The emerging spectrum of fetal acetylcholine receptor antibody-related disorders (FARAD).

In utero exposure to maternal antibodies targeting the fetal acetylcholine receptor isoform (fAChR) can impair fetal movement, leading to arthrogryposis multiplex congenita (AMC). Fetal AChR antibodies have also been implicated in apparently rare, milder myopathic presentations termed fetal acetylcholine receptor inactivation syndrome (FARIS). The full spectrum associated with fAChR antibodies is still poorly understood. Moreover, since some mothers have no myasthenic symptoms, the condition is likely underreported, resulting in failure to implement effective preventive strategies. Here we report clinical and immunological data from a multicentre cohort (n = 46 cases) associated with maternal fAChR antibodies, including 29 novel and 17 previously reported with novel follow-up data. Remarkably, in 50% of mothers there was no previously established myasthenia gravis (MG) diagnosis. All mothers (n = 30) had AChR antibodies and, when tested, binding to fAChR was often much greater than that to the adult AChR isoform. Offspring death occurred in 11/46 (23.9%) cases, mainly antenatally due to termination of pregnancy prompted by severe AMC (7/46, 15.2%), or during early infancy, mainly from respiratory failure (4/46, 8.7%). Weakness, contractures, bulbar and respiratory involvement were prominent early in life, but improved gradually over time. Facial (25/34; 73.5%) and variable peripheral weakness (14/32; 43.8%), velopharyngeal insufficiency (18/24; 75%) and feeding difficulties (16/36; 44.4%) were the most common sequelae in long-term survivors. Other unexpected features included hearing loss (12/32; 37.5%), diaphragmatic paresis (5/35; 14.3%), CNS involvement (7/40; 17.5%) and pyloric stenosis (3/37; 8.1%). Oral salbutamol used empirically in 16/37 (43.2%) offspring resulted in symptom improvement in 13/16 (81.3%). Combining our series with all previously published cases, we identified 21/85 mothers treated with variable combinations of immunotherapies (corticosteroids/intravenous immunoglobulin/plasmapheresis) during pregnancy either for maternal MG symptom control (12/21 cases) or for fetal protection (9/21 cases). Compared to untreated pregnancies (64/85), maternal treatment resulted in a significant reduction in offspring deaths (P < 0.05) and other complications, with treatment approaches involving intravenous immunoglobulin/ plasmapheresis administered early in pregnancy most effective. We conclude that presentations due to in utero exposure to maternal (fetal) AChR antibodies are more common than currently recognized and may mimic a wide range of neuromuscular disorders. Considering the wide clinical spectrum and likely diversity of underlying mechanisms, we propose 'fetal acetylcholine receptor antibody-related disorders' (FARAD) as the most accurate term for these presentations. FARAD is vitally important to recognize, to institute appropriate management strategies for affected offspring and to improve outcomes in future pregnancies. Oral salbutamol is a symptomatic treatment option in survivors.

Evaluación del ambiente sonoro de la Empresa Productora y Comercializadora de Glucosas, Almidón y Derivados del Maíz. Cienfuegos, Cuba / Evaluation of sound environment in the Manufacturing and Marketing Company of glucose, starch and other corn byproducts. Cienfuegos, Cuba

