Rising rates of obstetric interventions: exploring the determinants of induction of labour.

BACKGROUND: Rising rates of obstetric interventions in the UK are a concern for health-care providers and the public. Our aims were to identify the socio-demographic and clinical factors (case mix) predictive of one of the most common obstetric interventions, induction of labour (IOL), and quantify the extent to which observed rates can be explained by case mix factors. METHODS: We conducted a comparative analysis of induced and spontaneous labours, using contemporary clinical data from the Aberdeen Maternity and Neonatal Databank. Cases complicated by antenatal intrauterine death or a previous or planned caesarean section were excluded. In total, 17,736 cases were included in the analysis. RESULTS: In 5727 (32.3%) cases labour was induced and in 12,009 (67.7%) cases it was spontaneous. Multivariate logistic regression modelling was used. In total, 18 case mix factors were predictive of IOL. Among these were well-recognized clinical indications for IOL such as pre-labour rupture of membranes (OR 3.29, 95% CI 2.90, 3.73) and prolonged pregnancy (OR 4.15, 95% CI 3.82, 4.50) and previously unreported case mix factors (residing an intermediate distance and travel time from hospital) (OR 1.27, 95% CI 1.18, 1.37; BMI >35 OR 1.37, 95% CI 1.14, 1.65). Case mix explained 71.5% of the observed rate of IOL. CONCLUSIONS: More than one-quarter of the rate of IOL remains unexplained by case mix factors. This may be explained by women's preferences for care and clinicians' practice.

Relationship between probable nosocomial bacteraemia and organisational and structural factors in UK neonatal intensive care units.

OBJECTIVES: To assess the relationship between organisational and structural factors of UK neonatal intensive care units (NICUs) with risk adjusted probable nosocomial bacteraemia. DESIGN OF STUDY: A prospective observational study of infants concurrently admitted to 54 randomly selected UK NICUs between March 1998 and April 1999. RESULTS: Of the 13 334 infants admitted, 402 (2.97%) had probable nosocomial bacteraemia. The median unit level percentage of infants with probable nosocomial bacteraemia was 2.48% (minimum 0%, maximum 9%). The risk adjusted odds of probable nosocomial bacteraemia were increased by 1.13 (95% CI 1.07 to 1.20) for each additional level 1 cot per hand washbasin and decreased by 0.53 (95% CI 0.35 to 0.79) in infants admitted to units with an NICU infection control nurse compared with units without. There was no relation with an increase in the floor space of the unit per cot (odds ratio 0.99 (95% CI 0.98 to 1.00) per m(2)) or with the quality of hand washing signs (odds ratio 1.04 (95% CI 0.93 to 1.16) per increase in quality score). CONCLUSIONS: There is widespread variation in rates of probable nosocomial bacteraemia in UK NICUs. Probable nosocomial bacteraemia is reduced in units with a dedicated infection control nurse and with the presence of more hand washbasins. Further research is required to identify methods to eliminate nosocomial bacteraemia.

Identification of SNARE and cell trafficking regulatory proteins in the salivary glands of the lone star tick, Amblyomma americanum (L.).

Prostaglandin E(2) (PGE(2)) stimulates secretion of tick salivary gland proteins via a phosphoinositide signaling pathway and mobilization of intracellular Ca(2+) (). Highly conserved intracellular SNARE (soluble NSF attachment protein receptors) complex proteins are associated with the mechanism of protein secretion in vertebrate and invertebrate neuronal and non-neuronal cells. Proteins in the salivary glands of partially fed female lone star ticks cross-react individually with antibodies to synaptobrevin-2 (vesicle (v)-SNARE), syntaxin-1A, syntaxin-2 and SNAP-25 (target (t)-SNAREs), cytosolic alpha/beta SNAP and NSF (N-ethylmaleimide-sensitive fusion protein), Ca(2+) sensitive synaptotagmin, vesicle associated synaptophysin, and regulatory cell trafficking GTPases Rab3A and nSec1. V-SNARE and t-SNARE proteins form an SDS-resistant, boiling sensitive core complex in the salivary glands. Antibodies to SNARE complex proteins inhibit PGE(2)-stimulated secretion of anticoagulant protein in permeabilized tick salivary glands. We conclude that SNARE and cell trafficking regulatory proteins are present and functioning in the process of PGE(2)-stimulated Ca(2+) regulated protein secretion in tick salivary glands.

Identity and synthesis of prostaglandins in the lone star tick, Amblyomma americanum (L.), as assessed by radio-immunoassay and gas chromatography/mass spectrometry.

