[Beyond benefit evaluation: Considering the unintended consequences of telehealth]. / Au-delà de l'évaluation des bénéfices : réflexion sur les conséquences inattendues de la télésanté.

Telehealth is seen as a key lever in health policy choices. However, many challenges remain in terms of its successful integration into clinical practices. To date, many telehealth initiatives are struggling to move beyond the pilot project stage. This is partly due to a culture of innovation that is mainly focused on the expected benefits of the technology and less on the changes and transformations it can generate. Telehealth is used in health care organizations with complex social dynamics, to say the least. Its introduction has unintended consequences that can affect patients, communities, professionals, organizations, health systems and society as a whole. The aim of this article is to discuss some of the unintended consequences of using telehealth in health care organizations and systems.

Intrinsic Low-Temperature Magnetism in SmB_{6}.

By means of new muon spin relaxation experiments, we disentangle extrinsic and intrinsic sources of low-temperature bulk magnetism in the candidate topological Kondo insulator (TKI) SmB_{6}. Results on Al-flux-grown SmB_{6} single crystals are compared to those on a large floating-zone-grown ^{154}Sm ^{11}B_{6} single crystal in which a 14 meV bulk spin exciton has been detected by inelastic neutron scattering. Below ∼10 K, we detect the gradual development of quasistatic magnetism due to rare-earth impurities and Sm vacancies. Our measurements also reveal two additional forms of intrinsic magnetism: (1) underlying low-energy (∼100 meV) weak magnetic moment (∼10^{-2} µ_{B}) fluctuations similar to those detected in the related candidate TKI YbB_{12} that persist down to millikelvin temperatures, and (2) magnetic fluctuations consistent with a 2.6 meV bulk magnetic excitation at zero magnetic field that appears to hinder surface conductivity above ∼4.5 K. We discuss potential origins of the magnetism.

DNA methylation reprogramming, TE derepression, and postzygotic isolation of nascent animal species.

The genomic shock hypothesis stipulates that the stress associated with divergent genome admixture can cause transposable element (TE) derepression, which could act as a postzygotic isolation mechanism. TEs affect gene structure, expression patterns, and chromosome organization and may have deleterious consequences when released. For these reasons, they are silenced by heterochromatin formation, which includes DNA methylation. Here, we show that a significant proportion of TEs are differentially methylated between the "dwarf" (limnetic) and the "normal" (benthic) whitefish, two nascent species that diverged some 15,000 generations ago within the Coregonus clupeaformis species complex. Moreover, TEs are overrepresented among loci that were demethylated in hybrids, indicative of their transcriptional derepression. These results are consistent with earlier studies in this system that revealed TE transcriptional derepression causes abnormal embryonic development and death of hybrids. Hence, this supports a role of DNA methylation reprogramming and TE derepression in postzygotic isolation of nascent animal species.

Coexistence of ferromagnetic fluctuations and superconductivity in the actinide superconductor UTe2.

We report low-temperature muon spin relaxation/rotation (µSR) measurements on single crystals of the actinide superconductor UTe2. Below 5 K we observe a continuous slowing down of magnetic fluctuations that persists through the superconducting transition temperature (T c = 1.6 K), but we find no evidence of long-range or local magnetic order down to 0.025 K. The temperature dependence of the dynamic relaxation rate down to 0.4 K agrees with the self-consistent renormalization theory of spin fluctuations for a three-dimensional weak itinerant ferromagnetic metal. Our µSR measurements also indicate that the superconductivity coexists with the magnetic fluctuations.

Maternal Support of Children's Early Numerical Concept Learning Predicts Preschool and First-Grade Math Achievement.

The primary goal in this study was to examine maternal support of numerical concepts at 36 months as predictors of math achievement at 4½ and 6-7 years. Observational measures of mother-child interactions (n = 140) were used to examine type of support for numerical concepts. Maternal support that involved labeling the quantities of sets of objects was predictive of later child math achievement. This association was significant for preschool (d = .45) and first-grade math (d = .49), controlling for other forms of numerical support (identifying numerals, one-to-one counting) as well as potential confounding factors. The importance of maternal support of labeling set sizes at 36 months is discussed as a precursor to children's eventual understanding of the cardinal principle.