RESUMEN Fundamento el ruido se incluye dentro de los cinco principales factores de riesgo de naturaleza física para la salud en el medio laboral. Objetivo determinar si la contaminación acústica de la Empresa Productora y Comercializadora de Glucosas, Almidón y Derivados del Maíz, de Cienfuegos sobrepasa los valores máximos admisibles establecidos en la NC 871/11 de Seguridad y Salud en el trabajo. Métodos se realizó un estudio descriptivo, transversal en la Empresa Productora y Comercializadora de Glucosas, Almidón y Derivados del Maíz de Cienfuegos, en el mes de febrero de 2018. En la empresa laboraban 287 trabajadores, de ellos 247 directos a la producción. Las mediciones del nivel sonoro en el área de trabajo se realizaron según la metodología que establece la Norma Cubana vigente NC 19-01-14/83. Se analizaron las variables: nivel sonoro equivalente continuo, expresado en decibeles (dB(A)) y el tiempo de exposición (en horas). Para medir el ruido se utilizó un sonómetro integrador clase 2. Las mediciones se realizaron durante la jornada laboral. Resultados en el generador de vapor, caldera de compresores, área de molinación y generación, recepción de maíz y limpieza, empaque fábrica de pienso, secadores y centrífugas los niveles de ruido sobrepasan los 90 db(a) de exposición. En los previos 2 y 3 del área molinación y generación, los niveles de ruido fueron superiores a los 100 db(a) de exposición. Conclusiones: los niveles de ruido encontrados sobrepasan el valor máximo admisible, lo que pudiera ocasionar consecuencias nocivas en la salud de los trabajadores por lo que se hace necesario intervenir en este medio laboral.

ABSTRACT Foundation: noise is included among the 5 risk factors of physical origin for health in the working environment. Objective: to determine if sound pollution at the Cienfuegos Manufacturing and Marketing Company of glucose, starch and other corn byproducts, exceeds maximum admissible values on NC 871/11 of Health Safety and Health at Work. Methods: a cross descriptive study at the Cienfuegos Manufacturing and Marketing Company of glucose, starch and other corn byproducts was conducted, on February 2018. A number of 287 persons were working, out of them 247 directly in production processes. Measurements of sound levels in the working areas were done according to the valid Cuban standard NC 19-01-14/83. Variables continues equivalent sound level, express in decibels (dB(A) and time of exposure in hours. To measure noise, it was used and integrative sonometer type 2. Measurements were done the during working hours. Results: in the steam generator, compressor boiler, grinding and generation areas, corn reception and cleaning, animal feed factory, dryers and centrifugal equipment noise levels exceed 90 db (a) of exposition. Conclusion: the levels of noise found exceed the admissible maximum which might produce harmful health consequences on workers therefore it is necessary to intervene this working environment

The prevalence of pre-operative anaemia and an examination of its effect on transfusion practice between sexes: A multicentre retrospective study.

Pre-operative anaemia affects one third of patients presenting for surgery and is associated with increased peri-operative morbidity and mortality. Most studies on this subject make a distinction in acceptable haemoglobin level between sexes. We analysed data for patients undergoing major elective surgery, with pre-operative anaemia defined as haemoglobin <13 g/dL. Data was collected for 1074 patients, of whom 411 (38.3%) had pre-operative anaemia. The odds of red cell transfusion were significantly higher in patients with pre-operative anaemia, OR = 4.35 [95%CI OR: 3.0- 6.2]. Additional binary logistic regression results identified haemoglobin level, male gender and increasing age as independent predictors for red cell transfusion. The length of post-operative stay was also significantly higher in anaemic patients, those with lower haemoglobin, males and older patients. Women were twice as likely to have a haemoglobin < 13 g/dl as men. Women were also 3.55 times more likely not to be transfused despite being anaemic. This suggests differences in clinician's attitudes to transfusion limits in women, despite Blaudszun et al. 2018 showing that women with borderline anaemia (Hb 12-12.9 g/dL) are: more likely to be transfused; to be transfused more units of red cells; and to have longer lengths of hospital stay than non- anaemic women. A change in attitude to acceptable haemoglobin in women is needed. Increased clinician awareness of the associated morbidity of even a mild reduction in haemoglobin in women is required to result in more pro-active anaemia management pre-operatively and less allogenic red cell transfusion, shorter lengths of hospital stay and overall decreased morbidity.

No rest for the weary: a cross-sectional study comparing patients' sleep in the emergency department to those on the ward.