High concentrations of PGE(2) and PGF(2alpha) were identified by radio-immunoassay (RIA) and/or gas chromatography/mass spectrometry (GC/MS) in the hemolymph, salivary glands and saliva of the lone star tick Amblyomma americanum (L.). Binding studies indicated that PGE(2) was free and not bound to any proteins in the hemolymph. A small amount of 6-keto-PGF(1alpha) (breakdown product of PGI(2); prostacyclin) was also found in the salivary glands but not in the hemolymph or saliva. Neither PGD(2) nor PGA(2)/B(2) was detected in any tick material investigated. Although PGE(2) was found in the gut contents, only small amounts of label crossed the gut into the hemolymph during artificial feeding with labeled PGE(2), indicating that the high amounts of PGE(2) in hemolymph and salivary glands are not sequestered from the host blood meal. Isolated salivary glands and salivary gland homogenates demonstrated robust synthesis of PGE(2) at high concentrations of exogenous arachidonic acid. Synthesis by the salivary glands was monitored by measuring increasing PGE(2) with increasing arachidonic acid by RIA, GC/MS and labeled PGE(2) in the presence of labeled arachidonic acid. Synthesis was inhibited in a dose-dependent manner by indomethacin indicating that the cyclooxygenase synthesizing prostaglandins in ticks shares similarities to the enzyme found in mammals.

Sex differences in predictors of adolescent smoking cessation.

Sex differences in predictors of smoking cessation were investigated among 337 male and 490 female participants in the RAND adolescent panel study. Participants reported smoking at least 11-20 times during the past year at Grade 10, with cessation defined as not smoking during the past year at Grade 12. Controlling for demographics, sex-specific analyses indicated that girls who quit smoking within 2 years had friends who smoked less frequently, perceived less parental approval of their smoking, had weaker intentions to continue smoking, used marijuana less frequently, attended fewer different schools, were more likely to have an intact nuclear family, experienced greater peer support, and rated themselves as healthier. Similar analyses for boys yielded results that were generally weaker and nonsignificant, with smoking quantity accounting for several associations in the sex-specific models. Despite these differences, interaction tests revealed significant sex differences for only three predictors. Implications of these results for understanding adolescent smoking cessation are discussed.

High-risk behaviors associated with early smoking: results from a 5-year follow-up.

PURPOSE: To compare grade 7 nonsmokers, experimenters, and smokers on the basis of prevalence of other problem behaviors at both grade 7 and grade 12. METHODS: Based on longitudinal self-report data from 4327 California and Oregon students, we used logistic regression to develop weighted estimates of the prevalence of academic difficulties, substance use, and delinquent behavior within the three smoking status groups at grades 7 and 12. Huber variance estimates, which adjust for weighting and clustering of observations, were used to assess the statistical significance of differences across groups. RESULTS: Compared with nonsmokers, early smokers were at least 3 times more likely by grade 12 to regularly use tobacco and marijuana, use hard drugs, sell drugs, have multiple drug problems, drop out of school, and experience early pregnancy and parenthood. These adolescents were also at higher risk for low academic achievement and behavioral problems at school, stealing and other delinquent behaviors, and use of predatory and relational violence. Early experimenters were at significantly greater risk for these problems as well, although to a lesser extent than smokers. Importantly, the higher risk among experimenters and smokers of experiencing many of these problems was evident as early as grade 7. CONCLUSIONS: Early experimenters and smokers are more likely than nonsmokers to experience various problem behaviors by grade 12, with many of these problems evident as early as grade 7. Results suggest that substance use programs that target multiple problems in addition to smoking may be most effective for these high-risk adolescents.

Prospective risk factors for alcohol misuse in late adolescence.