Deformation twinning and the role of amino acids and magnesium in calcite hardness from molecular simulation.

We employ classical molecular dynamics to calculate elastic properties and to model the nucleation and propagation of deformation twins in calcite, both as a pure crystal and with magnesium and aspartate inclusions. The twinning is induced by applying uniaxial strain to the crystal and relaxing all stress components except the uniaxial component. A detailed analysis of the atomistic processes reveal that the twinning mechanism involves small displacements of the Ca ions and cooperative rotations of the CO3 ions. The volume of the twinned region expands under increased uniaxial strain via the propagation of steps along the twin boundaries. The energy cost of the twin boundaries is compensated by the reduced hydrostatic stress and strain energy. The presence of biogenic impurities is shown to decrease the strain required to induce twin formation in calcite and, thus, the yield stress. This increased propensity for twinning provides a possible explanation for the increased hardness and penetration resistance observed experimentally in biominerals.

Interaction between the Val158Met catechol-O-methyltransferase gene variant and second-generation antipsychotic treatment on blood pressure in children.

Second-generation antipsychotic (SGA) medications are associated with cardiometabolic risk factors such as obesity and elevated blood pressure (BP) in some individuals. The goal of this study is to determine whether the Val158Met variant (rs4680) in the catechol-O-methyltransferase (COMT) gene, associated with BP in adults, is associated with elevated BP in SGA-treated children. A cross-sectional population of SGA-treated (n=134) and SGA-naive (n=168) children, ⩽18 years of age, were genotyped and assessed for markers of cardiometabolic health. An interaction was found between SGA treatment and COMT genotype for BP. After adjusting for covariates, SGA-treated children with the Met allele had higher systolic and diastolic BP (P=0.014 and P=0.034, respectively), and higher fasting glucose concentrations (P=0.030) compared with children with the Val/Val genotype. This was not observed in SGA-naive children. The Met allele of the COMT Val158Met variant may identify SGA-treated children at risk for elevated BP and fasting blood glucose concentrations.

Neonatal intensive care unit discharge of infants with cardiorespiratory events: Tri-country comparison of academic centers.

OBJECTIVE: Compare how NICUs within academic centers in Canada, France, and the United States make discharge decisions regarding cardiorespiratory recordings and home use of apnea monitors, oximeters and caffeine. STUDY DESIGN: An anonymous survey was sent to neonatologists through the member listserv of the American Academy of Pediatrics Section on Perinatal Pediatrics, the Canadian Fellowship Program Directory, and to Level 3 NICUs in France. RESULTS: The response rates were 89% , 83% , and 79% for US, Canada and France respectively. In Canada, 45% perform pre-discharge recordings vs. 38% in France and 24% in the US. Apnea free days prior to discharge were required in 100% of centers in Canada, 96% in France, and 92% in the US. In Canada and France, 65% and 68% of units discharge patients on monitors vs. 99% in the US. 64% of the US centers sometimes use home caffeine compared to 40% in Canada and 34% in France. Over 60% of the centers in Canada and France wait until at least 40 weeks post menstrual age to discharge patients, whereas only about 33% of the US wait that late to discharge patients. CONCLUSIONS: Discharge practices from NICUs are not well standardized across institutions or countries. Canada and France keep infants in the hospital longer and are less likely than the US to use home monitoring and home caffeine.

Systemic arterial compliance following ultra-marathon.

