Increased mortality risk in congestive heart failure patients with comorbid sleep apnoea: 10-year follow up.

We aimed to determine the mortality rates of a congestive heart failure (CHF) research cohort during a 10-year follow up and compare survival between those with CHF only (controls), CHF and central sleep apnoea, and CHF and obstructive sleep apnoea. There was a significant detriment of survival in patients with CHF/central sleep apnoea compared with both CHF/obstructive sleep apnoea patients (mean survival time difference 3.8 years, P = 0.005) and controls (mean survival time difference 4.0 years, P = 0.01).

Effect of oxygen versus adaptive pressure support servo-ventilation in patients with central sleep apnoea-Cheyne Stokes respiration and congestive heart failure.

BACKGROUND AND AIMS: Central sleep apnoea with Cheyne-Stokes respiration (CSA-CSR) is a common, serious consequence of congestive heart failure. Optimal treatment is yet to be established. We compared two common treatments for CSA-CSR. METHODS: Subjects with CSA-CSR and stable congestive heart failure were randomised to 8 weeks treatment: oxygen 2 L/min through nasal prongs and concentrator or 8 weeks adaptive servo-ventilation (ASV) using a crossover design separated by a 3-week washout. Polysomnography, indices of sleep and breathing, shuttle walk distance, symptoms, urinary catecholamines, plasma brain natriuretic peptide (NT-BNP) and echocardiography were collected at baseline and completion of each arm. RESULTS: Ten subjects (age 64 ± 10 years, left ventricular ejection fraction (LVEF) 28 ± 10.5%, apnoea-hypopnoea index (AHI) 63 ± 30/h) were recruited. Seven completed the protocol (one died, one refused ASV, one was withdrawn after hospital admission). On therapy, an AHI of < 10/h was achieved in two out of seven using oxygen (29%), six of seven using ASV (86%) and six of seven with either (86%). Compliance with ASV: 5.2 ± 2 h/night (range 1.45-7.1 h/night). Median AHI on oxygen therapy: 13.4 /h (range 2.6-42.9/h), ASV, 1.4 /h (range 0.6-17.8/h, P = 0.03). LVEF was not changed by either therapy (oxygen 30.9% vs 30.9% P = 0.97, ASV 32.5% vs 35.0% P = 0.24). NT-BNP, urinary catecholamines, shuttle walk distance and symptoms were not significantly changed by either therapy. CONCLUSION: CSA-CSR is reduced to a greater extent by ASV than oxygen therapy over 8 weeks but was not accepted long term. Neither treatment improved prognostic indices of heart failure or symptoms in the short term.

Misoprostol for second trimester pregnancy termination in women with prior caesarean: a systematic review.

BACKGROUND: Second trimester pregnancy induction with misoprostol in women with prior caesarean delivery is not well studied. OBJECTIVE: To estimate the risk of uterine rupture using misoprostol as an induction agent for pregnancy termination in the second trimester of pregnancy in women with prior caesarean delivery. SEARCH STRATEGY: Cases of women with a history of prior caesarean delivery and subsequent misoprostol induction for pregnancy termination in the second trimester (16-28 weeks) were obtained from two main data sources. First, a retrospective chart analysis was performed at Thomas Jefferson University Hospital and Christiana Hospital between 1998 and 2004. Second, multiple Medline, Scopus and POPLINE literature searches were performed. SELECTION CRITERIA: Case series and cohort studies of women with one or more prior caesarean delivery (of any type), and with a subsequent pregnancy with induction of labour for pregnancy termination at 16-28 weeks using misoprostol as the initial primary agent were included. Case reports were analysed separately. DATA COLLECTION AND ANALYSIS: Total cases were analysed by type and number of prior caesarean delivery, for the primary outcome of uterine rupture. MAIN RESULTS: The incidence of uterine rupture associated with second trimester misoprostol termination was 0.4% (2/461) in women with one prior low transverse, 0% (0/46) in those with two prior low transverse and 50% (1/2) in those with a prior classical caesarean delivery. One of the cases of uterine rupture in a woman with a prior low transverse caesarean required transfusion. None of the total eight cases (including case reports) of uterine rupture was associated with hysterectomy. CONCLUSIONS: Second trimester misoprostol termination appears safe among women with one prior low transverse caesarean birth, as it is associated with incidences of uterine rupture of 0.4% (95% confidence interval 0.08-1.67%), of hysterectomy of 0% and of transfusion of 0.2%. There are insufficient data on risk with more than one prior caesarean birth or with prior classical caesarean birth.

