Decision making about mode of delivery among pregnant women who have previously had a caesarean section: A qualitative study.

OBJECTIVE: To explore prospectively women's decision making regarding mode of delivery after a previous caesarean section. MAIN OUTCOME MEASURES: The evolution of decision making, women's participation in decision making, and factors affecting decision making. DESIGN AND METHODS: A qualitative study using diaries, observations and semi-structured interviews. Data were analysed thematically from both a longitudinal and a cross-sectional perspective. SETTING: An antenatal unit in a large teaching hospital in Scotland and participants' homes. SAMPLE: Twenty-six women who had previously had a caesarean section for a nonrecurrent cause. RESULTS: Women were influenced by their own previous experiences and expectations, and the final decision on mode of delivery often developed during the course of the pregnancy. Most acknowledged that any decision was provisional and might change if circumstances necessitated. Despite a universal desire to be involved in the process, many women did not participate actively and were uncomfortable with having responsibility for decision making. Feelings about the amount and quality of the information received regarding delivery options varied greatly, with many women wishing for information to be tailored to their individual clinical circumstances and needs. In contrast to the impression created in the media, there was no evidence of clear preferences or strong demands for elective caesarean section. CONCLUSION: Women who have had a previous caesarean section do not usually have firm ideas about mode of delivery. They look for targeted information and guidance from medical personnel based on their individual circumstances, and some are unhappy with the responsibility of deciding how to deliver in the current pregnancy.

Circannual rhythm of measles subsequent to immunisation.

This is an epidemiological study of biennial and annual rhythms of measles in England and Wales between 1959-1994 highlighting changes following immunisation. The study describes annual rhythms starting in autumn (Week 41) and the statistical method tests the fit of a sine curve to annual data. Before immunisation the previously established biennial rhythm was seen: the two years differed in magnitude of seasonal variation, position of the peak, "visibility of school holidays" and peak breadth. After immunisation (1968) these biennial features tended to disappear, one annual rhythm becoming the predominant feature. By the late eighties adjacent years had very similar sine curve fits. About 1990 (89-91) the fit of the sine curve was no longer significant, was of low amplitude and numbers were at an all time low. In 1992 significant annual variation returned, numbers rose and magnitude of seasonal variation increased. At this time a new epidemic was being predicted on other evidence and this renewed sine curve fit may be an additional warning signal. A possible influence of normal birth rhythm on numbers of susceptibles is described.

The 3' flanking region of the human tyrosine hydroxylase gene directs reporter gene expression in peripheral neuroendocrine tissues.

Cell type-specific expression of the catecholamine synthetic enzyme, tyrosine hydroxylase (TH), appears to be mediated in part by cis-acting elements located at the 3' end of the human gene. Further delineation of this region indicated sequences corresponding to a CACGTG motif significantly stimulated transcription of a heterologous promoter in various cell types. Mutation of this site led to a complete loss of activity. DNase footprinting, gel retardation, and UV cross-linking experiments indicated that a 74-kDa cellular factor(s) bound specifically to the CACGTG motif in the pheochromocytoma cell line PC12. The size of this protein and its pattern of expression are compatible with those of the CACGTG binding protein TFE3. Transgenic animals were created using a 261-bp human TH 3' fragment encompassing the CACGTG motif in front of a thymidine kinase promoter/chloramphenicol acetyltransferase reporter gene. In three lines of mice this fragment was sufficient to direct a pattern of mRNA expression in peripheral neuroendocrine tissues that mimicked TH mRNA distribution. However, these sequences were not sufficient for CNS-specific patterns of expression. Thus, multiple cell type-specific enhancers may regulate TH gene expression in the CNS and periphery.

Sequences distal to the AP1/E box motif are involved in the cell type-specific expression of the rat tyrosine hydroxylase gene.

