Associations between social and behavioural factors and the risk of late stillbirth - findings from the Midland and North of England Stillbirth case-control study.

OBJECTIVE: To investigate behavioural and social characteristics of women who experienced a late stillbirth compared with women with ongoing live pregnancies at similar gestation. DESIGN: Case-control study. SETTING: 41 maternity units in the UK. POPULATION: Women who had a stillbirth ≥28 weeks' gestation (n = 287) and women with an ongoing pregnancy at the time of interview (n = 714). METHODS: Data were collected using an interviewer-administered questionnaire which included questions regarding women's behaviours (e.g. alcohol intake and household smoke exposure) and social characteristics (e.g. ethnicity, employment, housing). Stress was measured by the 10-item Perceived Stress Scale. MAIN OUTCOME MEASURE: Late stillbirth. RESULTS: Multivariable analysis adjusting for co-existing social and behavioural factors showed women living in the most deprived quintile had an increased risk of stillbirth compared with the least deprived quintile (adjusted odds ratio [aOR] 3.16; 95% CI 1.47-6.77). There was an increased risk of late stillbirth associated with unemployment (aOR 2.32; 95% CI 1.00-5.38) and women who declined to answer the question about domestic abuse (aOR 4.12; 95% CI 2.49-6.81). A greater number of antenatal visits than recommended was associated with a reduction in stillbirth (aOR 0.26; 95% CI 0.16-0.42). CONCLUSIONS: This study demonstrates associations between late stillbirth and socio-economic deprivation, perceived stress and domestic abuse, highlighting the need for strategies to prevent stillbirth to extend beyond maternity care. Enhanced antenatal care may be able to mitigate some of the increased risk of stillbirth. TWEETABLE ABSTRACT: Deprivation, unemployment, social stress & declining to answer about domestic abuse increase risk of #stillbirth after 28 weeks' gestation.

Gestational diabetes and the risk of late stillbirth: a case-control study from England, UK.

OBJECTIVE: To explore the separate effects of being 'at risk' of gestational diabetes mellitus (GDM) and screening for GDM, and of raised fasting plasma glucose (FPG) and clinical diagnosis of GDM, on the risk of late stillbirth. DESIGN: Prospective case-control study. SETTING: Forty-one maternity units in the UK. POPULATION: Women who had a stillbirth ≥28 weeks of gestation (n = 291) and women with an ongoing pregnancy at the time of interview (n = 733). METHODS: Causal mediation analysis explored the joint effects of (i) 'at risk' of GDM and screening for GDM and (ii) raised FPG (≥5.6 mmol/l) and clinical diagnosis of GDM on the risks of late stillbirth. Adjusted odds ratios (aOR) were estimated by logistic regression adjusted for confounders identified by directed acyclic graphs. MAIN OUTCOME MEASURES: Screening for GDM and FPG levels RESULTS: Women 'at risk' of GDM, but not screened, experienced 44% greater risk of late stillbirth than those not 'at risk' (aOR 1.44, 95% CI 1.01-2.06). Women 'at risk' of GDM who were screened experienced no such increase (aOR 0.98, 95% CI 0.70-1.36). Women with raised FPG not diagnosed with GDM experienced four-fold greater risk of late stillbirth than women with normal FPG (aOR 4.22, 95% CI 1.04-17.02). Women with raised FPG who were diagnosed with GDM experienced no such increase (aOR 1.10, 95% CI 0.31-3.91). CONCLUSIONS: Optimal screening and diagnosis of GDM mitigate the higher risks of late stillbirth in women 'at risk' of GDM and/or with raised FPG. Failure to diagnose GDM leaves women with raised FPG exposed to avoidable risk of late stillbirth. TWEETABLE ABSTRACT: Risk of #stillbirth in gestational diabetes is mitigated by effective screening and diagnosis.

Association between maternal sleep practices and late stillbirth - findings from a stillbirth case-control study.