Mandibular advancement splint titration in obstructive sleep apnoea.

INTRODUCTION: Mandibular advancement splints (MAS) allowing self-adjustment may be better tolerated, but the optimum titration protocol needs systematic study. AIM: The aims of the study are to assess the effectiveness of a titratable MAS device in consecutive patients with body mass index (BMI) < 35 kg/m(2) and obstructive sleep apnoea [OSA, apnoea-hypopnoea index (AHI) 10-40/h] and compare two methods of adjustment [self-adjustment or adjustment after polysomnographic (PSG) feedback]. MATERIALS AND METHODS: Twenty-eight patients (24 M, mean age 49 years, mean BMI 27.6 kg/m(2)) with symptomatic (Epworth Sleepiness score > 8/24, snoring, choking or poor sleep quality) OSA (mean AHI 25.7/h, range 10-46/h) had a MAS set at 70% maximal protrusion and were randomised to subjective self-adjustment for 6 weeks (n = 16) or objective adjustment (n = 12; fixed position for 3 weeks, then PSG based feedback at 3 weeks with self-adjustment instructions). Primary outcome variable (AHI) and OSA symptoms were compared by t tests and chi-squared tests at baseline and after 6 weeks. Resolution of apnoea was defined as AHI < 5/h; improvement was defined as AHI decreased by >50% but still >5/h. RESULTS: The groups had similar baseline demographics, OSA severity and occlusal type. MAS therapy improved or resolved OSA in 20 out of 28 (71%) and was reportedly used nightly by 91% of the objective group and 63% of the subjective group (p = 0.04). MAS were used all night by 75% of the objective group and 69% of the subjective group (p > 0.05). MAS adjustment following PSG feedback did not lower AHI further from 3 weeks (baseline 26.5 +/- 12.0/h, 3 weeks 15.3 +/- 13.5/h p = 0.01, 6 weeks 11.7 +/- 10.0/h, p = 0.11). The overall improvement was similar to that achieved with subjective adjustment (baseline AHI 25.4 +/- 7.4/h, 6 weeks 14.3 +/- 10.7/h, p = 0.0002). Symptomatic benefit was reported by both groups. CONCLUSION: In selected patients, titratable MAS improved or resolved OSA in the majority of patients and was well tolerated. PSG-based feedback at 3 weeks allowed objective confirmation of efficacy and increased device use but did not result in greater improvement in AHI or symptoms. Neither titration method was significantly superior for us to provide firm endorsement. However, we recommend a follow-up sleep study to confirm MAS efficacy.

Continuous positive airway pressure in heart failure patients with obstructive sleep apnoea.

BACKGROUND: The aim of the study was to study the effect of 6 months of continuous positive airway pressure (CPAP) in community heart failure (HF) patients with obstructive sleep apnoea (OSA). METHODS: Clinically stable outpatients with HF and OSA (left ventricular ejection fraction (LVEF) <45%, apnoea/hypopnoea index >15/h, n = 19) treated with CPAP and a control group (LVEF <45%, apnoea/hypopnoea index <10/h, n = 7) were compared at baseline and at 6 months by Minnesota heart failure score, Epworth sleepiness score, shuttle walk distance, brain natriuretic peptide, urinary catecholamines and echocardiographic indices using paired t-test, McNemar's tests and effect sizes. RESULTS: In HF patients with OSA, CPAP improved LVEF (35.9 +/- 6.1% to 40.6 +/- 8.0%, P = 0.015), decreased LV end-systolic volume (152 +/- 74 to 135 +/- 62 cm(3), P = 0.03), systolic blood pressure (P = 0.04) and sleepiness (Epworth sleepiness score 8.8 +/- 4.8 to 6.3 +/- 3.2, P = 0.01), whereas walk distance, catecholamines, brain natriuretic peptide levels and symptoms were unchanged. These outcomes did not change in the HF control group. CONCLUSION: In community HF patients with OSA, CPAP therapy over 6 months improved LVEF, systolic blood pressure and sleepiness, but not sympathetic activation, brain natriuretic peptide or exercise levels. Acceptance was relatively low, potentially limiting therapeutic effectiveness.

