The quality of routine examinations of the newborn performed by midwives and SHOs; an evaluation using video recordings

OBJECTIVE

To evaluate the quality of the routine examination of the newborn as carried out by senior house officers (SHOs) and midwives.

DESIGN

Randomised controlled trial set in a district general hospital in Southeast England. Eligible babies were randomised to a midwife (11) or an SHO (8) who were then video recorded undertaking the routine newborn examination.

MAIN OUTCOME MEASURES

Quality of 62 observed technical and communication components of the newborn examination, as agreed between independent consultant paediatrician and senior midwife raters.

RESULTS

Major differences were found in the rated quality of examinations between midwives and SHOs for the examinations of the heart and lungs, for the overall quality of the examination, and in areas of communication skills. Quality of examination of the hips was assessed as poor for both professional groups. Where there were significant differences between examiners, the quality of the midwives' examinations was higher. Inter-rater agreement between the consultant paediatricians and senior midwives ranged from excellent to poor for different items of the examination with a mean kappa value of 0.42 across all items indicating moderate agreement.

CONCLUSIONS

The quality of midwife examinations exceeded that of SHOs. All midwives who examine receive formalized training in the examination of the newborn; SHOs may benefit from similar specific training. Training for both professional groups may need to be reviewed, particularly in relation to agreement on 'gold standards' for the screening of developmental dysplasia of the hip.

Routine examination of the newborn: the EMREN study. Evaluation of an extension of the midwife role including a randomised controlled trial of appropriately trained midwives and paediatric senior house officers

OBJECTIVES

To assess the implications and cost-effectiveness of extending the role of midwives to include the routine (24-hour) examination of the healthy newborn usually carried out by junior doctors.

DESIGN

The study included a prospective randomised controlled trial (RCT) with mother and baby dyads randomised to either senior house officer (SHO) or midwife for the routine examination of the newborn. Midwives and SHOs were also videoed while performing the examinations and the videos were rated by an independent consultant and senior midwife. In addition extensive interviews, surveys, consultations and assessments were carried out.

SETTING

A District General Hospital (for the RCT), a London Teaching Hospital, general practices and mothers' homes (for interviews); questionnaires were sent to all maternity units in England (for the National Survey).

PARTICIPANTS

A total of 826 mother and baby dyads in a District General Hospital in south-east England. Midwives and SHOs, as well as midwifery managers, paediatric consultants; general practitioners (GPs) and representatives of key organisations.

INTERVENTIONS

A routine examination of a newborn baby was carried out at about 24 hours from birth and a further examination for half the babies in each group, at 10-days at home by the community midwife.

MAIN OUTCOME MEASURES

Referrals assessed as appropriate and as major or minor by three independent consultants. Problems identified during the first year of life assessed as identifiable at 24 hours. Quality assessment by video against an agreed written proforma. Maternal satisfaction. Opinion of professionals and mothers about aspects of the examination.

RESULTS

There was no statistical difference between SHO and midwife examinations in appropriate referral rates to hospital or community or in inappropriate referral rates to hospital. Videoed assessments were assessed as carried out more appropriately by the midwives than by the SHOs. Overall maternal satisfaction was high and higher when a midwife rather than an SHO examined. Few new health problems were identified at the 10-day examination. From the National Survey, it was estimated that about 2% of babies in England are examined by a midwife. If midwives were to examine all babies where there were no complications of birth or antenatal history, there would be savings of about 2 pounds per baby born, equivalent to savings of 1.2 pounds million nationally. Were midwives to examine all babies on normal wards savings would increase to about 4.30 pounds per baby born or 2.5 million pounds nationally. Representatives of the professional bodies were of the opinion that having trained midwives carrying out the examination would be valuable.

CONCLUSIONS

All component aspects of the study were consistent in showing benefits or at least no significant barriers to suitably qualified, trained midwives carrying out the examinations. Developing the role of the midwife to include examination of the newborn is likely to result in improved quality of examinations and higher satisfaction from mothers. It would slightly reduce overall health service costs, with some increased resources needed by midwifery departments, and some decrease in resource needs of paediatric departments. There is a need for further research into the value of the examination being carried out at home rather than in hospital; the overall unsatisfactory quality of the examination of the hips; and appropriate inclusion criteria for which babies' midwives should examine.

A new approach to extending the wheat marker pool by anchored PCR amplification of compound SSRs

A study was undertaken to determine the utility in bread wheat of anchored PCR for the development of single locus SSR markers targeted at compound repeat motifs. In anchored PCR, microsatellite amplification is achieved using a single primer complementary to the flanking sequence, and one which anchors to the repeat junction of the compound SSR. The recovery rate of useable markers was found to be similar (43%) to that reported for conventionally generated SSRs. Thus, anchored PCR can be used to reduce the costs of marker development, since it requires that only half the number of primers be synthesised. Where fluorescence-based platforms are used, marker deployment costs are lower, since only the anchoring primers need to be labelled. In addition, anchored PCR improves the recovery of useful markers, as it allows assays to be generated from microsatellite clones with repeat sequences located close to their ends, a situation where conventional PCR amplification fails as two flanking primers cannot be designed. Strategies to permit the large-scale development of compound SSR markers amplified by anchored PCR are discussed.

Tremor, ataxia and dementia in older men may indicate a carrier of the fragile X syndrome

Recently it has been reported that late-onset tremor, gait unsteadiness and dementia can be associated with brain atrophy in males of normal intelligence and the pre-mutation carrier state of the fragile X syndrome. We have shown, by means of a telephone survey, that this association is probably causal rather than coincidental. These findings have uncovered another testable cause of late-onset neurological symptoms in males, which also has serious genetic implications for their daughters who are at risk of having sons with full mutations causing mental handicap - the fragile X syndrome.

