, EFW has limited utility in the prediction of the LGA infant. FGV does not identify the LGA infant. EFW and FGV do not predict neonatal hypoglycaemia.