The actin binding domain of ACF7 binds directly to the tetratricopeptide repeat domains of rapsyn.

Formation of the neuromuscular junction requires the release of agrin from the presynaptic terminal of motor neurons. Clustering of acetylcholine receptors (AChRs) on the postsynaptic sarcolemma is initiated by agrin-dependent activation of the muscle-specific kinase. While the postsynaptic scaffolding protein rapsyn is vital for high density AChR aggregation, little is known about the mechanism through which AChRs are immobilized on the postsynaptic membrane. Ultrastructural and immunohistochemical studies of rat skeletal muscle have suggested that AChRs are anchored to a membrane-associated cytoskeleton that contains spectrin-like proteins and is thus similar to that of the human erythrocyte [Bloch RJ, Bezakova G, Ursitti JA, Zhou D, Pumplin DW (1997) A membrane skeleton that clusters nicotinic acetylcholine receptors in muscle. Soc Gen Physiol Ser 52:177-195]. We are studying a protein of the spectrin superfamily, ACF7 (also known as MACF), as a postsynaptic cytoskeletal component of the neuromuscular junction. ACF7 has multiple cytoskeleton-binding domains, including an N-terminal actin-binding domain that, we postulate, may interact with rapsyn, the scaffolding protein that binds directly to AChRs. To test this hypothesis, we co-expressed fragments of these molecules in cultured fibroblasts and assessed their co-distribution and interaction using confocal microscopy and co-immunoprecipitation. We demonstrate that the actin-binding domain of ACF7 specifically interacts with the tetratricopeptide repeat domains of rapsyn. Furthermore, we show using surface plasmon resonance and blot overlay that the actin-binding domain of ACF7 binds directly to rapsyn. These results suggest that, in mammalian skeletal muscle, AChRs are immobilized in the membrane through rapsyn-mediated anchoring to an ACF7-containing network that in turn is linked to the actin cytoskeleton.

Continuous positive airway pressure reduces daytime sleepiness in mild to moderate obstructive sleep apnoea: a meta-analysis.

BACKGROUND: Obstructive sleep apnoea syndrome (OSAS) affects an estimated 2-4% of the middle aged population. Meta-analyses of randomised controlled trials have shown that the severe presentation of the syndrome (apnoea hypopnoea index (AHI) >30/hour) is effectively treated with continuous positive airway pressure (CPAP). Until recently there have been insufficient data to determine whether CPAP improves sleepiness in the larger subgroup with mild to moderate OSAS (AHI 5-30/hour). METHODS: A systematic search of Medline and a hand search identified seven randomised controlled trials where CPAP was compared with either a placebo or with conservative management in the treatment of mild to moderate OSAS (AHI 5-30/hour). All trials used the Epworth Sleepiness Scale (ESS), four used the Multiple Sleep Latency Test (MSLT), and three used the Maintenance of Wakefulness Test (MWT) to measure sleepiness. RESULTS: Meta-analyses indicated that CPAP significantly reduced subjective daytime sleepiness (ESS) by 1.2 points (95% CI 0.5 to 1.9, p = 0.001), improved objective daytime wakefulness (MWT) by 2.1 minutes (95% CI 0.5 to 3.7, p = 0.011), but did not affect objective daytime sleepiness (MSLT, mean benefit -0.2 minutes, 95% CI -1.0 to 0.6, p = 0.6). The two significant effects were small (effect size <0.30). CONCLUSIONS: CPAP elicits small improvements in subjective sleepiness and objective wakefulness in people with mild to moderate OSAS. However, the effects on sleepiness are of limited clinical significance.