There is a growing interest in training for and competing in race distances that exceed the marathon; however, little is known regarding the vascular effects of participation in such prolonged events, which last multiple consecutive hours. There exists some evidence that cardiovascular function may be impaired following extreme prolonged exercise, but at present, only cardiac function has been specifically examined following exposure to this nature of exercise. The primary purpose of this study was to characterize the acute effects of participation in an ultra-marathon on resting systemic arterial compliance. Arterial compliance and various resting cardiovascular indices were collected at rest from 26 healthy ultra-marathon competitors using applanation tonometry (HDI CR-2000) before and after participation in a mountain trail running foot race ranging from 120-195 km which required between 20-40 continuous hours (31.2±6.8 h) to complete. There was no significant change in small artery compliance from baseline to post race follow-up (8.5±3.4-7.7±8.2 mL/mmHgx100, p=0.65), but large artery compliance decreased from 16.1±4.4 to 13.5±3.8 mL/mmHgx10 (p=0.003). Participation in extreme endurance exercise of prolonged duration was associated with acute reductions in large artery compliance, but the time course of this effect remains to be elucidated.

Comparing the Finapres and Caretaker systems for measuring pulse transit time before and after exercise.

We aimed to compare the Finapres system, which is designed for accurate intra-arterial amplitude measurement, to the Caretaker system, which is designed for temporal accuracy of intra-arterial measurement, in regard to measurement of pulse transit time (PTT) at baseline and following an endurance exercise session. Pulse transit time was evaluated between the R-wave of the ECG and the foot of the arterial waveform using either the Finapres (fpPTT) or Caretaker (ctPTT). 23 participants were measured before and after completion of endurance exercise. When comparing PTT values before and after an exercise intervention within devices, ctPTT was significantly different following exercise (P=0.03); however, the Finapres obtained values did not differ significantly. Before exercise, there was no significant relationship between devices, however, after exercise a significant moderate correlation was observed (r=0.45, P=0.02). Significant differences existed between ctPTT and fpPTT (P< 0.001). The Caretaker system appears to be more accurate at detecting changes in PTT occurring as a result of a single aerobic exercise session. This may be due to the servo-controller feedback loop in the waveform contour predicting algorithm within the Finapres system, which is not present in the Caretaker unit. The Finapres system also appears to have an inherent delay in pulse contour reporting.

PP023. Unexpected random urinary protein: creatinine ratio results - Insightsfrom clinician-laboratory medicine collaboration.

INTRODUCTION: Proteinuria assessment is important in pregnancy, particularly in determining whether or not a woman has pre-eclampsia. The random protein to creatinine ratio (PrCr) has been recommended as a confirmatory test for dipstick proteinuria in pregnancy, defined as random PrCr ⩾30mg/mmol. However, it has been our clinical impression that women with normal pregnancy outcomes have fluctuating or persistently elevated PrCr values. OBJECTIVES: As the primary goal of proteinuria testing in pregnancy should be to identify women at increased risk of adverse outcomes, we sought to explore our clinical impression that an elevated PrCr is seen not infrequently in pregnancies with normal outcome. METHODS: In this prospective cohort study, consecutive inpatients or outpatients (attending high-risk maternity clinics) were evaluated at a tertiary care facility. Random midstream urine samples were obtained as part of normal clinical care. Urine protein was measured using a pyrocatechol violet molybdate dye-binding method, and urine creatinine by an enzymatic method, both on an automated analyser (Vitros® 5.1 FS or Vitros® 5600, Ortho-Clinical Diagnostics, Rochester, NY) followed by PrCr calculation. Maternal and perinatal outcomes were abstracted from the hospital case notes. RESULTS: 160 women (81.9% outpatients) were screened at one/more antenatal visits providing a total of 233 samples for analysis. Ninety one (39.1%) samples had a random PrCr ⩾30 mg/mmol. This result was more common when urinary creatinine concentration was <3mM [64 (94.1%)] compared with ⩾3mM [27 (16.4%)], even among the 32 (20.0%) women with known normal pregnancy outcome [(13 (92.9%) vs. 0 (0%), respectively] (Panel A). In dilution studies using the same automated analyser, urinary protein (at a concentration of 0.12g/L) was 'detected' in deionised, double-distilled water. Method-specific re-analysis of data from two other published cohorts from our centre revealed substantially less inflation of PrCr values in dilute 24h urine samples tested using a pyrogallol red dye-binding based protein assay. When results were categorized according to urinary creatinine <3mM vs. ⩾3mM, PrCr ⩾30mg/mmol occurred in 12 (66.7%) vs. 99 (55.3%) respectively (p=0.35) in a 24-h urine completeness cohort and 92 (73.6%) vs. 313 (64.9%) respectively (p=0.07) in a cohort of women hospitalised for pre-eclampsia (Panel B). CONCLUSION: Random urinary PrCr results may be inflated in dilute urines because of overestimation of proteinuria in a common pyrocatechol violet dye-based method. This inflation was reduced but not eliminated when the dye used was pyrogallol red. Analytical methods do matter in the assessment of proteinuria in pregnant women. It may be prudent to consider the potential for falsely positive PrCr ⩾30mg/mmol in dilute urine, and to order PrCr testing on first voided (concentrated) urines whenever possible.

