The impact of maternal age over forty years on the caesarean section rate: six year experience at a busy district general hospital.

A retrospective study over a 6-year period was undertaken to determine the trend in age at booking for antenatal care at West Hertfordshire Hospitals NHS Trust and to investigate the relationship between maternal age at booking for antenatal care and mode of delivery. Between 2006 and 2011, there was an 80% increase in the number of women over the age of 40 years booking for antenatal care. The overall caesarean section rate in this cohort of women increased from 34.6% in 2006 to 53.7% in 2011, comprising of an increase in both elective and emergency caesarean sections. It appears that increasing maternal age may explain a significant proportion of the rising caesarean section rate in our unit.

Breast cancer metastasising to the pelvis and abdomen: what the gynaecologist needs to know.

A small proportion of breast cancers metastasise within the peritoneal cavity. With increasing breast cancer incidence rates, gynaecologists and oncologists will encounter such women more frequently. Most women with intraperitoneal breast cancer are premenopausal. Although data are limited and are likely to be subject to selection bias, the median survival of women undergoing resection appears superior to those not undergoing surgery. Furthermore, survival is broadly similar to that for women undergoing advanced ovarian cancer surgery, particularly when tumour debulking is optimal. Obtaining data via randomised trials is unlikely to be feasible and therefore we recommend prospective data collection via the establishment of an international intraperitoneal breast cancer patient registry. For individual women where survival is anticipated to be more than a few months, we suggest considering referral to a gynaecological oncology team for discussion of surgical options.

Trends in mortality following Clostridium difficile infection in Scotland, 2010-2016: a retrospective cohort and case-control study.

BACKGROUND: National surveillance of Clostridium difficile infection (CDI) in Scotland enables the monitoring of trends in incidence rates but not mortality. AIM: To assess factors associated with mortality for all CDI cases aged ≥15 years in Scotland between 2010 and 2016. METHODS: All CDI cases aged ≥15 years in Scotland between 2010 and 2016 were linked to hospital admission and mortality datasets. Logistic regression was used to assess factors associated with mortality (30-day all-cause). A case-control study of a hospitalized subset of cases and matched hospitalized controls assessed the impact of CDI on mortality and length of stay. FINDINGS: Thirty-day all-cause mortality decreased over the seven-year period (from 20.5% to 15.6%; P < 0.001), mainly among healthcare-associated CDI (HA-CDI). Increased age, higher Charlson score, HA-CDI, as well as liver, heart and malignancy comorbidities were associated with higher mortality. No association was observed between polymerase chain reaction ribotype and higher mortality, though 015 and 078 were associated with lower mortality. Adjusted odds ratio (OR) for 30-day mortality in hospitalized CDI cases compared to controls was 2.67 (95% confidence interval (CI): 2.42-2.94; P < 0.001). Whereas mortality declined over time in cases and controls, the trend in ORs remained relatively stable. Having CDI increased additional mean length of stay beyond infection by 22.3% (95% CI: 18.0-26.8%; P < 0.001). CONCLUSION: CDI is associated with an almost three-fold increase in 30-day mortality and places an increased burden on hospital resources by increasing mean LOS beyond the infection date by 22.3%. The decreasing CDI mortality trends may be due to overall improvements in mortality among the general and hospital population of Scotland. Therefore, despite large declines in incidence rates, CDI remains a serious healthcare problem.

A comparison of methods for the automated calculation of volumes and atrophy rates in the hippocampus.

