Disaster nursing in the Oklahoma City bombing

The Oklahoma City Federal Building disaster quickly changed a routine day of eye surgical procedures into a chaotic trauma center for the victims with not only eye injuries, but multiple deep lacerations and other injuries. The devastating and disruptive effect of the bombing was stressful for the nursing staff who became disaster survivors of the emotional trauma involved.

Neonatal vitamin K administration and in vivo somatic mutation

The glycophorin A (GPA) mutation assay was used to examine the risk of in vivo somatic mutation in infants following neonatal administration of vitamin K. The assay assesses damage to erythroid stem cells by measuring the frequency of NO and NN variant red cells of MN blood group heterozygotes using FACS analysis. Blood samples were obtained from 178 infants aged between 10 and 183 days. Twenty-six children were excluded from study having received a blood transfusion. Sixty-four of the remaining 152 infants were of the MN phenotype, samples from whom were analysed using the assay system, providing the first data of NO and NN variant frequencies (vfs) in children aged less than 1 year. Twenty of these 64 infants received vitamin K orally (group A), 17 intramuscularly (group B) and 25 intravenously (group C). Results were compared with those from a reference population of children aged 1-15 years. There were no significant differences in NO, NN and total vf between any of groups A, B and C. For all groups both NO and total vf were significantly lower than those for the control population. This result is of some interest and clearly warrants further investigation. NN and total vfs were greater than the 95th percentile for the pooled data from groups A, B and C in three instances, one in each group. It was thus not possible to demonstrate an association between the route of vitamin K administration and an increase in mutation at the GPA locus.

Allergic conjunctivitis disorders

Allergic conjunctivitis is one of the most common disorders of the external eye. Hypersensitivity of the conjunctiva to foreign substances is characterized by discharge, redness, itching, irritation, swelling, light sensitivity, and tearing. The tear fluid contains a small amount of eosinophils and histamine. Allergic eye conditions can be classified into four categories. They are hay fever conjunctivitis, vernal conjunctivitis, atopic keratoconjunctivitis, and giant papillary conjunctivitis.

Ocular injuries from driver's air bag

The air bag was introduced in automobiles as a device to reduce serious injuries and fatalities from front angle collisions. Although air bags have reduced the incidence of brain injury in motor vehicle accidents there are published reports of ocular trauma to the driver, secondary to air bag inflation.

Insulin dependent diabetes in children under 5: incidence and ascertainment validation for 1992

OBJECTIVE

To establish the incidence of insulin dependent diabetes diagnosed in children under 5 years of age in the British Isles during 1992, comparing the national and regional results with those of our 1988 national study, and estimating the 1992 study's level of case ascertainment.

DESIGN

Active monthly reporting of cases by consultant paediatricians through the framework of the British Paediatric Surveillance Unit, with additional reports from specialist diabetes nurses and regional health authorities.

SUBJECTS

All children diagnosed under the age of 5 years with primary insulin dependent diabetes from 1 January to 31 December 1992 (inclusive) and resident in the British Isles at diagnosis.

RESULTS

387 children (208 boys and 179 girls) were confirmed to have insulin dependent diabetes, giving a national incidence of 9.3/100,000/year. This is similar to the 9.9/100,000/year found in 1988. Three sample capture-recapture analysis, which could only be applied across the 12 (out of 18) regions supplying regional information to the study, suggested ascertainment rates of 78% for the British Paediatric Surveillance Unit, 67% for specialist nurses, 69% for regional health authorities, and 99% for the aggregated registry.

CONCLUSIONS

The national incidence of diabetes in the under 5s in the British Isles did not differ between 1988 and 1992. Nearly complete (99%) ascertainment of cases was possible only for regions for which three data sources were available. Capture-recapture analysis highlighted both the need for more than one data source and for each data source to be complete for the whole study area.

Complications of indirect laser photocoagulation

Potential complications of indirect laser photocoagulation for retinopathy of prematurity are: corneal burn; iris burn; lens burn; choroidal hemorrhage or neovascularization; inadvertent photocoagulation of fovea; preretinal membrane formation; late onset retinal detachment; and retinal, preretinal, or vitreous hemorrhage.