OBJECTIVE: This longitudinal study investigated Grade-7 and Grade-10 risk factors for alcohol misuse at Grade 12. Alcohol misuse was conceptualized as problem-related drinking (e.g., missing school), high-risk drinking (e.g., drunk driving) and high consumption. METHOD: Prospective analyses using two-part models predicted any alcohol misuse and the amount of misuse (given that some has occurred) for over 4,200 (52% male) participants in the RAND Adolescent Panel Study. Predictor variables were demographics, substance use and exposure, prodrug attitudes, rebelliousness and deviant behavior, self-esteem, family structure and relations, and grades. RESULTS: Grade-7 predictors of alcohol misuse 5 years later included early drinking onset, parental drinking, future intentions to drink, cigarette offers, difficulty resisting pressures to smoke, being white, being male, having an older sibling, deviant behavior and poor grades. By Grade 10, predictors of alcohol misuse 2 years later included drinking and marijuana use by self and peers, future intentions to drink, difficulty resisting pressures to drink and use marijuana, being male, coming from a disrupted family and deviant behavior. Somewhat different predictors were identified for problem-related, high-risk and high consumption drinking, emphasizing the importance of investigating multiple dimensions of misuse. CONCLUSIONS: The high social acceptability of alcohol use makes prevention difficult. Curbing alcohol misuse may be a more attainable goal than preventing any use. These results indicate that predictors of misuse in late adolescence can be identified by Grade 7 and are generally visible and modifiable. Prevention efforts should begin by early adolescence, address both familial and peer influences to drink and use other substances, and take into account problems that predict alcohol misuse (e.g., poor academic performance and early deviant behavior).

Prostaglandin E(2)-stimulated secretion of protein in the salivary glands of the lone star tick via a phosphoinositide signaling pathway.

Previous studies identified a prostaglandin E(2) (PGE(2)) receptor in the salivary glands of partially fed female lone star ticks, Amblyomma americanum (L.). In the present studies, protein secretion from dispersed salivary gland acini was shown to be specific for PGE(2), as compared with PGF(2alpha) or the thromboxane analog U-46619, in accordance with their respective binding affinities for the PGE(2) receptor. Furthermore, the selective PGE(2) EP1 receptor agonist, 17-phenyl trinor PGE(2), was as effective as PGE(2) in stimulating secretion of anticoagulant protein. Calcium ionophore A-23187 (1 to 100 microM) stimulated secretion of anticoagulant protein in a dose-dependent manner but the voltage-gated Ca(2+)-channel blocker verapamil (1 to 1000 microM) and the receptor-mediated Ca(2+)-entry antagonist, SK&F 96365 (1 and 10 microM), and 5mM ethylene glycol bis(beta-aminoethyl ether)-N,NN', N'-tetraacetic acid (EGTA) had no appreciable effect on inhibiting PGE(2)-stimulated secretion of anticoagulant protein. PGE(2) (0.1 microM) and the non-hydrolyzable analog of guanosine triphosphate (GTP), GTPgammaS (10 microM), directly activated phospholipase C (PLC) in a membrane-enriched fraction of the salivary glands after PLC was first incubated with the PGE(2) EP1 receptor antagonist AH-6809, which presumably antagonized endogenous PGE(2) (0.3 microM) in the broken-cell-membrane-enriched fraction. TMB-8, an antagonist of intracellular inositol trisphosphate (IP(3)) receptors, inhibited PGE(2)-stimulated secretion. The results support the hypothesis that PGE(2) stimulates secretion of tick salivary gland protein via a phosphoinositide signaling pathway and mobilization of intracellular Ca(2+).

Marital satisfaction in couples with rheumatoid arthritis.

OBJECTIVE: To understand correlates of marital satisfaction in persons with rheumatoid arthritis (RA) and their spouses. METHODS: In a cross-sectional survey, 79 persons with RA and 78 spouses completed the Kansas Marital Satisfaction Scale, the revised Ways of Coping Questionnaire scales, and the Health Assessment Questionnaire. A series of linear regression analyses were then performed to investigate correlates of marital satisfaction for patients and spouses. RESULTS: Seventy-six percent of patients were women. Mean patient age was 56.5 years (+/- 12.5 years), number of years married was 30.7 (+/- 13.5), and duration of RA was 14.2 years (+/- 9.0 years). Demographic features of spouses resembled those of patients. Patients and spouses were generally satisfied with their marriages. Linear regression analyses showed that lower marital satisfaction in patients was associated with higher education level (P < 0.01), patient's greater use of escape into fantasy (P < 0.01), patient's greater use of finding blame (P < 0.05), and spouse's higher use of escape into fantasy (P < 0.001). Spouses less satisfied with their marriages were more likely to use passive acceptance (P < 0.05) and less likely to find blame (P < 0.05). Female spouses were less likely to be satisfied in their marriages (P < 0.01) than male spouses. CONCLUSIONS: This study indicates that certain passive coping styles are associated with lower marital satisfaction in persons with RA and their spouses. More highly educated patients and female spouses are also less satisfied in their marriages. These cross-sectional correlations should not be regarded as causal and should be examined further in longitudinal studies.

Molecular cloning of cAMP-dependent protein kinase catalytic subunit isoforms from the lone star tick, Amblyomma americanum (L.).