OBJECTIVE: To report maternal sleep practices in women who experienced a stillbirth compared with controls with ongoing live pregnancies at similar gestation. DESIGN: Prospective case-control study. SETTING: Forty-one maternity units in the United Kingdom. POPULATION: Women who had a stillbirth after ≥ 28 weeks' gestation (n = 291) and women with an ongoing pregnancy at the time of interview (n = 733). METHODS: Data were collected using an interviewer-administered questionnaire that included questions on maternal sleep practices before pregnancy, in the four weeks prior to, and on the night before the interview/stillbirth. MAIN OUTCOME MEASURES: Maternal sleep practices during pregnancy. RESULTS: In multivariable analysis, supine going-to-sleep position the night before stillbirth had a 2.3-fold increased risk of late stillbirth [adjusted Odds Ratio (aOR) 2.31, 95% CI 1.04-5.11] compared with the left side. In addition, women who had a stillbirth were more likely to report sleep duration less than 5.5 hours on the night before stillbirth (aOR 1.83, 95% CI 1.24-2.68), getting up to the toilet once or less (aOR 2.81, 95% CI 1.85-4.26), and a daytime nap every day (aOR 2.22, 95% CI 1.26-3.94). No interaction was detected between supine going-to-sleep position and a small-for-gestational-age infant, maternal body mass index, or gestational age. The population-attributable risk for supine going-to-sleep position was 3.7% (95% CI 0.5-9.2). CONCLUSIONS: This study confirms that supine going-to-sleep position is associated with late stillbirth. Further work is required to determine whether intervention(s) can decrease the frequency of supine going-to-sleep position and the incidence of late stillbirth. TWEETABLE ABSTRACT: Supine going-to-sleep position is associated with 2.3× increased risk of stillbirth after 28 weeks' gestation. PLAIN LANGUAGE SUMMARY: Stillbirth, the death of a baby before birth, is a tragedy for mothers and families. One approach to reduce stillbirths is to identify factors that are associated with stillbirth. There are few risk factors for stillbirth that can be easily changed, but this study is looking at identifying how mothers may be able to reduce their risk. In this study, we interviewed 291 women who had a stillbirth and 733 women who had a live-born baby from 41 maternity units throughout the UK. The mothers who had a stillbirth were interviewed as soon as practical after their baby died. Mothers who had a live birth were interviewed during their pregnancies at the same times in pregnancy as when the stillbirths occurred. We did not interview mothers who had twins or who had a baby with a major abnormality. Mothers who went to sleep on their back had at least twice the risk of stillbirth compared with mothers who went to sleep on their left-hand side. This study suggests that 3.7% of stillbirths after 28 weeks of pregnancy were linked with going to sleep lying on the back. This study also shows that the link between going-to-sleep position and late stillbirth was not affected by the duration of pregnancy after 28 weeks, the size of the baby, or the mother's weight. Women who got up to the toilet once or more at night had a reduced risk of stillbirth. This is the largest of four similar studies that have all shown the same link between the position in which a mother goes to sleep and stillbirth after 28 weeks of pregnancy. Further studies are needed to see whether women can easily change their sleep position in late pregnancy and whether changing the position a mother goes to sleep in reduces stillbirth.

A comparison of sub-Tenon's with peribulbar anaesthesia in patients undergoing sequential bilateral cataract surgery.

The aim of this study was to compare efficacy and particularly patient preference of sub-Tenon's anaesthesia with peribulbar anaesthesia in patients undergoing sequential, bilateral, cataract surgery. Fifty patients were randomised to either sub-Tenon's or peribulbar anaesthesia for their first operation and the alternative technique for their subsequent operation. Intra-ocular pressure was measured, globe and lid akinesia were scored, patients completed a visual rating score of injection and operative pain and their preference for anaesthesia was assessed. Intra-ocular pressure rose significantly following peribulbar injection (p = 0.02) but was comparable at 5 min. There was no significant difference in lid or globe movement. Injection and operative pain scores were low and comparable. Both methods provided similar anaesthesia and akinesia. The majority (86%) chose the method they received first irrespective of whether it was sub-Tenon's or peribulbar, but 10% of patients preferred sub-Tenon's, disliking the facial numbness from peribulbar anaesthesia.