Fructosamine and glycated haemoglobin in the assessment of long term glycaemic control in diabetes

Fructosamine and glycated haemoglobin were measured simultaneously in 147 children with diabetes. If glycated haemoglobin is considered as the 'gold standard' for long term glycaemic control, then fructosamine is a poor indicator of actual glycated haemoglobin values, with wide 95% confidence (fiducial) limits. This shows that it is impossible to accurately predict glycated haemoglobin concentrations and therefore, by implication, longer term glycaemic control, from measurements of fructosamine. As the major studies on the prevention of microvascular complications in diabetes have used glycated haemoglobin levels to assess glycaemic control, it is suggested that this measurement should be used in all children with diabetes in preference to the measurement of fructosamine.

Experimental studies of infant-parent co-sleeping: mutual physiological and behavioral influences and their relevance to SIDS (sudden infant death syndrome)

We hypothesize that maternal sensory exchanges, likely involving a combination of heat, sound, gas, smells, movement, and touch, induce important physiological changes, especially in the healthy infant's arousal patterns, body temperature, and sleep architecture as defined by standard physiological measures. We summarize the results of two preliminary physiological studies, and some early data from a third, in which mothers and infants are monitored using standard polysomnographic techniques as they sleep in the same bed, and then in adjacent rooms. Our data suggest that infant-parent co-sleeping alters the infant's sleep experience as, for example, the characteristics of arousals, the frequency and duration of nursing, infant sleep position and the number of maternal inspections. For example, while sleeping in the same bed, mothers nurse their infants three times more frequently than they do while their infants sleep in an adjacent room. These preliminary data demonstrate significant differences between routine co-sleeping and solitary sleeping environments. This work underscores the importance of studying infant sleep as it unfolds in the co-sleeping environment, the environment within which it evolved over at least 5 million years of human evolution. Should our preliminary findings be confirmed in future studies they will provide a beginning point for considering additional, possibly unconventional ways of helping to reduce SIDS risks.

Treatment of advanced acute leukaemia with allogeneic bone marrow transplantation from unrelated donors

Bone marrow transplantation from a histocompatible sibling donor may produce complete remission in patients with induction failure or relapsed acute leukaemia. Through the National Marrow Donor Program, histocompatible bone marrow from unrelated donors has become available for high-risk patients. In this study we analyse the results of matched unrelated bone marrow transplant in 55 patients with highly advanced acute myelogenous and acute lymphoblastic leukaemia. 28 patients with advanced acute lymphoblastic leukaemia and 27 patients with advanced acute myelogenous leukaemia, age 2-51, were treated with high-dose chemoradiotherapy and transplantation of 6/6 HLA matched (n = 46) or one antigen mismatched (n = 9) unrelated donor bone marrow. After a median follow-up of 36 months, 13 patients remain alive 17-74 months after transplant for a 2-year actuarial disease-free and overall survival of 23 +/- 12% (median disease-free survival 3.5 months). The actuarial risk of relapse is 24 +/- 16% at 1 year. Moderate to severe graft-versus-host disease occurred in 27/47 evaluable patients (57%). Significant prognostic factors for poor leukaemia-free survival include age > 21, abnormal karyotype, and active leukaemia at the time of transplant. Other pretreatment characteristics such as gender or type of leukaemia were not significant prognostic factors. Our results show that matched unrelated bone marrow transplant for patients with advanced acute leukaemia may provide long-term leukaemia-free survival, but transplant-related complications produce a significant impact on survival with older age and adverse disease characteristics predicting for poor prognosis.