Hippocampal atrophy rates have been used in a number of studies in Alzheimer's disease (AD) to assess disease progression and are being increasingly utilized as an outcome measure in clinical trials of new pharmaceutical agents. Owing to the labor-intensive nature of hippocampal segmentation, more automated approaches are required for such analysis. In this study we compared methods of automatically segmenting the hippocampus (single-person template and template library) on the baseline image in a group of probable AD (n=36) and control (n=19) subjects with serial images. Using the method that gave most similar results to manual, three automated methods of calculating change within the hippocampal region were compared: fluid change calculated using (1) Jacobian change or (2) region propagation and (3) boundary shift. Rates were compared with manual measures. We found that segmentation of baseline hippocampus was most accurate using a template library combined with morphological operations (intensity thresholding plus one conditional dilation). This gave a voxel similarity of 0.69 (0.05) and 0.72 (0.06) in controls and probable AD subjects respectively compared with manual measures. Atrophy rates within these regions were most similar to the manual rates using the boundary shift integral (mean difference from manual rate 0.03% (1.29) in controls and 0.48% (2.44) in AD). A template library segmentation approach, together with morphological operations, provides a segmentation accurate enough to quantify relative change over time. The change over time can then be calculated automatically using boundary shift or fluid measures, with boundary shift giving most similar results to manual.

Do symptoms of memory impairment correspond to cognitive impairment: a cross sectional study of a clinical cohort.

BACKGROUND: Symptoms of memory loss are a common complaint within the general population and a frequent reason for seeking medical advice. However, the clinical relevance of these symptoms to future development of neurodegenerative disease is uncertain. The aim of this study is to characterise a cohort of individuals with symptoms of memory loss and varying memory impairment, who will be followed longitudinally with serial neuropsychology and neuroimaging to evaluate the clinical relevance of symptoms of memory loss. METHOD: Fifty-eight subjects with symptoms of memory loss were recruited from the National Hospital for Neurology and Neurosurgery. All subjects underwent clinical assessment, APOE4 genotyping, neuroimaging and neuropsychological tests. RESULTS: Those with mild cognitive impairment (MCI) had an increased prevalence of the APOE4 allele, impaired performance on tests of memory, measures of IQ and naming compared to controls. Baseline brain volumes were decreased and ventricular size increased. Those with symptoms of memory loss but no cognitive impairment (SNCI) performed significantly worse on tests of memory than the control group. CONCLUSIONS: The MCI represent a group with multiple risk factors for progression to AD. The SNCI group may represent a heterogeneous group with some individuals in the early stages of AD whilst others' memory complaints are more likely linked to anxiety or personality traits.

Differential drug effects on dopamine concentrations and rates of turnover in the median eminence, olfactory tubercle and corpus striatum.

Dopamine synthesis rates were determined in terminals of tuberoinfundibular, mesolimbic and nigrostriatal neuronal systems by observing the decline of dopamine contents in the median eminence, olfactory tubercle and corpus striatum after administration of alpha-methyltyrosine. In control (no drug treatment) animals the rate of synthesis of dopamine was greater in the median eminence than in the other two brain regions. Haloperidol increased and piribedil decreased dopamine turnover in the corpus striatum and olfactory tubercle, but not in the median eminence. Gamma-Butyrolactone increased dopamine concentrations in the olfactory tubercle and striatum without altering the concentration in the median eminence. Thus, the regulatory mechanisms governing the activity of central dopaminergic neurons in the tuberoinfundibular system appear to differ from those in the mesolimbic and nigrostriatal systems.

Microbiological profile of the cervix in 1,000 sexually active women.

One thousand consecutive women who attended the Richmond Family Planning Association Clinic and who were to undergo a vaginal examination were asked to participate in a large prospective microbiological study. Participants were questioned about their sexual activity during the previous 12 months and any apparent signs of sexually transmitted disease. On examination the cervix was inspected for evidence of inflammation, ectopy or discharge and cervical swabs were taken microbiological assessment. Chlamydia trachomatis was isolated in 5.1% of women tested while Ureaplasma urealyticum and Mycoplasma hominis were found in 48.8% and 16.4% of women respectively. Significant associations were found between the number of sexual partners during the previous 12 months and the incidence of all 3 organisms. The carriage rate of the genital mycoplasmas was significantly affected by the type of contraception. In addition the association between the presence of the genital mycoplasmas and pelvic and cervical abnormalities was determined.

A prospective single-blind trial of minocycline and doxycycline in the treatment of genital Chlamydia trachomatis infection in women.