BACKGROUND: Boarding in emergency departments (EDs) is a persistent problem worldwide. We hypothesised that patients sleeping while being boarded in EDs have worse self-rated sleep than those admitted from EDs who sleep on the ward. METHODS: Prospective cross-sectional study conducted at the University College Hospital, Galway between October and November 2016. Self-rated sleep in patients boarded in EDs from 23:00 to 07:00 was compared with those admitted to the ward before 23:00. Patients rated their sleep using the Richards-Campbell Sleep Questionnaire. Patients were excluded if they had cognitive impairment, were unable or incapacitated or had evidence of alcohol or drug use in the previous 24 hours. Continuous data are shown as medians (IQRs 25th-75th percentiles). Linear regression models of log-transformed outcome variables were performed. RESULTS: Ninety-three patients were included and 22 were excluded. Patients who boarded in the ED were significantly more likely to be medical patients (78% vs 21%, p<0.001), to be older (median age (IQR)=60 (39-71) vs 47 (32-68), p=0.04) and have more urgent presentations (74% vs 48% presenting as Manchester triage category 1 or 2, p=0.01) than patients who sleep on a ward. Patients who slept on the ward had significantly better sleep scores (mean log-transformed sleep scores (SD)=2.92 (1.05) vs 3.72 (0.66), p<0.001)). Those sleeping in the ED reported greater noisiness than those sleeping on the ward (mean log-transformed noisiness scores (SD)=3.18 (1.10) vs 4.15 (0.57), p<0.001). These significant differences in sleep scores and noisiness ratings persisted after adjustment for age, triage category and admitting service. CONCLUSION: We found those who sleep boarded in EDs have worse self-rated sleep than those who sleep on the ward.

404 Porous titanium revision shells permit early weight-bearing and rapid rehabilitation in revision hip surgery.

An aging population and younger primary arthroplasty candidates have led to increased demand for acetabular bone deficient revision hip surgery. Seventy consecutive revision arthroplasty porous titanium shells prior to December 2011 were reviewed. We sought to determine evidence of implant instability in a cohort of patients that are mobilised early. Radiological data were analysed for stability. Primary endpoint was revision of implant. Mean age at surgery was 69.9 (±10) years. Median time since primary surgery was 13 years (range: 0.3-37). Forty-nine per cent had Paprosky Type IIb or greater acetabular deficiency. Bone graft and augments were not used. One shell was revised for ingrowth failure. Mean acetabular inclination was 35.4 ̊ (±7.3) post- operatively and 36.9 ̊ (±7.28) at latest follow up. There were no screw fractures. Porous titanium shells in revision arthroplasty are stable and permit rapid rehabilitation.

Critical care nurses' knowledge of alarm fatigue and practices towards alarms: A multicentre study.

OBJECTIVES: To determine critical care nurses' knowledge of alarm fatigue and practices toward alarms in critical care settings. RESEARCH METHODOLOGY/DESIGN: A cross-sectional survey using an adaptation of The Health Technology Foundation Clinical Alarms Survey. SETTING: A sample of critical care nurses (n = 250) from 10 departments across six hospitals in Ireland. RESULTS: A response rate of 66% (n = 166) was achieved. All hospital sites reported patient adverse events related to clinical alarms. The majority of nurses (52%, n = 86) did not know or were unsure, how to prevent alarm fatigue. Most nurses (90%, n = 148) agreed that non-actionable alarms occurred frequently, disrupted patient care (91%, n = 145) and reduced trust in alarms prompting nurses to sometimes disable alarms (81%, n = 132). Nurses claiming to know how to prevent alarm fatigue stated they customised patient alarm parameters frequently (p = 0.037). Frequent false alarms causing reduced attention or response to alarms ranked the number one obstacle to effective alarm management; this was followed by inadequate staff to respond to alarms. Only 31% (n = 50) believed that alarm management policies and procedures were used effectively. CONCLUSION: Alarm fatigue has the potential for serious consequences for patient safety and answering numerous alarms drains nursing resources.