Unrelated donor bone marrow transplants in children

Only a small proportion of children who might benefit from bone marrow transplant (BMT) have an HLA-identical sibling. To provide this potentially curative therapy to patients without a matched related donor, marrow transplants using less well matched related donors or unrelated donors (identified through computerized donor registries) have been performed. We report the outcome of 24 consecutive unrelated donor BMT's performed on children. Eligible diagnosis included acute leukemia (AL) (n = 15), chronic myelogenous leukemia (CML) (n = 4), myelodysplastic syndrome (MDS) (n = 3), and severe aplastic anemia (SAA) (n = 2). All donor/recipient pairs were sero-matched at 5 or 6 of the 6 HLA A, B, and DR antigens. Several different preparative regimens were used, but fractionated total body irradiation (TBI) was used in 20 patients. All recipients received graft-versus-host-disease (GVHD) prophylaxis with cyclosporine-A (CSA), four with short course methotrexate (MTX), 14 in combination with short course MTX and methylprednisolone (MPS), and five in combination with a mouse monoclonal antibody to CD5, coupled to the A-chain of ricin (Xomazyme-65). One patient received CSA and MPS alone after a T-cell depleted marrow transplant. Twenty of 23 evaluable recipients engrafted (87%). Two patients with CML never engrafted and had autologous marrow recovery, one patient with SAA died at 128 days without evidence of engraftment, and there was one early death at day + 9. Fourteen of 20 patients (70%) with stable donor-derived hematopoiesis developed significant acute GVHD > or = grade II). Eleven of 15 engrafted patients who survived > 100 days after BMT developed chronic GVHD (73%).(ABSTRACT TRUNCATED AT 250 WORDS)

Drug abuse and the rapid eye test

Drug effects contribute to impaired eye movements and visual information processing. Only a small percentage of clinical conditions can cause a positive rapid eye test, therefore, drug use must be suspected and should be confirmed by body fluid analysis. A drug may not reach the urine for one to two hours, while eye signs occur within fifteen minutes after sniffing, inhaling, or injecting the drug. The rapid eye test is inexpensive, nonintrusive, and detects the actual influence of the drug on the body.

Serum Lp(a) lipoprotein concentration and outcome of thrombolytic treatment for myocardial infarction

BACKGROUND

Lp(a) lipoprotein has structural homology with plasminogen and has been shown to inhibit plasminogen activation in vitro.

OBJECTIVE

To determine whether the serum concentration of Lp(a) lipoprotein present when streptokinase was given in acute myocardial infarction influenced the outcome as judged by electrocardiographic methods.

PATIENTS AND DESIGN

Serum Lp(a) lipoprotein concentration was measured in 135 consecutive patients admitted with a diagnosis of acute myocardial infarction who received streptokinase treatment. Recovery from myocardial injury was assessed by the reduction in the sum of ST segment elevation measured from the J point (STJ) in the electrocardiogram immediately before streptokinase was given compared with that three hours later.

RESULTS

The serum Lp(a) lipoprotein concentrations were measured within 12 hours of the onset of symptoms of myocardial infarction and were higher than in healthy reference populations. Recovery from myocardial infarction could be assessed from the STJ in 116 patients (86% of the series). Those in whom it could not had bundle branch block, left ventricular hypertrophy, did not survive three hours, or had started intravenous nitrate treatment or some other clinical procedure before or at the time the second electrocardiogram was to be recorded. Patients with reductions in STJ after streptokinase that were > 4 mm (the median decrease) had mean (range) serum Lp(a) lipoprotein concentrations of 41.0 (0.8-220) mg/dl and those with a smaller reduction in STJ had concentrations of 29.1 (1.7-151) mg/dl. The difference was not statistically significant.

CONCLUSION

In this study Lp(a) lipoprotein concentration did not significantly influence the outcome of thrombolytic treatment with streptokinase.

Immunochemical studies of heat-shock protein 80 of Histoplasma capsulatum

A monoclonal antibody (MAb) of the IgG1 subclass, with greater activity to the yeast than the mycelial phase of Histoplasma capsulatum was raised and was found to predominantly recognize a molecule of 80 kDa by immunoblot. Enzymatic deglycosylation and chemical degradation, followed by reaction with MAb 69F on Western blots showed the molecule to be O-glycosylated, and immunofluorescence studies showed it to be heat-inducible and its distribution to be cytoplasmic and possibly cell membraneous. There was no apparent staining of the cell wall. Culture filtrate was positive by ELISA and Western blot when reacted with MAb 69F. In addition, ELISA and Western blot demonstrated that a similar epitope was present in other fungal species. The glycoprotein had a pI of approximately 4.7. N-terminal amino acid sequencing revealed this molecule to be homologous to members of the heat-shock protein 70 family and to a recently described antigen from H. capsulatum.