Randomised controlled crossover trial of humidified continuous positive airway pressure in mild obstructive sleep apnoea.

BACKGROUND: It is unclear whether continuous positive airway pressure (CPAP), the treatment of choice for severe obstructive sleep apnoea (OSA), is effective at improving outcomes in mild OSA. METHODS: To help define the role of humidified CPAP in mild OSA, a randomised crossover study was undertaken of patients with an apnoea hypopnoea index (AHI) of 5-30/hour. Subjective sleepiness, objective wakefulness, mood, reaction time, and quality of life were measured at baseline, after 3 weeks treatment with humidified CPAP and 3 weeks sham CPAP (2 week washout). RESULTS: Twenty nine of 31 enrolled patients (age 25-67 years, seven women, mean (SD) body mass index 31.5 (6) kg/m2) completed the protocol. Humidified CPAP improved polysomnographic indices of OSA and Epworth Sleepiness Scale (2.4 points (95% CI 0.6 to 4.2)). Objective wakefulness (modified maintenance of wakefulness test) showed a trend towards improvement (5.2 minutes (95% CI -0.6 to 11)). Mood (Hospital Anxiety and Depression Scale), quality of life (SF 36, Functional Outcomes of Sleep Questionnaire), and reaction times (Psychomotor Vigilance Task) were not improved more than sham CPAP. Compliance with humidified and sham CPAP both averaged 4.9 hours/night. Placebo effects were evident in many outcomes and there was no clear treatment preference. CONCLUSIONS: Humidified CPAP improves subjective sleepiness and possibly objective wakefulness but not reaction times, quality of life, or mood. These results do not support the routine use of CPAP in all patients with mild OSA, but offers some support for the trialling of CPAP in those with severe sleepiness.

Humidified nasal continuous positive airway pressure in obstructive sleep apnoea.

Heated humidification of nasal continuous positive airway pressure (nCPAP) reduces upper airway symptoms and improves initial use in obstructive sleep apnoea syndrome (OSAS). The present study aimed to assess the effect of heated humidification of nCPAP on upper airway symptoms and initial use in obstructive sleep apnoea. This study was of a randomised, crossover design. Subjects with polysomnographically confirmed OSAS were randomised to 3 weeks nCPAP treatment with heated humidification (nCPAP-humid) or placebo humidification (nCPAP pl-humid). Objective and subjective nCPAP use, upper airway symptoms, and treatment satisfaction were compared. Thirty seven of 42 patients completed the protocol. nCPAP-humid reduced the frequency of adverse upper airway symptoms. nCPAP use over 3 weeks was greater with nCPAP-humid compared with nCPAP pl-humid. No difference was found between the treatment arms in terms of subjective treatment satisfaction or alertness. Heated humidification of nasal continuous positive airway pressure reduces upper airway symptoms and is associated with a small increase in initial use but not subjective sleepiness or treatment satisfaction. The results support the use of heated humidification as a strategy to reduce side-effects related to continuous positive airway pressure but not routine initial use.

Hazards of assisted conception in women with severe medical disease.

The issues relating to assisted reproduction in women with severe medical disease can be divided into the likely effect of pregnancy upon the medical condition, and how the medical condition may adversely affect pregnancy outcome. In addition, consideration of the hazards relating to the process of assisted conception, in particular the risk of ovarian hyperstimulation syndrome and multiple pregnancy, must be remembered. In some women, successful assisted reproduction may result in a life-threatening pregnancy. Clinicians advising women about assisted conception should be aware of the medical conditions that are absolute contra-indications to pregnancy. Some women with severe medical disease may have a significantly reduced life expectancy, in which case ethical issues regarding the future welfare of the child must be considered. Examples include sickle cell disease, cystic fibrosis and HIV. One of the biggest advantages of assisted reproduction for women with severe medical disorders is that the pregnancy is planned. Thus, there is an opportunity for the patient to be informed fully about any risks, both to herself and her fetus. This article reviews the general management of women with severe medical disorders who seek assisted reproduction and gives specific guidelines for the more common conditions.