PP024. Random urine albumin: Creatinine ratio in high-risk pregnancy - Is it clinically useful?

INTRODUCTION: The albumin:creatinine ratio (ACr) is the newest of available methods of proteinuria assessment in pregnancy. Published cut-offs for detection of ⩾0.3g/d proteinuria vary from 2mg/mmol to 8mg/mmol. Up to 20% of women have an elevated ACr in pregnancy but normal outcome. In addition, it is our impression that the urine albumin component of the ACr is frequently below the detection limit of the assay. OBJECTIVES: To evaluate the frequency with which a measurable ACr can be obtained in a high-risk outpatient maternity population. METHODS: In this prospective cohort study, consecutive inpatients or outpatients (attending primarily morning high-risk maternity clinics) were evaluated at a tertiary care facility. Random midstream urine samples were obtained as part of normal clinical care. In the hospital laboratory, urinary albumin was measured using an immunoturbidimetric method, and urinary creatinine by an enzymatic method, both on an automated analyser (Vitros® 5,1 FS or Vitros® 5600, Ortho-Clinical Diagnostics, Rochester NY). ACr was calculated for samples with measurable urine albumin, and for samples with albumin below the assay range, ACr was calculated using the assay cut-off for albumin of 6.00mg/L. RESULTS: One hundred and sixty women (81.9% outpatients) were screened at one/more antenatal visits, providing a total of 233 urine samples for analysis. 68 (29.2%) urine samples were dilute (i.e., had urinary creatinine <3mM); only 13 (19.1%) of these had measurable urinary albumin for calculation of the ACr. Overall, 117/233 samples (50.2%) had measurable urine albumin that could be used to calculate the ACr. 76 (65.0%) had ACr >2mg/mmol and 34 (29.1%) had ACr >8mg/mmol. For the 116/233 (49.8%) samples with urine albumin below the assay detection limit, ACr was calculated using 6.00mg/L as the value for urine albumin. All of the 55 dilute samples had an ACr >2mg/mmol and 3 (2.6%) had an ACr >8mg/mmol. If dilute samples were excluded, none of the remaining 61 samples had an ACr value >2mg/mmol. CONCLUSION: Among a population of pregnant women attending primarily morning high-risk maternity clinics, urine is often dilute and urine albumin is often below the assay detection limit. This combination may result in uninterpretable ACr values if an ACr cut-off of 2mg/mmol is used as the decision limit for proteinuria ⩾0.3g/d. ACr may be best performed on first voided (concentrated) urine if ACr is used to assess proteinuria in pregnancy.

PP025. Urinary dipstick proteinuria testing - Does automated strip analysis offer an advantage over visual testing?