Transesophageal echocardiography: procedures and clinical application.

In existence for more than a decade, transesophageal echocardiography has gained renewed interest because of technologic advances including high resolution transducers, multiple imaging planes and Doppler color flow mapping. The heart is imaged from within the esophagus with a gastroscope-mounted transducer, obviating technical difficulties encountered in transthoracic echocardiography. Transesophageal echocardiography is utilized intraoperatively to monitor patients undergoing open heart surgery or high risk cardiac patients undergoing noncardiac surgery. In the ambulatory patient, the procedure facilitates imaging of many structures (including the left atrium and appendage, mitral and aortic native and prosthetic valves and thoracic aorta), with better resolution than that obtained by routine transthoracic echocardiography. Technical aspects of transesophageal echocardiography as well as its indications and limitations are reviewed.

Enhanced adhesion of polymorphonuclear leukocytes to anoxic cultured vascular endothelium.

This study showed that the adherence of human polymorphonuclear leukocytes (PMN) to monolayer cultures of human umbilical vein endothelial cells (HUVEC) was increased when the latter were rendered anoxic. This adhesion was greater after 4-5 h than after 8 h of anoxia, but even at 8 h was significantly above the level of adhesion to HUVEC maintained under normoxic conditions for the same period. The changes in adhesion were not dependent on the viability of HUVEC during anoxia. Anoxia-induced adhesion was prevented by addition of cycloheximide (5 micrograms/ml) to the cultures, suggesting that it depended on HUVEC protein synthesis. Enhanced adhesion was also prevented by addition of a monoclonal antibody directed against the cytokine, interleukin-1 alpha (IL-1 alpha). These findings are consistent with a role of endogenous IL-1 alpha as a mediator of the anoxia-induced adhesion of PMN to HUVEC.

Measuring the impact of venous leg ulcers on quality of life.

OBJECTIVE: To identify health-related quality-of-life (HRQoL) issues in patients with venous leg ulcers, with the aim of generating items for a treatment outcome measure. METHOD: Thirty-eight patients with venous leg ulcers were interviewed by a psychologist using a semi-structured guide; they also completed a HRQoL questionnaire (modified Skindex). Data from the questionnaire were examined to explore the impact of venous leg ulcers on patients' lives. Interview transcripts were analysed using qualitative methods to identify additional venous leg ulcer-specific HRQoL items. RESULTS: Skindex scores indicated that older patients had worse HRQoL (p<0.05), as did those with pain and non-healing ulcers. Ulcer duration and size did not correlate with HRQoL. Interviews revealed the following effects of ulceration: pain (80.5%); itching (69.4%); altered appearance (66.7%); loss of sleep (66.6%); functional limitation (58.3%); and disappointment with treatment (50%). Based on the interview transcripts, items were generated and discussed with an expert panel, with a view to including them in a venous leg ulcer-specific HRQoL questionnaire. CONCLUSION: Disease-specific HRQoL outcome measures should be considered when evaluating treatments for venous leg ulcers.

Aortic plaque in patients with brain ischemia: diagnosis by transesophageal echocardiography.

We evaluated 183 patients with brain ischemia for an embolic source, using transesophageal echocardiography with extensive imaging of the thoracic aorta. There were mobile, frond-like projections of aortic plaque in seven (4%) patients. The plaque originated on a wide base on the posterior aspect of the ascending aorta at its junction with the transverse arch in six patients, and on the aortic root in one. The acute event was a cerebral infarction in five patients, and a transient ischemic attack in two. This type of aortic plaque could be a previously underdiagnosed source of cerebral embolism that is now easily visualized by transesophageal echocardiography.

Relapsing post-transfusion purpura. A preventable disease.