Household oven doors: a burn hazard in children.

Contact with hot oven doors is an important cause of burns in pediatric patients. These burns are of particular concern because of their frequent localization to the hands, with the resulting negative implications for financial cost, long-term cosmesis, and hand function. A 5-year review of pediatric oven door burn cases admitted to a burn referral center was conducted. Of the 14 cases identified, the median age was 12 months. The median total body surface area (TBSA) was 1.75% (range, 0.5%-4.5%). Twelve of 14 cases involved 1 or both hands. The median length of hospital stay was 10 days. In 7 cases, burns were sustained from contact to an external surface of the oven. Based on the results obtained, we propose several prevention strategies.

The pharmacokinetics of oral fleroxacin and ciprofloxacin in plasma and sputum during acute and chronic dosing.

AIMS: To examine the pharmacokinetics of ciprofloxacin and fleroxacin in plasma and sputum of patients with an acute exacerbation of chronic bronchitis or bronchiectasis following the first dose and again during the third day of treatment. METHODS: Twelve patients, aged >35 years, with acute infective exacerbation of bronchitis or bronchiectasis were allocated randomly to treatment with either fleroxacin 400 mg daily or ciprofloxacin 500 mg twice daily in an open, parallel group design. Plasma and sputum were collected during the first and third days of treatment. The time course of concentrations in sputum was modelled assuming that it acted as a negligibly small compartment of distribution. RESULTS: The mean sputum to plasma ratios of both ciprofloxacin and fleroxacin were approximately 1 on both days 1 and 3. Peak concentrations of ciprofloxacin in sputum were achieved 1.6 (95% CI on mean difference 0.8-2.3) and 1.2 (0.4-1.9) h later than in plasma on day 1 and day 3, respectively (mean difference +/- 95% confidence interval). For fleroxacin, the corresponding delay in time to peak concentrations was less marked and not significant. Fleroxacin accumulated in plasma (accumulation index 1.52+/-0.07) and sputum (accumulation index 1.79+/-0.39) from day 1 to day 3. Accumulation did not occur for ciprofloxacin because the dose interval (12 h) was considerable longer than its half life (3-4 h). CONCLUSIONS: The sputum to plasma ratio of ciprofloxacin and fleroxacin is approximately 1. The time to peak concentrations of ciprofloxacin in sputum is slightly delayed compared with plasma. Fleroxacin accumulates over time in both plasma and sputum consistent with its longer half-life.

Multicenter phase II trial of temozolomide in patients with anaplastic astrocytoma or anaplastic oligoastrocytoma at first relapse. Temodal Brain Tumor Group.

PURPOSE: To determine the antitumor efficacy and safety profile of temozolomide in patients with malignant astrocytoma at first relapse. PATIENTS AND METHODS: This open-label, multicenter, phase II trial enrolled 162 patients (intent-to-treat [ITT] population). After central histologic review, 111 patients were confirmed to have had an anaplastic astrocytoma (AA) or anaplastic mixed oligoastrocytoma. Chemotherapy-naive patients were treated with temozolomide 200 mg/m(2)/d. Patients previously treated with chemotherapy received temozolomide 150 mg/m(2)/d; the dose could be increased to 200 mg/m(2)/d in the absence of grade 3/4 toxicity. Therapy was administered orally on the first 5 days of a 28-day cycle. RESULTS: Progression-free survival (PFS) at 6 months, the primary protocol end point, was 46% (95% confidence interval, 38% to 54%). The median PFS was 5.4 months, and PFS at 12 months was 24%. The median overall survival was 13.6 months, and the 6- and 12-month survival rates were 75% and 56%, respectively. The objective response rate determined by independent central review of gadolinium-enhanced magnetic resonance imaging scans of the ITT population was 35% (8% complete response [CR], 27% partial response [PR]), with an additional 26% of patients with stable disease (SD). The median PFS for patients with SD was 4.4 months, with 33% progression-free at 6 months. Maintenance of progression-free status and objectively assessed response (CR/PR/SD) were both associated with health-related quality-of-life (HQL) benefits. Adverse events were mild to moderate, with hematologic side effects occurring in less than 10% of patients. CONCLUSION: Temozolomide demonstrated good single-agent activity, an acceptable safety profile, and documented HQL benefits in patients with recurrent AA.