Individual traveller health priorities and the pre-travel health consultation.

The purpose of this study was to examine the principal travel health priorities of travellers. The most frequently selected travel health concerns were accessing medical care abroad, dying abroad, insect bites, malaria, personal safety and travel security threats. The travel health risks of least concern were culture shock, fear of flying, jet lag and sexually transmitted infections. This study is the first to develop a hierarchy of self-declared travel health risk priorities among travellers.

Knowledge of palliative care and attitudes towards nursing the dying patient.

AIMS: This study examines the palliative care knowledge and attitudes towards caring for the dying patient of nurses working in care of older people settings in one rural region in Ireland. DESIGN: A cross-sectional survey design was used combining two questionnaires: the palliative care quiz for nurses (PCQN) and the thanatophobia scale (TS). RESULTS: A total of 61 nurses completed the questionnaire. There was a significant correlation found between level of knowledge and attitudes towards palliative care (p=0.007), highlighting that as participants' level of palliative care knowledge increased, attitudes become more positive. While palliative care training did not impact on the mean overall scores, there was a significant difference in the PCQN scores of those who had completed the European Certificate in Essential Palliative Care (ECEPC) compared with those who had attended information sessions within their unit. Furthermore, increasing years as a registered nurse improved palliative care knowledge and attitudes towards caring for the dying. CONCLUSION: Nurses who completed the ECEPC had better knowledge of palliative care when compared with nurses who had not undertaken the programme. This article also considers areas of focus for palliative care training.

Secondary traumatic stress among emergency nurses: a cross-sectional study.

Emergency department nurses are required to deal with emotional trauma issues on a daily basis, which may result in them experiencing symptoms of secondary traumatic stress, a consequence of stress experienced when helping or wanting to help a person traumatised or suffering. This study measured emergency department nurses' self-reported levels of secondary traumatic stress. Registered nurses (n = 117) working at three emergency departments in the Western geographical region of Ireland were invited to complete the secondary traumatic stress scale (STSS). A response rate of 90% (n = 105) was achieved. Most participants (n = 67/64%) met the criteria for secondary traumatic stress. A statistically significant finding was that the highest proportion (82%) of secondary traumatic stress existed in the staff nurse group (p = 0.042). Moreover, for those nurses reporting secondary traumatic stress, statistical significance was found for the variables 'change of career considered' (p = 0.017) and 'finds alcohol helpful in alleviating work-related stress' (p = 0.004), when compared with nurses not reporting secondary traumatic stress. The findings suggest the need to examine current crisis management interventions and to introduce new systems to support nurses in Irish emergency departments. Moreover, because different types of traumatic events in the ED require different types of interventions, the prevention and management of STS among emergency department nurses must be tackled using a variety of approaches.

ATLANTIC-DIP: excessive gestational weight gain and pregnancy outcomes in women with gestational or pregestational diabetes mellitus.

CONTEXT: Women who have diabetes mellitus during pregnancy are at higher risk of adverse outcomes. Excessive gestational weight gain (GWG) is also emerging as a risk factor for maternofetal complications, and in 2009, the Institute of Medicine published recommendations for appropriate GWG. It is unclear whether excessive GWG confers additional risk to women with diabetes in pregnancy and whether Institute of Medicine recommendations are applicable to this population. OBJECTIVE: The objective of this study was to examine whether excessive GWG in pregnancies complicated by diabetes mellitus is associated with higher adverse obstetric outcomes. DESIGN: This was an observational study. SETTING: The study was conducted at five antenatal centers along the Irish Atlantic seaboard. PARTICIPANTS: 802 women with diabetes in pregnancy participated in the study. MAIN OUTCOME MEASURE: Maternal outcomes examined included preeclampsia, gestational hypertension, and cesarean delivery. Fetal outcomes included large for gestational age (LGA), macrosomia, and small for gestational age. RESULTS: Excessive GWG was noted in 59% of women. In all women, excessive GWG resulted in higher odds for LGA [adjusted odds ratio (aOR) 2.01, 95% confidence intervals 1.24-3.25 in GDM; aOR 3.97, CI 1.85-8.53 in pregestational diabetes mellitus (PGDM)] and macrosomia (aOR 2.17, CI 1.32-3.55 in GDM; aOR 3.58, CI 1.77-7.24 in PGDM). Excessive GWG was also associated with an increased odds for gestational hypertension (aOR 1.72, CI 1.04-2.85) in women with GDM, and treatment with insulin further increased the odds for LGA (aOR 2.80, CI 1.23-6.38) and macrosomia (aOR 5.63, CI 2.16-14.69) in this group. CONCLUSION: We show that in the already high-risk settings of both GDM and PGDM, excessive GWG confers an additive risk for LGA birth weight, macrosomia, and gestational hypertension.