Post-transfusion purpura is an isoimmune disorder that can recur if unrecognized. A 56-year-old woman is described who had her third episode of post-transfusion purpura 17 years after her last exposure to the inciting antigen. Clinical and immunologic features are reviewed, and specific preventive measures are proposed.

Family correlates of a 10-year pulmonary health trend in cystic fibrosis.

In this study, 33% of the variance in the 10-year trend of forced expiratory volume in 1 second (FEV1), used as an index of pulmonary health, was explained by differences in family characteristics at the start of the study. Balanced family coping, a family emphasis on personal growth, and compliance with treatment for 91 children with cystic fibrosis were assessed at the start of the study and the FEV1 was observed at every clinic visit over the next 10 years. When both parents' coping emphasized family integration, support for self, and medical consultation, the FEV1 trend was better. Compliance with daily chest physical therapy and with quarterly clinic visits was associated with a better FEV1 trend. Poorer FEV1 trend was associated with active social involvement of family members. Older patients and patients whose parents worked more hours outside the home had lower compliance. These findings support the importance of encouraging families to balance their resources between the child's health needs and family needs.

Eccentric fixation with macular scotoma.

People with macular scotoma tend to read and visually scan more slowly than others with equivalently reduced visual acuity but intact central fields. We measured fixation eye movements and considered the contribution of fixation variability and centripetal eye drift to poor visual performance. These factors might confound efforts to consistently use an optimum retinal locus outside of the macula. We measured monocular horizontal and vertical eye movements using a search coil eyetracker while subjects with naturally occurring central scotomata or control subjects with simulated scotomata eccentrically fixated a single character that was sized to their visual acuity. Motivated subjects with long-standing stable maculopathies were chosen to estimate attainable performance limits. During attempts to eccentrically fixate, an ubiquitous foveal pursuit or centripetal drift tendency was not found; rather a pattern of drift was idiosyncratic from subject to subject. This finding was confirmed by an analysis of eye drift of 32 eyes with long-standing bilateral macular scotomata. Moreover, the eye drift speeds (15-200 minarc/sec) were too low to be of functional significance. Drift speeds during eccentric fixation with a visible target were not significantly different than those after the target was extinguished; however, drift speeds were greater than during foveal fixation. This suggests that the fovea has a specialized control of slow eye movements. Fixation variability increased with scotoma size for both simulated and real scotomata, with an abrupt rise when scotomata diameters exceeded 20 degrees C. A significant minority of subjects (39%) adopted two or more distinct preferred retinal loci (PRL) during fixation. Multiple PRL were also more likely if scotoma size exceeded 20 degrees C. Reasonably steady fixation is thus attainable when central scotoma sizes are smaller than approximately 20 degrees C.

Extrastriate feedback to primary visual cortex in primates: a quantitative analysis of connectivity.

Knowledge-based or top-down influences on primary visual cortex (area V1) are believed to originate from information conveyed by extrastriate feedback axon connections. Understanding how this information is communicated to area V1 neurons relies in part on elucidating the quantitative as well as the qualitative nature of extrastriate pathway connectivity. A quantitative analysis of the connectivity based on anatomical data regarding the feedback pathway from extrastriate area V2 to area V1 in macaque monkey suggests (i) a total of around ten million or more area V2 axons project to area V1; (ii) the mean number of synaptic inputs from area V2 per upper-layer pyramidal cell in area V1 is less than 6% of all excitatory inputs; and (iii) the mean degree of convergence of area V2 afferents may be high, perhaps more than 100 afferent axons per cell. These results are consistent with empirical observations of the density of radial myelinated axons present in the upper layers in macaque area V1 and the proportion of excitatory extrastriate feedback synaptic inputs onto upper-layer neurons in rat visual cortex. Thus, in primate area V1, extrastriate feedback synapses onto upper-layer cells may, like geniculocortical afferent synapses onto layer IVC neurons, form only a small percentage of the total excitatory synaptic input.

Ro 32-3555, an orally active collagenase inhibitor, prevents cartilage breakdown in vitro and in vivo.