Parent-infant cosleeping: the appropriate context for the study of infant sleep and implications for sudden infant death syndrome (SIDS) research

Nearly all laboratory research on human infant sleep assumes that solitary sleeping is the normal and desirable environment. Yet solitary sleeping in infancy is a very recent custom limited to Western industrialized societies, and most of the world's people still practice parent-infant cosleeping. A hypothesis is presented that cosleeping provides a sensory-rich environment which is the more appropriate environment in which to study normal infant sleep. In addition, two preliminary, in-laboratory, polygraphic investigations of mother-infant cosleeping are reported in normal infants within the peak age range for sudden infant death syndrome (SIDS). Five mother-infant pairs coslept for 1 night in the first study; in the second, three additional pairs slept separately for 2 nights and coslept the third consecutive night. The results suggest that cosleeping is associated with enhanced infant arousals and striking temporal overlap in infant and maternal arousals. Infant sleep also showed subtle alterations with cosleeping, as manifested in increased overlap with corresponding maternal sleep stages and decreased amount of Stage 3-4. These are the first in-laboratory investigations of parent-infant cosleeping. The implications of the hypothesis and preliminary results for research on the normal development of infant sleep and on SIDS are discussed.

Vision screening for infants and preschool children

Eye examinations and vision screening at the recommended ages are preventive health measures that can yield immense benefits in preventing visual loss. Educational programs can be designed to provide parents and healthcare workers about children's eye screening and referral procedures.

HLA mismatching and cytomegalovirus infection as risk factors for transplant failure in cyclosporin-treated renal allograft recipients

In a study of the effects on renal allograft survival of HLA mismatching, mismatching for cytomegalovirus (CMV) antibody status, and post-transplant CMV infection, 148 cyclosporin-treated renal transplant recipients were given kidneys optimally matched for HLA-A, -B, and -DR antigens but not matched for CMV antibody status. Mismatching for HLA-B and -DR antigens was associated with a greater number of rejection episodes and a lower graft survival, but mismatching for CMV antibody status and posttransplant primary or recurrent CMV infection exerted no effect on graft survival. The role of matching of renal transplant recipients and donors for CMV antibody status in preference to HLA matching (proposed as a means of reducing the mortality associated with primary CMV infection) is discussed.

Analysis of pre- and post-donation haematological values in plateletpheresis donors

Pre- and post-donation haematological values were measured in 112 donors undergoing plateletpheresis using Haemonetics PCS machines. We found significant differences between pre- and post-donation means for males (M) and females (F) for haemoglobin (M: pre 14.73 g/dl, post 15.25 g/dl; F: pre 13.57 g/dl, post 13.94 g/dl), haematocrit (M: pre 0.418, post 0.431; F: pre 0.389, post 0.4), total protein (M: pre 73.1 g/l, post 66 g/l; F: pre 72.2 g/l, post 63.7 g/l) and albumin (M: pre 42.2 g/l, post 38.5 g/l; F: 41.4 g/l, post 37 g/l). Significant differences were also seen for platelet count (pre 258.6 x 10(9)/l, post 229.2 x 10(9)/l), total white cells (pre 5.3 x 10(9)/l, post 5.55 x 10(9)/l) and neutrophils (pre 3.15 x 10(9)/l, post 3.33 x 10(9)/l), but there were no differences between males and females. This information was of value in establishing post-donation reference ranges which could be utilised when reviewing the suitability of donors for subsequent donations.

Assessment and education of the diabetic with vision loss

An educational program is essential for patients whose diabetes is complicated by significant visual loss. Nurses have a unique opportunity to assess the patient's learning needs and to provide pertinent educational experiences for the patient. A check off educational assessment tool can provide a quick survey of patient teaching and discharge needs. A patient teaching record can be utilized to document when and what is taught as well as patient response. A teaching packet can be designed that contains the purpose, teaching objectives, methods of teaching, and available resources for the patient. Appropriate tools will encourage staff involvement in patient teaching and documentation by making the process easier.