Applying current screening tools for gestational diabetes mellitus to a European population: is it time for change?

OBJECTIVE: The optimal screening regimen for gestational diabetes mellitus (GDM) remains controversial. Risk factors used in selective screening guidelines vary. Given that universal screening is not currently adopted in our European population, we aimed to evaluate which selective screening strategies were most applicable. RESEARCH DESIGN AND METHODS: Between 2007 and 2009, 5,500 women were universally screened for GDM, and a GDM prevalence of 12.4% using International Association of Diabetes in Pregnancy Study Groups (IADPSG) criteria was established. We retrospectively applied selective screening guidelines to this cohort. RESULTS: When we applied National Institute for Health and Clinical Excellence (NICE), Irish, and American Diabetes Association (ADA) guidelines, 54% (2,576), 58% (2,801), and 76% (3,656) of women, respectively, had at least one risk factor for GDM and would have undergone testing. However, when NICE, Irish, and ADA guidelines were applied, 20% (120), 16% (101), and 5% (31) of women, respectively, had no risk factor and would have gone undiagnosed. Using a BMI≥30 kg/m2 for screening has a specificity of 81% with moderate sensitivity at 48%. Reducing the BMI to ≥25 kg/m2 (ADA) increases the sensitivity to 80% with a specificity of 44%. Women with no risk factors diagnosed with GDM on universal screening had more adverse pregnancy outcomes than those with normal glucose tolerance. CONCLUSIONS: This analysis provides a strong argument for universal screening. However, if selective screening were adopted, the ADA guidelines would result in the highest rate of diagnosis and the lowest number of missed cases.

Increases in triglyceride levels are associated with clinical response to clozapine treatment.

Increases in serum triglyceride (TG) levels are associated with clinical response to clozapine treatment. Clozapine is the most efficacious therapy for treatment of refractory schizophrenia, although its use is well recognised to be associated with substantial metabolic dysfunction. Interestingly, there is some evidence that the therapeutic benefit of clozapine is associated with treatment-emergent weight gain and dyslipidaemia, specifically hypertriglyceridaemia. In this prospective observational study, we examine associations between therapeutic response to clozapine in 49 patients with treatment-resistant schizophrenia and lipid dysregulation. An increase in TG levels was strongly predictive of clinical improvement (B=9.33, t =3.56, df=4, p<0.001) and of improvement in positive PANSS scores (B=2.85, t=3.61, df=4, p=0.001) as well as negative PANSS scores (B=1.93, t=2.36, df=4, p=0.02), when controlling for potential confounds of weight gain, change in waist circumference, baseline antipsychotic polypharmacy and serum clozapine levels. This finding suggests that clozapine's therapeutic efficacy is linked to serum lipid changes. Hypertriglyceridaemia as a predictor of clinical response in patients treated with clozapine merits further investigation in order to better elucidate its effect on the pharmacological activity of clozapine.

ATLANTIC DIP: closing the loop: a change in clinical practice can improve outcomes for women with pregestational diabetes.