1. Ro 32-3555 (3(R)-(cyclopentylmethyl)-2(R)-[(3,4,4-trimethyl-2,5-dioxo-1- imidazolidinyl)methyl]-4-oxo-4-piperidinobutyrohydroxamic acid) is a potent, competitive inhibitor of human collagenases 1, 2 and 3 (Ki values of 3.0, 4.4 and 3.4 nM, respectively). The compound is a selective inhibitor of collagenases over the related human matrix metalloproteinases stromelysin 1, and gelatinases A and B (Ki values of 527, 154 and 59 nM, respectively). 2. Ro 32-3555 inhibited interleukin-1 alpha (IL-1 alpha)-induced cartilage collagen degradation in vitro in bovine nasal cartilage explants (IC50 = 60 nM). 3. Ro 32-3555 was well absorbed in rats when administered orally. Systemic exposure was dose related, with an oral bioavailability of 26% at a dose of 25 mg kg-1. 4. Ro 32-3555 prevented granuloma-induced degradation of bovine nasal cartilage cylinders implanted subcutaneously into rats (ED50 = 10 mg kg-1, twice daily, p.o.). 5. Ro 32-3555 dosed once daily for 14 days at 50 mg kg-1, p.o., inhibited degradation of articular cartilage in a rat monoarthritis model induced by an intra-articular injection of Propionibacterium acnes. 6. Ro 32-3555 is a potential therapy for the treatment of the chronic destruction of articulating cartilage in both rheumatoid and osteoarthritis.

A rule for the early detection of chronic changes in cystic fibrosis patient status.

A statistical decision-making system has been developed which will predict the clinical status of a patient with cystic fibrosis based on daily self measurements obtained at home. The data for the study were collected from CF patients within 7-12 years of age. Thirty-two participants recorded four daily measurements (weight, vital capacity, breathing rate, and resting pulse) and one weekly measurement (height). In addition to the 4 daily measured values, the clinical status of each patient at his/her most recent previous clinic visit was used as a predictor variable. The measured values were used as the basis for the development of a discriminant rule. The goal of the rule was to determine whether each patient's clinical status was deteriorating, stable, or improving at the time of the most recent set of weekly measurements. Three types of analysis were performed: linear discriminant analysis, quadratic discriminant analysis, and nearest neighbor. Quadratic discriminant analysis provided the best discrimination due to the differences in the covariance matrices among the populations. The rule was able to correctly classify 77% of the 103 cases in the learning set. To further evaluate the rule, both a weighted classification percentage and weighted kappa statistic were calculated for the rule. Bootstrapping was used to predict the performance of the rule on the population with results of 77% correctly classified overall.

The incidence of patent foramen ovale in 1,000 consecutive patients. A contrast transesophageal echocardiography study.

STUDY OBJECTIVE: Patent foramen ovale (PFO) is present in 10 to 35% of people and has been reported to be an important risk factor for cardioembolic cerebrovascular accidents (CVAs) and transient ischemic attacks (TIAs), especially in younger patients. While contrast transthoracic echocardiography has been used to detect PFO, contrast transesophageal echocardiography (TEE) has a greater sensitivity. Prior studies reported the incidence of PFO in patients presenting with a CVA or TIA. DESIGN: To determine the incidence of PFO in a more general population, we reviewed 1,000 consecutive TEEs performed with contrast and color Doppler for the presence of PFO and other cardioembolic risk factors, including atrial septal aneurysm (ASA), aortic plaque, atrial fibrillation (AFib), and atrial thrombi. While imaging with monoplane or biplane TEE, multiple injections of agitated saline solution were injected during cough or Valsalva maneuver to detect flow through a PFO. PATIENTS: There were 482 male and 518 female patients with mean age of 60 +/- 17 years (range 11 to 93 years). RESULTS: Patent foramen ovale was found in 9.2% of all patients and, though seen in all age groups divided by decade, the incidence in patients aged 40 to 49 years was greater than those aged 70 to 79 years (12.96% vs 6.15%, p = 0.03). Contrast TEE had a much higher detection rate than color Doppler alone. Importantly, there was no greater incidence of PFO in patients with CVA vs those without CVA, or in male vs female patients. Also, there was a very strong correlation between the presence of ASA and PFO (p < .001). CONCLUSION: Thus, PFO detected by TEE, frequently seen with ASA, is seen in all age groups and does not in itself present a risk factor for CVA. The association of PFO with peripheral thrombosis and CVA needs further study.