Aging and the visual system

The ocular aging process involves everyone. Misconceptions about visual changes from aging versus visual changes from a disease have resulted in needless vision loss for many in the older population. Lack of understanding and misinformation may cause a delay in seeking medical attention for diagnosis and treatment.

Driving performance in persons with mild senile dementia of the Alzheimer type

OBJECTIVE

To assess the effect of mild senile dementia of the Alzheimer type (SDAT) on driving ability.

DESIGN

Cross-sectional study with correlation analysis.

SETTING

A university-based Alzheimer's Disease Research Center, which evaluates community-living older adult volunteers, and the university's Program in Occupational Therapy.

PARTICIPANTS

Healthy elderly controls (n = 13) and subjects with very mild (n = 12) and mild (n = 13) SDAT. Dementia severity was staged by the Washington University Clinical Dementia Rating.

MEASUREMENTS

The driving ability of participants on the in-car road test was scored independently by a driving instructor, blinded to the study design and to the dementia status of the subjects, and an unblinded occupational therapist. Interview-based perceptions of driving ability were obtained independently from the subjects and their collateral sources. Attentional and visuospatial performances of the subjects were assessed prior to the road test.

RESULTS

All control and very mild SDAT subjects were judged to be "safe" drivers (ie, passed the in-car road test), but five (40%) of the mild SDAT subjects had driving impairment sufficient to "fail" the road test. Neither subject self-assessment nor caregiver perceptions of driving ability consistently predicted driving performance. Attentional task performance correlated well with road test results.

CONCLUSIONS

Some SDAT subjects retain "safe" driving skills. The greater the dementia severity, the greater the likelihood of poor driving ability. Performance-based (road test) evaluations are necessary to properly determine driving skills at present, but attention and other cognitive screening measures should be developed.

Does elective cryopreservation of all embryos from women at risk of ovarian hyperstimulation syndrome reduce the incidence of the condition?

OBJECTIVES

To analyse the incidence and factors associated with the ovarian hyperstimulation syndrome (OHS) in our IVF/GIFT programme before and after the introduction of a strategy to cryopreserve all embryos from women judged to be at risk.

DESIGN

Two hundred forty-one consecutive IVF/GIFT cycles from January to December 1989.

SETTING

Specialist fertility unit, Manchester, UK.

INTERVENTIONS

Pituitary suppression was effected by a daily subcutaneous injection of buserelin (500 micrograms) beginning 7 days before the expected menses. The ovarian stimulation was with variable amounts of human menopausal gonadotrophin. Ovulation was induced with 10,000 i.u. human chorionic gonadotrophin (hCG). From January to May (period A), gametes/embryos were replaced and 2000 i.u. hCG given, irrespective of the serum oestradiol (E2) concentration. From June to December (period B), all the embryos from women with an E2 > 3500 pg/ml on the day of ovulatory trigger were electively cryopreserved.

MAIN OUTCOME MEASURES

Serum E2, features of moderate or severe OHS, clinical pregnancies.

RESULTS

The OHS occurred in 10/105 (9.5%) and 12/136 (8.8%) cycles in periods A and B, respectively. Fewer women (6% versus 60%, P < 0.05) who had their embryos cryopreserved developed severe OHS compared with women with an E2 > 3500 pg/ml who became pregnant after gamete/embryo transfer in period A. The main factors associated with the development of OHS were serum E2 concentrations > 3500 pg/ml, whether gamete/embryos were replaced and the additional hCG given, the occurrence of a pregnancy and the presence of polycystic ovary disease.

CONCLUSION

The elective cryopreservation of all embryos from women with high E2 levels reduced the severity, but not the incidence of symptomatic OHS.