OBJECTIVE: Prospective evaluation of pregnancy outcomes in women with pregestational diabetes over 6 years. RESEARCH DESIGN AND METHODS: The ATLANTIC Diabetes in Pregnancy group provides care for women with diabetes throughout pregnancy. In 2007, the group identified that women were poorly prepared for pregnancy and outcomes were suboptimal. A change in practice occurred, offering women specialist-led, hub-and-spoke evidence-based care. We now compare outcomes from 2005 to 2007 with those from 2008 to 2010. RESULTS: There was an increase in the numbers attending preconception care (28-52%, P = 0.01). Glycemic control before and throughout pregnancy improved. There was an overall increase in live births (74-92%, P < 0.001) and decrease in perinatal mortality rate (6.2-0.65%, P < 0.001). There was a decrease in large-for-gestational-age babies in mothers with type 1 diabetes mellitus (30-26%, P = 0.02). Elective caesarean section rates increased, while emergency section rates decreased. CONCLUSIONS: Changing the process of clinical care delivery can improve outcomes in women with pregestational diabetes.

ATLANTIC-DIP: raised maternal body mass index (BMI) adversely affects maternal and fetal outcomes in glucose-tolerant women according to International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria.

CONTEXT: Raised maternal body mass index (BMI) in association with hyperglycemia is associated with adverse pregnancy outcome. The contribution of raised BMI as an independent risk factor for adverse pregnancy outcome is of growing concern and increasing prevalence. OBJECTIVE: The aim of this study was to investigate the effects of raised maternal BMI on pregnancy outcome in glucose-tolerant women using the International Association of Diabetes and Pregnancy Study Groups criteria. PARTICIPANTS AND SETTING: We studied a cohort of glucose-tolerant, pregnant women (n = 3656) who were attending antenatal obstetric clinics and were recruited to a universal screening program for gestational diabetes under the ATLANTIC-DIP partnership. DESIGN: We conducted a prospective observational study of pregnancy outcome. Maternal outcomes include glucose, delivery mode, pregnancy-induced hypertension, preeclampsia, antepartum hemorrhage, and postpartum hemorrhage. Fetal outcomes included birthweight, congenital malformation, fetal death, neonatal jaundice, hypoglycemia, and respiratory distress. RESULTS: Increasing maternal BMI was associated with adverse pregnancy outcomes: higher cesarean section rates, preeclampsia, pregnancy-induced hypertension, increased birth weight, and congenital malformation. The association of glucose with adverse pregnancy outcome was weak and did not interact with raised BMI. A BMI threshold of 28 kg/m(2) was associated with a significant rise in adverse pregnancy outcome. CONCLUSIONS: Raised maternal BMI, within the overweight range, is associated with adverse pregnancy outcomes. These adverse effects of BMI occur independently of maternal glucose. It is apparent that pregnancy unmasks an underlying unhealthy metabolic milieu in obese and overweight women.

Trimester-specific reference intervals for haemoglobin A1c (HbA1c) in pregnancy.

BACKGROUND: Diabetes in pregnancy imposes additional risks to both mother and infant. These increased risks are considered to be primarily related to glycaemic control which is monitored by means of glycated haemoglobin (HbA(1c)). The correlation of HbA(1c) with clinical outcomes emphasises the need to measure HbA(1c) accurately, precisely and for correct interpretation, comparison to appropriately defined reference intervals. Since July 2010, the HbA(1c) assay in Irish laboratories is fully metrologically traceable to the IFCC standard. The objective was to establish trimester-specific reference intervals in pregnancy for IFCC standardised HbA(1c) in non-diabetic Caucasian women. METHODS: The authors recruited 311 non-diabetic Caucasian pregnant (n=246) and non-pregnant women (n=65). A selective screening based on risk factors for gestational diabetes was employed. All subjects had a random plasma glucose <7.7 mmol/L and normal haemoglobin level. Pregnancy trimester was defined as trimester 1 (T1, n=40) up to 12 weeks +6 days, trimester 2 (T2, n=106) 13-27 weeks +6 days, trimester 3 (T3, n=100) >28 weeks to term. RESULTS: The normal HbA(1c) reference interval for Caucasian non-pregnant women was 29-37 mmol/mol (Diabetes Control and Complications Trial; DCCT: 4.8%-5.5%), T1: 24-36 mmol/mol (DCCT: 4.3%-5.4%), T2: 25-35 mmol/mol (DCCT: 4.4%-5.4%) and T3: 28-39 mmol/mol (DCCT: 4.7%-5.7%). HbA(1c) was significantly decreased in trimesters 1 and 2 compared to non-pregnant women. CONCLUSIONS: HbA(1c) trimester-specific reference intervals are required to better inform the management of pregnancies complicated by diabetes.