The salivary glands of ixodid ticks are central to tick feeding and to survival during off-host periods. They produce and secrete a number of molecules critical to maintaining the complex host-vector interface and to maintaining osmotic balance. We have previously shown that a cyclic AMP-dependent protein kinase (cAPK) is involved in the mechanism of salivary gland secretion. We have now cloned cDNAs encoding three isoforms of the catalytic subunit (cAPK-C) of the cAPK from Amblyomma americanum, which are probably produced from alternative RNA processing of a single cAPK-C gene. The cDNAs contain unique N-termini of variable lengths that are linked to a common region containing the alpha A helix, catalytic core, and a C-terminal tail. The common region is highly similar to both insect and vertebrate cAPK-Cs. We have examined mRNA profiles in whole ticks and in isolated salivary glands throughout feeding and find that a single cAPK-C isoform is expressed in the salivary glands of both unfed and feeding females.

Birth weight, childhood lower respiratory tract infection, and adult lung function.

BACKGROUND: Historical cohort studies in England have found that impaired fetal growth and lower respiratory tract infections in early childhood are associated with lower levels of lung function in late adult life. These relations are investigated in a similar study in Scotland. METHODS: In 1985-86 a follow up study was carried out of 1070 children who had been born in St Andrew's from 1921 to 1935 and followed from birth to 14 years of age by the Mackenzie Institute for Medical Research. Recorded information included birth weight and respiratory illnesses. The lung function of 239 of these individuals was measured. RESULTS: There was no association between birth weight and lung function. Pneumonia before two years of age was associated with a difference in mean forced expiratory volume in one second (FEV1) of -0.39 litres (95% confidence interval (CI) -0.67, -0.11; p = 0.007) and in mean forced vital capacity (FVC) of -0.60 litres (95% CI -0.92, -0.28; p < 0.001), after controlling for age, sex, height, smoking, type of spirometer, and other illnesses before two years. Similar reductions were seen in men and women. Bronchitis before two years was associated with smaller deficits in FEV1 and FVC. Asthma or wheeze at two years and older and cough after five years were also associated with a reduction in FEV1. CONCLUSIONS: The relation between impaired fetal growth and lower lung function in late adult life seen in previous studies was not confirmed in this cohort. The deficits in FEV1 and FVC associated with pneumonia and bronchitis in the first two years of life are consistent with a causal relation.

Parental divorce: effects on individual behavior and longevity.

Using an archival prospective design, the authors studied associations among parental divorce occurring during participants' childhood, adult psychosocial mediators, and mortality over the life span of a subgroup of participants (N = 1,261) in the Terman Life Cycle Study (1921-1991). Children from divorced families grew up to show a higher risk of premature mortality across the life span. The higher mortality risk for men was explained, in part, when 3 mediating factors were controlled: Men who had experienced parental divorce were more likely to have their own marriages end in divorce, obtained less education, and engaged in fewer service activities. Women who had experienced parental divorce smoked more and were more likely themselves to divorce, both of which predicted higher mortality risk. The findings extend previous work on the negative sequelae of parental divorce to long-term effects on personality and longevity.

Cloning and sequence of a gene for the homologue of the stearoyl CoA desaturase from salivary glands of the tick Amblyomma americanum.

A 1488 base pair cDNA clone has been isolated from a cDNA library made from salivary glands from 3-day feeding adult female ticks. The sequence of this cDNA suggests it is the gene for the tick homologue of the stearoyl CoA desaturase. This gene is expressed in eggs and all feeding stages of the adult examined, but appears to be transcribed to an 8 kb mRNA as well as a 1.5 kb mRNA. Because ticks have the ability to synthesize monounsaturated fatty acids and demonstrate a large increase in salivary monounsaturated fatty acids during tick feeding, we hypothesize that stearoyl CoA desaturase may be a key enzyme in the morphogenesis of tick salivary glands during feeding.

Cloning and sequence of a gene for a homologue of the C subunit of the V-ATPase from the salivary gland of the tick Amblyomma americanum (L).

A 1084 base pair partial cDNA showing similarity to the C subunit of the vacuolar ATPase (V-ATPase) was isolated on a clone from a cDNA library made from salivary glands from 3-day-old feeding adult Amblyomma americanum (L.) female ticks. The 5' end was completed using primer extension and the two pieces joined to form a complete cDNA of 1373 bp. This mRNA is expressed in embryos and the salivary glands of unfed adults and adult females at all stages of feeding. Specific inhibitors of the V-ATPase decrease the rate of dopamine-stimulated secretion of isolated salivary glands, but not as much as ouabain, an inhibitor of the Na+, K+ ATPase, indicating that a V-ATPase may participate in the mechanism of salivary fluid secretion in A. americanum, but the volume of saliva secreted is more dependent on an active Na+, K+ ATPase.