Comparison of two forms of enteric-coated pancrelipase In six teenagers with cystic fibrosis.

The digestive efficiency of two forms of enteric-coated pancrelipase, Cotazym-STM and Pancrease, was compared in three boys and three girls, aged 12 through 15, with cystic fibrosis. Each patient served as his or her own control, taking one type of pancrelipase for half of the two-week study and the other type for the second half of the study. Monitoring of the patients' oral intake (calories, protein, fat, carbohydrate), collection and analysis of their stools (volume, nitrogen, fat, fat loss, protein loss), and tests of their urine (creatinine, uric acid), blood (24 determinations), and pulmonary function revealed no significant differences in any of the measures between patients taking Cotazym-S and those taking Pancrease.

Correlates and consequences of workplace violence.

A random telephone survey was used to interview 598 employees about instances, if any, when they had been physically attacked or threatened in the workplace. Demographic and workplace characteristics are analyzed as correlates of these forms of violence. The only characteristic consistently associated with higher risk is a work schedule that included nighttime hours. However, although few strong or consistent correlates of workplace violence were found, there were clear negative consequences associated with being victimized at work: lower job satisfaction, greater job stress, increased considerations of job change, and an increased likelihood of bringing mace, a gun, or another weapon to work.

Mortality of young-of-the-year rainbow smelt (Osmerus mordax) in Lake Erie associated with the occurrence of Glugea hertwigi.

An extensive mortality of young-of-the-year rainbow smelt (Osmerus mordax) occurred in Lake Erie during the fall of 1969. Dead and dying smelt were observed along the north shore from west of Long Point in the central basin to Port Maitland in the eastern basin. No other fish species was involved. Glugea hertwigi, a microsporidan parasite, was observed in 90% of the distressed smelt examined, and is believed to have been a major contributing factor to the mortality.

A study of two species of fish inoculated with spruce budworm nuclear polyhedrosis virus.

Preliminary studies conducted on rainbow trout (Salmo gairdneri) and white suckers (Castostomus commersoni) exposed to spruce budworm nuclear polyhedrosis virus revealed minor histopathologic changes in various organs of each fish which were interpreted as not being significant. However, an evaluation (mean values) of the total changes in groups of fish suggested that a relationship may exist in the suckers exposed to either purified polyhedra or virions. A more extensive and definitive study must be done before any conclusions are warranted.

Aerosol scintigraphy in the assessment of therapy for cystic fibrosis.

Thirteen patients with cystic fibrosis (aged 11 to 32 years) who were hospitalized for exacerbation and who had sputum cultures positive for Pseudomonas organisms were treated initially for 4 days with bronchodilators and physiotherapy followed by the addition of antibiotic (14 days, n = 8) or placebo (14 days, n = 4; 7 days, n = 1). Tc-99m DTPA aerosol scintigraphy was performed on the day before bronchodilators and physiotherapy, on the day before antibiotic or placebo, and on the day after completion of antibiotic or placebo therapy. Scintigrams were evaluated for change in the number of nonventilated segments and change in the number of bronchial deposits of aerosol. Sixty-nine percent of patients showed improvement after bronchodilators and physiotherapy alone. Sixty-two percent showed further improvement after antibiotic or placebo was added; this improvement was independent of whether antibiotic or placebo was administered (P greater than 0.1). These aerosol scintigraphy results failed to demonstrate that the effectiveness of bronchodilators and physiotherapy is enhanced by antibiotics in the treatment of cystic fibrosis exacerbations.