Atlantic DIP: high prevalence of abnormal glucose tolerance post partum is reduced by breast-feeding in women with prior gestational diabetes mellitus.

OBJECTIVE: Gestational diabetes (GDM) is associated with adverse fetal and maternal outcomes, and identifies women at risk of future type 2 diabetes mellitus (T2DM). Breast-feeding may improve post partum maternal glucose tolerance. Our objective was to identify the prevalence of post partum dysglycemia after GDM, to delineate associated factors and to examine the effect of lactation on post partum glucose tolerance. DESIGN: We compared post partum 75 g oral glucose tolerance test (OGTT) results from 300 women with GDM and 220 controls with normal gestational glucose tolerance (NGT) in five regional centers. Breast-feeding data was collected at time of OGTT. Methods Post partum OGTT results were classified as normal (fasting plasma glucose (FPG) <5.6 mmol/l, 2 h <7.8 mmol/l) and abnormal (impaired fasting glucose (IFG), FPG 5.6-6.9 mmol/l; impaired glucose tolerance (IGT), 2 h glucose 7.8-11 mmol/l; IFG+IGT; T2DM, FPG ≥7 mmol/l±2 h glucose ≥11.1 mmol/l). Binary logistic regression was used to identify factors predictive of persistent hyperglycemia. RESULTS: Five hundred and twenty women were tested; six (2.7%) with NGT in pregnancy had post partum dysglycemia compared with 57 (19%) with GDM in index pregnancy (P<0.001). Non-European ethnicity (odds ratio (OR) 3.40; 95% confidence interval (CI) 1.45-8.02, P=0.005), family history of T2DM (OR 2.14; 95% CI 1.06-4.32, P=0.034), and gestational insulin use (OR 2.62; 95% CI 1.17-5.87, P=0.019) were associated with persistent dysglycemia. The prevalence of persistent hyperglycemia was significantly lower in women who breast-fed vs bottle-fed post partum (8.2 vs 18.4%, P<0.001). CONCLUSIONS: Non-European ethnicity, gestational insulin use, family history of T2DM, and elevated body mass index were associated with persistent dysglycemia after GDM. Breast-feeding may confer beneficial metabolic effects after GDM and should be encouraged.

ATLANTIC DIP: the impact of obesity on pregnancy outcome in glucose-tolerant women.

OBJECTIVE A prospective study of the impact of obesity on pregnancy outcome in glucose-tolerant women. RESEARCH DESIGN AND METHODS The Irish Atlantic Diabetes in Pregnancy network advocates universal screening for gestational diabetes. Women with normoglycemia and a recorded booking BMI were included. Maternal and infant outcomes correlated with booking BMI are reported. RESULTS A total of 2,329 women fulfilled the criteria. Caesarean deliveries increased in overweight (OW) (odds ratio 1.57 [95% CI 1.24-1.98]) and obese (OB) (2.65 [2.03-3.46]) women. Hypertensive disorders increased in OW (2.30 [1.55-3.40]) and OB (3.29 [2.14-5.05]) women. Reported miscarriages increased in OB (1.4 [1.11-1.77]) women. Mean birth weight was 3.46 kg in normal BMI (NBMI), 3.54 kg in OW, and 3.62 kg in OB (P < 0.01) mothers. Macrosomia occurred in 15.5, 21.4, and 27.8% of babies of NBMI, OW, and OB mothers, respectively (P < 0.01). Shoulder dystocia occur in 4% (>4 kg) compared with 0.2% (<4 kg) babies (P < 0.01). Congenital malformation risk increased for OB (2.47 [1.09-5.60]) women. CONCLUSIONS OW and OB glucose-tolerant women have greater adverse pregnancy outcomes.