INTRODUCTION: The visual urinary test strip is widely accepted for screening for proteinuria in pregnancy, given the convenience of the method and its low cost. However, test strips are known to lack sensitivity and specificity. The 2010 NICE (National Institute for Health and Clinical Excellence) guidelines for management of pregnancy hypertension have recommended the use of an automated test strip reader to confirm proteinuria (http://nice.org.uk/CG107). Superior diagnostic test performance of an automated (vs. visual) method has been proposed based on reduced subjectivity. OBJECTIVES: To compare the diagnostic test properties of automated vs. visual read urine dipstick testing for detection of a random protein:creatinine ratio (PrCr) of ⩾30mg/mmol. METHODS: In this prospective cohort study, consecutive inpatients or outpatients (obstetric medicine and high-risk maternity clinics) were evaluated at a tertiary care facility. Random midstream urine samples (obtained as part of normal clinical care) were split into two aliquots. The first underwent a point-of-care testing for proteinuria using both visual (Multistix 10SG, Siemens Healthcare Diagnostics, Inc., Tarrytown NY) and automated (Chemstrip 10A, Roche Diagnostics, Laval QC) test strips, the latter read by an analyser (Urisys 1100®, Roche Diagnostics, Laval QC). The second aliquot was sent to the hospital laboratory for analysis of urinary protein using a pyrocatechol violet molybdate dye-binding method, and urinary creatinine using an enzymatic method, both on an automated analyser (Vitros® 5,1 FS or Vitros® 5600, Ortho-Clinical Diagnostics, Rochester NY); random PrCr ratios were calculated in the laboratory. Following exclusion of dilute samples with urinary creatinine concentration <3mM (given inflation of PrCr values in dilute urine by our method), diagnostic test properties were determined for visual and automated dipstick proteinuria testing (⩾1+) for detection of a random PrCr ⩾30mg/mmol. RESULTS: 160 women (81.9% outpatients) were screened at one/more antenatal visits, providing a total of 233 urine samples for analysis. Both visual and automated read urinary dipstick testing showed low sensitivity (56.0% and 53.9%, respectively). Positive likelihood ratios (LR+) and 95% CI were 15.0 [5.9,37.9] and 24.6 [7.6,79.6], respectively. Negative LR (LR-) were 0.46 [0.29,0.71] and 0.47 [0.31,0.72], respectively. CONCLUSION: Automated dipstick urinalysis is not more sensitive than visual read urinalysis for detection of proteinuria in a primarily outpatient setting in pregnancy. Both have excellent LR+ but only fair to poor LR- as previously recognised for visual dipstick testing. Performance of automated strip analysis testing may vary with the test strips and analyser used.

PIERS proteinuria: relationship with adverse maternal and perinatal outcome.

OBJECTIVE: To examine the ability of three different proteinuria assessment methods (urinary dipstick, spot urine protein:creatinine ratio [Pr/Cr], and 24-hour urine collection) to predict adverse pregnancy outcomes. METHODS: We performed a prospective multicentre cohort study, PIERS (Preeclampsia Integrated Estimate of RiSk), in seven academic tertiary maternity centres practising expectant management of preeclampsia remote from term in Canada, New Zealand, and Australia. Eligible women were those admitted with preeclampsia who had at least one antenatal proteinuria assessment by urinary dipstick, spot urine Pr/Cr ratio, and/or 24-hour urine collection. Proteinuria assessment was done either visually at the bedside (by dipstick) or by hospital clinical laboratories for spot urine Pr/Cr and 24-hour urine collection. We calculated receiver operating characteristic area under the curve (95% CI) for each proteinuria method and each of the combined adverse maternal outcomes (within 48 hours) or adverse perinatal outcomes (at any time). Models with AUC ≥ 0.70 were considered of interest. Analyses were run for all women who had each type of proteinuria assessment and for a cohort of women ("ALL measures") who had all three proteinuria assessments. RESULTS: More women were proteinuric by urinary dipstick (≥ 2+, 61.4%) than by spot urine Pr/Cr (≥ 30 g/mol, 50.4%) or 24-hour urine collection (≥ 0.3g/d, 34.7%). Each proteinuria measure evaluated had some discriminative power, and dipstick proteinuria (categorical) performed as well as other methods. No single method was predictive of adverse perinatal outcome. CONCLUSION: The measured amount of proteinuria should not be used in isolation for decision-making in women with preeclampsia. Dipstick proteinuria performs as well as other methods of assessing proteinuria for prediction of adverse events.