In order to define cell type-specific elements associated with the catecholamine biosynthetic enzyme, tyrosine hydroxylase (TH), transient transfections of promoter deletion constructs were used to test relative reporter-gene activities in TH-expressing and -nonexpressing cell lines. Such assays demonstrated that a region between -503 and -578 contributed to rat TH promoter activity in the pheochromocytoma cell line PC12. Deletion of these sequences resulted in a 66% loss in cell type-specific activity. Mutations within the E box/dyad symmetry element (CAGGTGCCTGTGACAGTG) did not affect the basal and cell type-specific pattern of expression exhibited by the rat TH promoter. Promoter fusion constructs between the rat TH promoter (-741 and -197) and the human TH promoter (-197 and +1) exhibited reporter-gene activities equivalent to that of wild-type -741 rat TH constructs, further demonstrating that sequence elements upstream of the rat E box/dyad symmetry are important for cell type-specific expression. Gel-shift experiments indicated that a PC12 nuclear factor could bind to a 39-bp sequence within this region in a cell type-specific manner. The size of this factor was 52 kDa as determined by UV cross-linking experiments.

Measles, mumps, rubella antibody surveillance: pilot study in Grampian, Scotland.

The prevalence of measles, mumps and rubella antibodies for ages over six months was obtained using a stratified random sample of stored sera submitted in 1988 prior to the implementation of MMR vaccine. Besides reflecting the different vaccination policies for the three viruses the results showed that males display earlier sero-conversion for all three infections and a higher proportion of older males are susceptible. Two-thirds of children aged 6-15 months had antibodies to measles, the majority of which were apparently vaccine induced. However, the possibility that a few children contract natural measles before the recommended age for MMR vaccine cannot be ruled out. A system of continuous sero-surveillance to monitor the effect of MMR vaccine is suggested.

Surveillance of antibody to rubella virus in Grampian: closing the immunity gap.

OBJECTIVES: To identify causes for the continuing deficit of rubella immunity in women of childbearing age with a view to further reducing the risk of the congenital rubella syndrome. DESIGN: A questionnaire was sent to the general practitioner and a laboratory follow up study conducted in a one year cohort of women found on screening to have inadequate protection against rubella. SETTING: Virus laboratory of the department of medical microbiology, Aberdeen, serving the health board areas of Grampian, Orkney, and Shetland. PATIENTS: 239 women whose concentration of antibodies to rubella virus was either absent or below standard (15,000 IU/l) and whose general practitioner could be contacted to supply a history of infection, immunisation, pregnancy, and antibody testing. MAIN OUTCOME MEASURES: Whether rubella vaccination was given and whether those vaccinated were tested for seroconversion. RESULTS: Only 122 (55%) of the women for whom information was available received the recommended vaccine; only 74 (61%) of these were tested for seroconversion. Oversight was the reason given for not vaccinating 64 (65%) of the women who remained at risk. Women who were pregnant when tested were significantly less likely to receive vaccine (odds ratio 3.36) than women who were not pregnant, and even if vaccinated were less likely to have a follow up antibody test (odds ratio 1.94). CONCLUSION: Once women are identified as being unprotected against rubella they are often overlooked and not vaccinated. Prompting mechanisms aimed at general practitioners, such as the one recently set up in Grampian, should reduce the immunity gap and help to eradicate rubella in pregnancy.

Connective tissue naevi in a child with intra-uterine varicella infection.

A child with connective tissue naevi is described. She was exposed in utero to maternal varicella and has evidence of congenital varicella infection. It is proposed that her cutaneous lesions are also a manifestation of this infection.

The effect of the dosage of steroids on the incidence of cytomegalovirus infections in renal transplant recipients.

In a retrospective survey of 92 cadaver renal transplant recipients, cytomegalovirus (CMV) infections were detected in 23 of 34 (68 per cent) patients treated with high doses of steroids but in only 27 of 58 (47 per cent) patients given low doses. Pretransplant blood transfusions were associated with both an improvement in one-year allograft survival-rates (P less than 0.05) and an increase in the incidence of CMV infections. When standardised for any transfusion effect, the incidence of CMV infections was significantly higher in those patients given high doses of steroids (P less than 0.05). In the same group of patients, moreover, CMV infections were associated with a statistically significant increase in the renal allograft survival-rate (P = 0.03).

Thyroid hormones in the sudden infant death syndrome (SIDS).