Better off in the community? A 5-year follow up study of long-term psychiatric patients discharged into the community.

BACKGROUND: The quality of life of long-term psychiatric inpatients relocated to the community was investigated in this study. The aim was to investigate what changes, if any occurred, on standardised quality of life related instruments between discharge from hospital and at 1 year after discharge into the community. We were also interested to see if these changes continued 5 years after discharge into the community. METHOD: 87 long-stay psychiatric patients were enrolled in the study. Each patient was assessed on four standardised assessment instruments designed to assess their attitudes towards community living and level of functioning in the community. RESULTS: Patients reported being satisfied in their new community environment. They showed improvements in their level of self-care and social functioning after 1 year in the community. These improvements were not maintained in their fifth year in the community. In addition, there were no improvements in patient's domestic skills, community skills or activity and social relations levels. Weekly occupation levels increased after 5 years in the community and their level of interests in things increased over the first year but not after 5 years in the community. CONCLUSIONS: This study adds to the previous work carried out on patients discharged from large psychiatric hospitals into the community. Patients expressed a desire to continue to live in the community and while they showed improvements in self care and social functioning in the first year following discharge, these improvements were not sustained after 5 years in the community. Further training is needed for staff in the community residences so that patients can achieve their maximum potential.

Factors influencing delivery mode for nulliparous women with a singleton pregnancy and cephalic presentation during a 17-year period.

OBJECTIVE: To evaluate the effects of maternal age, induction of labour, epidural analgesia and birth weight on mode of delivery in nulliparous women with a singleton pregnancy and cephalic presentation at > or =36 weeks gestation, and to describe how these factors and their influence have changed over a 17-year period from 1989 to 2005. STUDY DESIGN: The study was conducted in the obstetric department of a university teaching hospital in Ireland. Of 45,647 women delivered, 14,867 were nulliparous with a singleton pregnancy and cephalic presentation and undergoing labour at > or =36 weeks gestation, and were included in the study. The main outcome measures were the influence of maternal age, induction of labour, epidural analgesia and birth weight on the mode of delivery. Multinomial logistic regression analysis for type of delivery and the associated explanatory variables and trend analysis of these variables were performed. RESULTS: There was a significant progressive increase in both unplanned abdominal delivery and instrumental vaginal delivery, with advancing maternal age. Induction of labour increased the risk of unplanned abdominal delivery (OR 1.92; 95% CI 1.73-2.14). Epidural analgesia was associated with an increased risk of instrumental vaginal delivery (OR 4.68; 95% CI 4.18-5.25), and unplanned abdominal delivery (OR 2.29; 95% CI 1.98-2.66). Mothers of infants with birth weight > or =4.5 kg were less likely to be delivered by instrumental vaginal delivery (OR 0.60; 95% CI 0.41-0.88), than mothers delivering infants in the 2.50-4.49 kg birth weight category. Between 1989 and 2005 there was a significant increase in maternal age (P=0.0001), birth weight (P=0.042) and unplanned abdominal delivery rates (P=0.0004), and a reduction in instrumental vaginal delivery rates (P=0.0013). CONCLUSIONS: These data demonstrate that the increasing trend of unplanned abdominal delivery in nulliparous women with a singleton pregnancy and cephalic presentation may be partially explained by advancing maternal age, and other obstetric factors also play a significant role.