A systematic review of exercise as a therapeutic intervention to improve arterial function in persons living with spinal cord injury.

STUDY DESIGN: All randomized controlled trials, prospective cohort, case-controlled, pre-post studies and case reports that assessed exercise interventions, which influence arterial structure and function after spinal cord injury (SCI), were included. OBJECTIVE: To review systematically the evidence for exercise as a therapy to alter arterial function in persons with SCI. SETTING: Literature searches were conducted for appropriate articles using several electronic databases (e.g. MEDLINE, EMBASE). METHODS: Three independent reviewers evaluated each investigation's quality, using the Physiotherapy Evidence Database Scale for randomized controlled trials and Downs and Black Scale for all other studies. Results were tabulated and levels of evidence assigned. RESULTS: A total of 283 studies were found through the systematic literature search. Upon review of the articles, 27 were included. The articles were separated into those investigating arterial benefits, resulting from either acute bouts of exercise or long-term exercise interventions. The ability of both acute and long-term exercise interventions to improve arterial structure and function in those with SCI was supported by limited to moderate methodological quality. Upper body wheeling is the most commonly examined exercise therapy for improving arterial function. It appears from the evidence that a variety of exercise interventions, including passive exercise, upper body wheeling, functional electrical stimulation and electrically stimulated resistance exercise, can improve arterial function in those living with SCI. CONCLUSIONS: Although the quality and volume of evidence is low, the literature supports exercise as a useful intervention technique for improving arterial function in those with SCI.

[Coumarin-induced necrosis--a rare complication of oral anticoagulant therapy]. / Necroza cumarinica--complicatie rara a terapiei anticoagulante orale.

Coumarin-induced skin necrosis represents a clinical entity that occurs very rarely, with an approximate incidence of 0.01-0.1% at patients following oral anticoagulant therapy. Most of the cases become clinical manifest between the 3rd and 6th of anticoagulant treatment (there were reports of late onset of skin necrosis after 15 years of anticoagulant therapy) and the most involved areas include breast, buttocks and thighs microcirculation-rich areas. Early symptoms include paresthesia and sensation of tension associated with an erythematous flush in the affected area. Lesions are well demarcated, painful, initially erythematous or hemorrhagic, with the onset of skin necrosis in the end stage. Early lesions can be reversible with the discontinuation of anticoagulant therapy, but skin necrosis can reoccur even without any other coumarin based treatment. We report the case of a 55-year-old female who presented with coumarin-induced skin necrosis affecting the right breast and the right deltoid area.

Intercellular calcium signaling between astrocytes and oligodendrocytes via gap junctions in culture.

To understand further how oligodendrocytes regulate brain function, the mechanism of communication between oligodendrocytes and other cell types needs to be explored. An important mode of communication between various cell types in the nervous system involves gap junctions. Astroglial cells are extensively connected through gap junctions forming the glial syncytium. Although the presence of gap junctions between oligodendrocytes and astrocytes have been well documented, evidence for gap junction-mediated calcium transfer between these two glial populations is still missing. To measure functional coupling between astrocytes and oligodendrocytes and to test whether this coupling is mediated by gap junctions we used laser photostimulation and monitored Ca(2+) propagation in cultures from transgenic animals in which oligodendrocytes express enhanced green fluorescent protein (eGFP). We show that waves of Ca(2+) spread from astrocytes to oligodendrocytes and that these waves are blocked by the broad-spectrum gap junction blocker carbenoxolone, but not the neuron-specific gap junction blocker quinine. We also show that the spread of Ca(2+) waves between astrocytes and oligodendrocytes is bi-directional. Thus, increase of Ca(2+) concentration in astrocytes triggered by surrounding neuronal activity may feed back onto different neuronal populations through oligodendrocytes.

[Left laparoscopic lobectomy]. / Lobectomie stânga pe cale laparoscopica pentru hepatocarcinom dezvoltat pe ficat non-cirotic--prezentare de caz.