A total of 2124 women who attended the Richmond Family Planning Association Clinic in Melbourne consecutively were screened for the presence or absence of Chlamydia trachomatis. One hundred and three women were found to have Chl. trachomatis infection of the cervix and were invited to participate in a clinical trial of minocycline and doxycycline for the treatment of chlamydial infection. A 10-day course of either drug resulted in a negative result of a chlamydial culture for all patients at the follow-up assessment, which occurred between 11 days to 12 weeks after the therapy. Minocycline and doxycycline showed equal effectiveness in the eradication of mycoplasmas in over 80% of the treated patients. Minocycline appeared to have a slight advantage with respect to the resolution of the gynaecological symptoms that were associated with the chlamydial infection. The number of adverse events that were recorded during the trial was similar for both treatment regimens. Gynaecological symptoms were associated with chlamydial infection in approximately 50% of the women in the study. The lack of association between chlamydial infection and gynaecological symptoms has led to the instigation of routine testing for the presence of Chlamydia spp. in young women who have more than one sexual partner.

The prevalence of Chlamydia trachomatis in a young, sexually-active population.

A prospective study was carried out to determine the prevalence of Chlamydia trachomatis among 1000 sexually-active women at the Family Planning Association Clinic in Melbourne. This organism was isolated from the cervices of 5.1% of screened women. The women were surveyed about their sexual and gynaecological history, and symptoms of discharge or pain. It was found that women who gave positive results for the presence of Chlamydia were younger, and had commenced intercourse at an earlier age. Risk factors of multiple sexual partners, cervical ectopy and symptoms of urethritis were identified. We recommend that women who have more than one sexual partner should ask their partners to use condoms or, failing this, undergo annual screening for Chlamydia by immunofluorescent staining.

PIP: A prospective study was conducted over the December 11, 1985-May 29, 1986, period to determine the prevalence of "Chlamydia trachomatis" among 1000 sexually-active women at Melbourne's (Australia) Family Planning Association Clinic. An epidemiological and clinical history was recorded on a code sheet for study participants. Patients' ages, weights, coitarches, numbers of sexual partners during the last 12 months, and lengths of association with their present partners were recorded along with current contraceptive usage and the results of the last Papanicolaou smear-test. Patients also were asked about the presence of any symptoms of sexually-transmitted disease (STD). The appearance of the cervix was ascertained on speculum examination. Cervical specimens were taken from all women for microbiological assessment. 995 patients completed the patient record form. In 994 of these women, satisfactory swabs were taken for microbiological examination. The patients ranged in age from 15-50 years with a mean age of 25.4. The age at 1st intercourse (coitarche) ranged from 12-30 years and the number of sexual partners during the last 12 months from none to more than 10 partners. 573 (57.6%) women were using oral contraceptives (OCs), 141 (14.2%) no contraception, 101 (10.2%) an IUD, 118 (11.9%) a barrier method, and the remainder a progestagen-only pill, an injectable contraceptive agent, sterilization, or natural contraceptive methods. The previous cervical cytology was available for 775 (77.9%) women; 625 (80.6%) of these showed no abnormal cells. Of the 150 smear-tests that showed some abnormality, only 10 tests demonstrated dysplastic lesions. The rest were indicative of infection or a benign abnormality. Of the 994 cervical swabs, 51 (5.1%) swabs grew Chlamydia trachomatis. 42 swabs gave positive results of both immunofluorescence staining and culture; 9 swabs gave positive results of culture alone. An association between other factors and the presence or absence of Chlamydia was determined. When the ages of patients were compared, patients whose swabs gave positive results for Chlamydia were significantly younger than those whose swabs gave negative results. The women whose swabs gave positive results for Chlamydia began intercourse at a significantly younger age. The prevalence of Chlamydia trachomatis in a young sexually-active population was 5.1%; the group with multiple partner was identified as being at high risk (9.3% positive results). In trying to identify women with an increased risk of carrying Chlamydia, 5 factors appeared relevant: younger age at coitarche; a younger age; more than 1 sexual partner during the previous 12 months; symptoms of urethritis; and the presence of cervical ectopy.