Human ehrlichiosis--an overview

Canine ehrlichiosis, previously thought to be restricted to dogs, has gained prominence in the human population since 1986. In the United States, human ehrlichiosis is a newly recognized disease ranging from a mild infection to a severe life threatening or fatal disease. Since antibody titers were found to be highest to E. canis in human ehrlichiosis patients, it was believed that E. canis or a closely related species was the etiologic agent. Investigators from the Centers for Disease Control recently have isolated a bacterium believed to be the etiologic agent of human ehrlichiosis and proposed the name Ehrlichia chaffeensis. Human cases of the disease have been identified primarily in the southeastern and south-central areas of the United States. Although relatively few cases are diagnosed, Oklahoma, according to one source, has been found to have the highest incidence rate. The human disease could be misdiagnosed as Rocky Mountain spotted fever, murine typhus fever, or Q fever.

Prediction of birthweight by fetal ultrasound biometry

A total of 104 women with singleton pregnancies who were delivered between 37 and 42 weeks gestation had ultrasound scans during the fortnight before delivery. The biparietal diameter (BPD), abdominal circumference (AC) and femur length (FL) were measured in all cases. Estimation of fetal weight (EFW) was done by four different methods: using AC alone, AC/BPD, AC/FL and AC/BPD/FL. Results were compared with values of actual birthweights at delivery. There was no significant difference between the mean birthweights of the 47 boy and 57 girl fetuses studied. The EFW(Shepard) method showed the least bias overall: mean percentage error 1.7%, standard deviation (SD) 10.6%. The other three methods significantly underestimated birthweights on average: EFW(Deter), mean error 2.2%, SD 9.3%, p < 0.02; EFW(Campbell), mean error 5.4%, SD 9.5%, p < 0.001; EFW(Hadlock), mean error 5.6%, SD 9.3%, p < 0.001. The percentage error in each group was significantly negatively correlated (p < 0.001) with the scan-delivery interval. Two new equations were generated which gave more accurate predictions for the cases under study using AC, BPD and FL as a combination and also in addition to scan-delivery interval (SDI) in days.

Eyeglasses and common complaints

About one-half of the population wear eyeglasses. For them, a pair of eyeglasses is a necessary aid and when properly fit, can provide clear and comfortable vision for a variety of daily activities.

Ophthalmic nursing assessment

This article is written to assist the ophthalmic nurse in performing a basic assessment of the eye and provide a system for easy documentation. Many nursing physical assessment forms are developed to collect and organize data. However, there is very little published in gathering pertinent data on the ophthalmic patient in either the outpatient or inpatient setting.

Renal carcinoma in patients undergoing nephrectomy: analysis of survival and prognostic factors

A series of 155 patients who underwent nephrectomy for renal carcinoma between 1965 and 1985 at Manchester Royal Infirmary were analysed for survival in relationship to presenting features, surgical staging and histopathology. Univariate and multivariate analyses were carried out. Five-year survival estimates for stage 1 disease were 81%, for stage 2 disease 65%, for stage 3 disease 39% and for stage 4 disease 6%. An erythrocyte sedimentation rate (ESR) greater than 30 mm/h was associated with worse survival and a history of hypertension was associated with better survival. Renal vein invasion alone was related to worse survival. Perinephric fat invasion was also associated with worse survival and this association in the multivariate analysis was more significant than expected, suggesting that the principles of radical surgery should be observed. The presence of granular cells as opposed to clear cells worsened survival. Patients with papillary tumours had a better survival than those with solid tumours.

The complex visual task of driving

Inadequate vision as a cause of traffic accidents hasn't received a lot of publicity. Good vision is required to estimate automobile speeds, see potential danger from the side, and judge distance.

Does catheter immobilization reduce exit-site infections in CAPD patients?

This study was undertaken to ascertain the effectiveness of an immobilization device in reducing exit site infections (ESI) in CAPD patients, and whether immuno-suppressive therapy, diabetes, disconnect system and Staphylococcus aureus nasal carriage had any bearing on the incidence of ESI. Sixty-six patients having a Tenckhoff catheter placement were randomly allocated into one of three groups; immobilizer, tape and non-immobilized group. The groups were monitored for the incidence of ESI over a total period of 347 patient months. The results show no significant difference in infection rates between the three groups, nor do the factors mentioned have any bearing on ESI rate. Whilst immobilization is important, the ineffectiveness of this device was probably related to its design problem.