The authors present a case of a 61-year-old patient diagnosed with a hepatic tumor located in the second segment with expression on the anterior (diaphragmatic) side. The diagnosis and treatment applied in this case are presented. The specific feature was the surgical intervention because it was performed a left laparoscopic lobectomy using the LigaSure Atlas sealer. The short hospitalization period and quick recovery make this method an efficient one, with a wide application. Laparoscopic surgery started with a cholecystectomy which was performed by Mouret in 1987. Since then it knew a continuous development with progressive extension of this type of approach to almost all of the digestive tract organs, cavitary as well as parenchymal organs like liver or spleen. Second and third bisegmentectomy was made for the first time in 1996 by Azagra. The segments II, III, IVb, V and VI are the most frequently resected in hepatic laparoscopic surgery. Surgeons are more interested in left hepatic lobe diseases because of the anatomy which makes the approach of the biliary and blood vessels easier. Lately we assist to an increase of hepatic cancer incidence, primary or secondary; therefore we consider necessary the development of hepatic laparoscopic surgical techniques.

Expectant management of severe preeclampsia remote from term: a structured systematic review.

OBJECTIVE: To compare outcomes associated with expectant vs. interventionist care of severe preeclampsia in observational studies. DATA SOURCES: Medline (01/1980-07/2007), bibliographies of retrieved papers, personal files, Cochrane Database of Systematic Reviews. STUDY SELECTION: Expectant or interventionist care of preeclampsia at <34 wk. TABULATION, INTEGRATION, RESULTS: Data abstraction independently by two reviewers. Median [IQR] of clinical maternal/perinatal outcomes presented. RESULTS: 72 publications, primarily from tertiary care centres in Dutch and developed world sites. Expectant care of severe preeclampsia <34 wk (39 cohorts, 4,650 women), for which 40% of women are eligible, is associated with pregnancy prolongation of 7-14 d, and few serious maternal complications (median <5%), similar to interventionist care (2 studies, 42 women). Complication rates are higher with HELLP <34wk (12 cohorts, 438 women) and severe preeclampsia <28wk (6 cohorts, 305 women), similar to interventionist care (6 cohorts, 467 women and 2 cohorts, 70 women, respectively). Expectant care of HELLP <34 wk (12 cohorts, 438 women) is associated with fewer days gained (median 5), but more serious maternal morbidity (e.g., eclampsia, median 15%). More than half of women have at least temporary improvement of HELLP. In the developed world, expectant (vs. interventionist) care of severe preeclampsia or HELLP <34 wk is associated with reduced neonatal death and complications. Stillbirth is higher in Dutch and developing world sites where viability thresholds are higher. For preeclampsia <24wk (4 cohorts), perinatal mortality is >80%. No predictors of adverse maternal/perinatal outcomes were identified (13 studies). CONCLUSIONS: Future research should establish the best maternal/fetal monito regimen and indications for delivery with expectant care. A definitive RCT is needed.

Sudden infant deaths in sitting devices.

BACKGROUND: As episodes of decreased oxygenation levels have been recorded in premature infants placed in car seats, it is believed that these infants are at risk of life-threatening events and death. No data on the prevalence of such infant deaths are available. The aim of our study was to determine the incidence of sudden deaths in infants occurring in sitting devices in a whole population and to determine whether premature infants account for a disproportionate number of these deaths. DESIGN: Retrospective population-based cohort study reviewing all cases of sudden unexpected death in infants between birth and 1 year of age that occurred in the province of Quebec between January 1991 and December 2000. RESULTS: Of the 508 deaths reviewed, 409 were unexplained and 99 were explained after investigation. Seventeen deaths occurred in a sitting device, of which 10 were unexplained. There was no excess of premature infants dying. However, there was an excess of infants of less than 1 month of age found to have died in a sitting position in the unexplained death group. In addition, three infants who died in a sitting position had an increased risk of upper airway obstruction. CONCLUSION: Although very few deaths occurred in car seats, our results suggest that caution should be used when placing younger infants in car seats and similar sitting devices, whether the infants have been born prematurely or not. We also recommend that more attention be given to infants at increased risk of upper airway obstruction.