Should obstetricians see women with normal pregnancies? A multicentre randomised controlled trial of routine antenatal care by general practitioners and midwives compared with shared care led by obstetricians.

OBJECTIVE: To compare routine antenatal care provided by general practitioners and midwives with obstetrician led shared care. DESIGN: Multicentre randomised controlled trial. SETTING: 51 general practices linked to nine Scottish maternity hospitals. SUBJECTS: 1765 women at low risk of antenatal complications. INTERVENTION: Routine antenatal care by general practitioners and midwives according to a care plan and protocols for managing complications. MAIN OUTCOME MEASURES: Comparisons of health service use, indicators of quality of care, and women's satisfaction. RESULTS: Continuity of care was improved for the general practitioner and midwife group as the number of carers was less (median 5 carers v 7 for shared care group, P<0.0001) and the number of routine visits reduced (10.9 v 11.7, P<0.0001). Fewer women in the general practitioner and midwife group had antenatal admissions (27% (222/834) v 32% (266/840), P<0.05), non-attendances (7% (57) v 11% (89), P<0.01) and daycare (12% (102) v 7% (139), P<0.05) but more were referred (49% (406) v 36% (305), P<0.0001). Rates of antenatal diagnoses did not differ except that fewer women in the general practitioner and midwife group had hypertensive disorders (pregnancy induced hypertension, 5% (37) v 8% (70), P<0.01) and fewer had labour induced (18% (149) v 24% (201), P<0.01). Few failures to comply with the care protocol occurred, but more Rhesus negative women in the general practitioner and midwife group did not have an appropriate antibody check (2.5% (20) v 0.4% (3), P<0.0001). Both groups expressed high satisfaction with care (68% (453/663) v 65% (430/656), P=0.5) and acceptability of allocated style of care (93% (618) v 94% (624), P=0.6). Access to hospital support before labour was similar (45% (302) v 48% (312) visited labour rooms before giving birth, P=0.6). CONCLUSION: Routine specialist visits for women initially at low risk of pregnancy complications offer little or no clinical or consumer benefit.

Marital history at midlife as a predictor of longevity: alternative explanations to the protective effect of marriage.

The association between marital history at midlife (in 1950) and mortality (as of 1991) was studied in a group of intelligent, educated men and women (N = 1,077) who participated in the Terman Life-Cycle Study initiated by Lewis Terman in 1921. Results confirm that consistently married people live longer than those who have experienced marital breakup but suggest that this is not necessarily due to the protective effects of marriage itself. Individuals who were currently married, but had previously experienced a divorce, were at significantly higher mortality risk compared with consistently married individuals. Furthermore, individuals who had not married by midlife were not at higher mortality risk compared with consistently married individuals. Part of the relationship between marital history and mortality risk may be explained by childhood psychosocial variables, which were associated with both future marital history and mortality risk.

Is birth order associated with adult mortality?

The objective of this study was to determine whether birth order is associated with total or cause-specific adult mortality and whether the association differed by sex, was confounded by age, number of siblings, or socioeconomic status, or was mediated by personality, education, or health behaviors. Teachers throughout California identified intellectually gifted children as part of a prospective study begun in the 1920s by Lewis Terman. Information on birth order was available on 1162 subjects (85% of cohort) who have since been followed for over 70 years. Cox proportional hazards models indicated that birth order was not associated with adult all-cause, cardiovascular, or cancer mortality. Among women, middle children were more likely than oldest children to die from causes of death other than cardiovascular disease or cancer, although the numbers in this category were small. This study did not provide evidence that birth order is associated with adult mortality in this highly intelligent, middle-class cohort.

An archival prospective study of mental health and longevity.

The relationship between mental health status and longevity was examined in an archival prospective cohort study (N = 1,103) derived from work begun by Lewis Terman in the 1920s. Degree of psychological maladjustment, cumulatively rated by Terman and his colleagues as of 1950, was found to be related to higher risk of all-cause mortality over a 4-decade follow-up period. The differences among causes of death were nonsignificant, but there was some indication that mental health problems were more strongly related to deaths from injury and cardiovascular disease. The overall relationship was significant for men but weaker for women. The effect was not substantially mediated by alcohol consumption, obesity, or cigarette smoking.