Vision and migraine

Migraine is classified into four basic categories: common, classic, cluster, and complicated. Ocular migraine is a periodic loss of vision in one eye typically lasting 30 minutes or less. Ophthalmoplegia is a severe ipsilateral hemicranial headache that is preceded by aura of lightning flashes and expanding circles of light, accompanied by temporary ocular motor nerve palsies.

Serum lipoprotein(a) in patients heterozygous for familial hypercholesterolemia, their relatives, and unrelated control populations

Serum lipoprotein(a) (Lp[a]) levels were significantly higher in 89 patients with heterozygous familial hypercholesterolemia (FH) (geometric mean, 22.7 mg/dl) than in 109 normocholesterolemic controls (10.0 mg/dl, p less than 0.05) and 40 controls (9.1 mg/dl, p less than 0.05) with similarly elevated low density lipoprotein cholesterol levels due to other primary hypercholesterolemias. To provide further evidence that the increased serum Lp(a) concentration was due to inheritance of the FH gene, 24 unaffected first-degree relatives were compared with their FH probands. Serum Lp(a) in affected individuals was significantly greater than in unaffected relatives (geometric means, 26.5 versus 13.7 mg/dl, respectively; p less than 0.05). Family membership exerted an effect on serum Lp(a) concentrations, indicating that other genetic influences were also operating, as is known to be the case in general populations. Serum Lp(a) in 30 of the FH patients, who had coronary heart disease, was not significantly different from 30 age- and sex-matched controls with FH but with coronary heart disease (geometric means, 23.6 versus 24.7 mg/dl, respectively). FH is associated with an increase in serum Lp(a). Elevated serum Lp(a) concentrations should probably now be regarded as a component of the clinical syndrome of FH. However, within our FH population Lp(a) did not distinguish those with clinically overt coronary heart disease from those without the disease.

Clinical predictors and radiological reliability in atlantoaxial subluxation in Down's syndrome

Clinical signs and symptoms that might predict atlantoaxial subluxation were studied prospectively in 135 of 180 children with Down's syndrome aged 6-14 years who form the Hester Adrian Research Centre cohort. Lateral radiographs of the cervical spine were taken in flexed, extended, and neutral positions, and the percentage of abnormalities in each view was 14, 10, and 10%, respectively. Gait was the only significant clinical predictor. The relative risk of having an abnormal neck radiograph with an abnormal gait was 2.91 (95% confidence interval (CI) 1 to 8). The sensitivity was 50% and the specificity 81%. Nineteen children had repeat radiographs to assess the reliability of radiological diagnosis. Six had abnormalities; five of 19 (26%) had an abnormality on the first radiograph, and four of 19 (21%) had an abnormality on a second radiograph, but only three (15%) had an abnormality on both occasions in any view (95% CI 0 to 25). We conclude that radiographs of the cervical spine are unreliable at identifying atlantoaxial subluxation in children with Down's syndrome, and we failed to identify any reliable clinical predictor.

Life events and low birthweight--analysis by infants preterm and small for gestational age

Social stress was assessed in 92 women with low-birthweight babies and 92 controls using the detailed LEDS measure of life events and severe chronic difficulties. The low-birthweight group was divided into preterm delivery (n = 40), small for gestational age (SGA) (n = 40) and mixed groups. Multivariate analysis was performed using a binomial-logit model to examine whether social factors were independently and significantly associated with low birthweight once the effect of demographic factors, obstetric factors and smoking/drinking were taken into account. Comparison of preterm births with controls indicated that three factors were significantly associated: a previous low-birthweight baby, severe life event/difficulty and bleeding during pregnancy. For SGA babies the factors were: previous low-birthweight baby, low social support and smoking. By using a reliable measure of life events and adequate numbers of low-birthweight babies, this study overcame the potential inaccuracies of previous studies and indicates a more specific relation between social stress and low birthweight.