Legionella, Chlamydia pneumoniae and Mycoplasma infection in patients admitted to Christchurch Hospital with pneumonia.

AIMS: To determine the incidence, clinical features and outcome of community acquired pneumonia caused by Mycoplasma pneumoniae, Legionella species, Coxiella burnetti, Chlamydia pneumoniae and Chlamydia psittaci requiring admission to hospital. METHODS: Over 12 months the clinical findings and severity of pneumonia were recorded prospectively. Sputum, blood, serum and urine samples were collected for diagnostic testing. Management was supervised by the admitting medical team. Subjects were followed-up six weeks after discharge. RESULTS: Two hundred and fifty-five patients met the entry criteria of whom 20 died, including five who had Legionella infection. M pneumoniae (16%) infection was more often of mild/moderate severity (95%), occurred in a younger age group (mean age 31.4 years, p=0.002), with more frequent myalgia and headache. The length of hospital stay was shorter and clearing of chest radiograph and return to normal activity occurred more rapidly in this group of patients. Legionellosis was common as judged by culture and serological testing (26 cases, 11%) and a further 22 cases were identified by polymerase chain reaction. Legionella infection was not distinguishable clinically from other pneumonias. C pneumoniae was uncommon (8 cases, 3%). C burnetti and C psittaci were not identified in this study. CONCLUSIONS: Some cases of pneumonia caused by Mycoplasma pneumoniae can be identified at presentation, however pneumonia due to Legionella is not distinguishable on clinical grounds. Development of molecular diagnostic techniques may enable therapy to be directed against specific organisms earlier in the course of the disease.

Daytime pulmonary hemodynamics in patients with obstructive sleep apnea without lung disease.

It is controversial whether obstructive sleep apnea (OSA) causes pulmonary hypertension (PH) in the absence of hypoxemic lung disease. To investigate this further we measured awake pulmonary hemodynamics, pulmonary gas exchange, and small airways function in 32 patients with OSA (apnea- hypopnea index, mean +/- SE, 46.2 +/- 3. 9/h) who had normal screening lung function. Pulmonary artery pressure (Ppa) and cardiac output were measured by Doppler echocardiography at three levels of inspired oxygen (FIO2 0.50, 0.21, and 0.11) and during incremental increases in pulmonary blood flow (10, 20, and 30 microgram/kg/min dobutamine infusions) while breathing 50% oxygen. Eleven patients had PH (mean Ppa >/= 20 mm Hg, Group I). They did not differ from patients without PH (Group II) in lung function, severity of sleep-disordered breathing, age, or body mass. Compared with Group II, Group I patients had increased small airways closure during tidal breathing (FRC-closing capacity: Group I, -0.16 +/- 0.11; Group II, 0.27 +/- 0.09 L; p < 0.05), more ventilation-perfusion inequality (AaPO2: 23.8 +/- 2.8; 19.8 +/- 1.4 mm Hg; p = 0.08), a greater pulmonary artery pressor response to hypoxia (DeltaPpa FIO2, 0.50 to 0.11: 16.4 +/- 1.93; 6.4 +/- 0.77 mm Hg; p < 0.05) and a marked rise in Ppa during increased pulmonary blood flow. We conclude that PH may develop in some patients with OSA without lung disease and that it is associated with small airways closure during tidal breathing and heightened pulmonary pressor responses to hypoxia and during increased pulmonary blood flow. Such changes are consistent with remodeling of the pulmonary vascular bed in affected patients with OSA, seemingly unrelated to severity of sleep-disordered breathing.