Results are presented of serum total T4, T3, and TSH measurements on 92 patients. There are 34 infants exhibiting the sudden infant death syndrome, 36 in control group 1, who are matched both for age of infant and for duration of storage of specimen, and 22 post-mortem sera from non-SIDS deaths. There is no significant difference between the groups for total T4 measurements, but there is a highly significant elevation of both total serum T3 and TSH in the SIDS group compared with control group 1. It is suggested that the TSH elevation may be due to a post-mortem effect, but the T3 results appear to confirm and extend the recent publication of Chacon et al [1]. Evidence of one case of a near-SID that subsequently died is presented, demonstrating that disturbances of thyroid function tests occurred in this patient before death.

Chronic or fatal Q-fever infection: a review of 16 patients seen in North-East Scotland (1967-80).

Sixteen patients with serologically proven Q-fever infection are reviewed. Fifteen had significantly raised antibody titres to both phase I and phase II Coxiella burneti antigens, indicating persistent or chronic infection. One patient, a premature infant who died, had raised phase II titres only, but is included together with the mother who had chronic Q-fever and was the presumed source of infection. Chronic Q-fever infection has previously been regarded as virtually synonymous with Q-fever endocarditis, but only seven of the patients in this survey had evidence of valvular endocarditis. In those who did, the infection had arisen on prosthetic valves or those affected by rheumatic or syphilitic heart disease. One patient had inexorably progressive destruction of an infected congenitally bicuspid aortic valve. Eight patients had infections associated with extra-valvular sites and several of these associations have not been previously described. These include extreme prematurity with perinatal death, possibly following transplacental infection, the sudden infant death syndrome (SIDS), multiple lower limb emboli from endocarditis of an abdominal aortic dacron graft, and colonization of ventricular endocardium following left ventricular myotomy/sub-aortic diaphragm resection. The current concept that chronic Q-fever is invariably associated with endocarditis is therefore untenable and the indications for phase I antibody screening should be extended to include patients other than those under investigation for 'culture-negative' endocarditis, for example those with unusual osteomyelitis of vertebrae.

Serum antibody to poliovirus in patients in a mental deficiency hospital, with particular reference to Down's syndrome.

Neutralization tests for poliovirus antibodies were carried out on 74 patients in an adult mental deficiency hospital: 37 patients with Down's syndrome and 37 non-Down's mental defectives. The distribution of antibody titres to poliovirus types 1, 2 and 3 did not differ significantly between the two groups. Most patients had antibody to at least one poliovirus type but less than a third had antibodies at a titre of 1/8 or greater to all three types. The low level of poliovirus immunity in this population may be of epidemiological importance.

Rubella in Orkney: seroepidemiology and vaccination.

Rubella haemagglutination inhibiting (HAI) antibody titres were determined in 54 seronegative women and 31 naturally immune women after vaccination and revaccination with Wistar RA27/3 strain rubella vaccine administered by the intranasal or subcutaneous routes or revaccination with the Cendehill strain administered subcutaneously. In addition, HAI antibody titres were determined in 46 seronegative schoolgirls after vaccination with the Cendehill strain and revaccination with the RA27/3 strain.All seronegative women vaccinated with the RA27/3 strain developed antibody, peak titres being reached 6 weeks after vaccination. Six months after vaccination with the Cendehill strain, 45 (98%) of the 46 seronegative girls had developed antibody, but 11 (24%) had not reached their peak titre by 6 weeks, suggesting a slower response than that elicited by the RA27/3 strain. Revaccination did not induce significant antibody responses in the seronegative women vaccinated 6 months previously with RA27/3 but 4 naturally immune women developed an eightfold increase in antibody. In 10 (22%) of 46 schoolgirls previously vaccinated with the Cendehill strain a significant rise in antibody followed revaccination with RA27/3. These results provide further evidence of the more rapid antibody responses elicited by the RA27/3 vaccine in comparison with the Cendehill vaccine.An outbreak of natural rubella occurred in 1972 and 97 cases were confirmed serologically. The clinical disease was more common in older school-children and in adults. More males than females were affected in the 11-15 age group, the sex ratio being 18:12; this may be explained by the routine vaccination of girls of this age group as part of the national programme which began in 1970. The significance of the persistence of high HAI antibody titres after natural infection and the effect of the epidemic on the serological status of the population are discussed.