Portable computerized polysomnography in attended and unattended settings.

STUDY OBJECTIVE: We compared the validity of a new portable polysomnographic recorder against a laboratory-based polysomnographic system from the same manufacturer. DESIGN AND PATIENTS: Simultaneous, full polysomnographic recordings from the portable device (PSGP) and the laboratory-based system (PSGL) were obtained using separate sets of sensors on 20 patients referred for investigation of sleep apnea. SETTING: After initial optimization of signals, the portable device was left unattended in 10 of the patients (to simulate home studies), while in the other 10 the signals were reviewed on a laptop computer screen and adjustments to electrode or sensor placement made as needed during the studies. Recordings were manually scored by a technologist blinded to the origin of the data. MEASUREMENTS AND RESULTS: The quality of signals was comparable between the PSGP and PSGL studies, apart from a slight decrease in respiratory signal quality during PSGP studies that led to reduced confidence in respiratory event scoring. SaO2 signal loss was also greater in unattended PSGP. There was good agreement between PSGP and PSGL for sleep variables and the apnea-hypopnea index (r=0.99). The periodic limb movement index was slightly lower during unattended PSGP. Blinded physician assessment of the records led to a recommendation for repeat studies due to poor signal quality in one (10%) attended and one (10%) unattended portable recording. There was no significant discordance between PSGP and PSGL in the final diagnostic formulations. CONCLUSION: Portable polysomnography is a viable alternative to laboratory-based polysomnography and may be improved further by better sensor attachment.

Detection of penicillin susceptibility in Streptococcus pneumoniae by pbp2b PCR-restriction fragment length polymorphism analysis.

A PCR-restriction fragment length polymorphism strategy directed against the pbp2b gene was evaluated for identification of penicillin susceptibility. A total of 106 United Kingdom (U.K.), 30 Danish, and 11 Papua New Guinean strains were tested. Of the U.K. strains, all the susceptible and all but one of the resistant isolates were correctly assigned. By using conventional definitions of "not resistant" and "not susceptible," the sensitivities were 97. 5 and 94.4%, the specificities were 100 and 98.9%, the positive predictive values were 100 and 94.4%, and the negative predictive values were 93.1 and 98.9%, respectively. This technique may allow susceptible (MIC, <0.1 mg/liter) and resistant (MIC, >1 mg/liter) isolates to be distinguished in a single PCR.

The 'Folic Acid Campaign': has the message got through? A questionnaire study.

There is now clear evidence that folic acid reduces the risk of neural tube defects. In February 1996 the Health Education Authority launched a publicity campaign to inform women of the benefits of periconceptual folic acid. We have surveyed 1000 women to assess the compliance of pregnant women with the Department of Health's recommendations about taking folic acid. Of the women, 761 (76%) said they knew about the benefits of folic acid but only 433 (43%) of them took it before pregnancy. Of the 567 women who did not take folic acid before conception, 227 had not planned their pregnancy and 239 did not know about the benefits. Of the 644 women who planned their pregnancy and knew about the benefits of folic acid before conception 211 still did not take folic acid pre-pregnancy. These findings have important implications for public policy and health professionals if the incidence of neural tube defect is to be reduced further.

Shoulder dystocia: room for improvement?

A questionnaire was completed by 166 midwives and obstetric junior doctors to assess their knowledge of the management of shoulder dystocia and to establish whether mandatory teaching and updating is required. Ninety-six participants (58%) claimed they were confident in the management of shoulder dystocia. However, only six (4%) respondents gained full marks on the scoring system devised to assess their knowledge. Furthermore 36 (22%) of those surveyed suggested rotation of the shoulders to the anterior-posterior position to alleviate the dystocia and 32 (19%) proposed pulling the head hard. Although there are limitations in assessing competence by the use of a questionnaire, the results of this survey suggest that there is considerable room for improvement. We suggest that a shoulder dystocia drill is introduced to all labour wards in the United Kingdom so that birth attendants can develop and memorize a sequence of procedures to use when confronted with this life-threatening emergency.