Monitoring the coral disease, plague type II, on coral reefs in St. John, U.S. Virgin Islands

In July 1997, conspicuous white patches of necrotic tissue and bare skeleton began to appear on scleractinian corals in several bays around St. John, US Virgin Islands. Analysis of diseased coral tissue from five different species confirmed the presence of a Sphingomonas-like bacterium, the pathogen for plague type II. To date, 14 species of hard corals have been affected by plague type II around St. John. This disease was monitored at Haulover and Tektite Reefs at depths of 7-12 meters. The study site at Tektite Reef has > 50% cover by scleractinian corals with 90% of hard corals being composed of Montastraea annularis. Monthly surveys at Tektite Reef from December 1997 to May 2001 documented new incidence of disease (bare white patches of skeleton) every month with associated loss of living coral and 90.5% of all disease patches occurred on M. annularis. The frequency of disease within transects ranged from 3 to 58%, and the area of disease patches ranged from 0.25 to 9000 cm2. The average percent cover by the disease within 1 m2 ranged from 0.01% (+/- 0.04 SD) to 1.74% (+/- 9.08 SD). Photo-monitoring of 28 diseased corals of 9 species begun in September 1997 at Haulover Reef revealed no recovery of diseased portions with all necrotic tissue being overgrown rapidly by turf algae, usually within less than one month. Most coral colonies suffered partial mortality. Very limited recruitment (e.g., of Agaricia spp., Favia spp. and sponges) has been noted on the diseased areas. This coral disease has the potential to cause more loss of live coral on St. John reefs than any other stress to date because it targets the dominant reef building species, M. annularis.

Use-effectiveness of the female versus male condom in preventing sexually transmitted disease in women

BACKGROUND

Data are limited on the female condom's effectiveness against STDs.

GOAL

The goal was to compare STD rates between women given small-group education on, and free supplies of, either female or male condoms.

STUDY DESIGN

Female patients at an STD clinic (n = 1442) were randomly assigned to condom type and followed via medical records for STDs (gonorrhea, chlamydia, early syphilis, or trichomoniasis).

RESULTS

In an intention-to-treat analysis, the odds ratio for a comparison of STD occurrence between the female and male condom groups was 0.75 (95% confidence interval [CI], 0.56-1.01), and it did not change with adjustment. In a second analysis among women returning for subsequent screening, incidence rates for the first new postintervention STD per 100 woman-months of observation were 6.8 in the female condom group and 8.5 in the male condom group (rate ratio = 0.79 [CI, 0.59-1.06]).

CONCLUSION

Compared with those provided with male condoms alone, women counseled on, and provided with, female condoms fared no worse and experienced a nonsignificant reduction in STDs.

Dustborne and airborne fungal propagules represent a different spectrum of fungi with differing relations to home characteristics

BACKGROUND

Exposure to fungi is often assessed by culturing floor dust or air samples. Our objective was to evaluate the relationships between dustborne and airborne fungi and to identify factors that modify these relationships.

METHODS

From November 1994 to September 1996 sequential duplicate 45-l air samples were collected in bedrooms of 496 homes in the Boston area, using a Burkard culture plate sampler. After air sampling, bedroom floors were sampled with a vacuum cleaner that was modified to collect dust in a cellulose extraction thimble. Dust was sieved, and the fine dust was dilution-plated onto DG-18 media.

RESULTS

Concentrations of total culturable fungi per gram of bedroom-floor dust were correlated weakly, but significantly, with those of indoor air (r = 0.13, P < 0.05). Concentrations of some individual taxa in the dust and indoor air were also weakly associated. Adjusting for the concentrations of fungi in outdoor air, dustborne fungal concentrations were positively associated with those in indoor air for the taxa Cladosporium and Penicillium, but not for total fungi. The indoor air fungal levels were often predicted by different covariates to those predicting fungal levels in dust. The type of housing (house or apartment) and the presence of carpeting were often predictive factors for dust fungi. In contrast, outdoor fungal levels were often predictive of the indoor air fungal levels.

CONCLUSIONS

Because our data do not indicate a strong overall relationship between culturable fungi in dust and indoor air, the results from these two methods (dust and air sampling) likely represent different types of potential fungal exposures to residents. It may be essential to collect both air and dust samples, as well as information on housing characteristics, as indicators for fungal exposure.

Development of a protocol for evaluation of mammographic surveillance services in women under 50 with a family history of breast cancer

BACKGROUND

Preliminary retrospective data suggest it is possible to identify impalpable breast cancer in women presenting with a family history of breast cancer under the age of 50, by using regular mammography. In consequence, this service is offered in a number of centres in the UK. The effectiveness of such a service, however, has not been fully evaluated.

METHODS

We propose to perform such an evaluation in a cohort of 20000 women under the age of 50 with a significant family history of breast cancer, given regular mammographic surveillance over 5 years. Comparison of surgical and pathological data with completed and ongoing population screening trials using analysis techniques of varying complexity will be performed to obtain an accurate prediction of future breast-cancer mortality reduction. The formal aims are: i) to estimate the difference in breast-cancer mortality in women under the age of 50 with a significant family history of breast cancer having regular mammography, compared with those not being screened; ii) to estimate the cost-effectiveness of regular mammography in this group of women, compared with no screening. The increase in health service resource use attributable to such a policy will be compared with no screening, and costed. Incremental cost-effectiveness ratios of implementing the standardised mammography strategy compared with no screening will be presented in terms of the additional cost per cancer detected, per life saved and per life-year saved.

The implementation of guidelines and computerised forms improves the completeness of cancer pathology reporting. The CROPS project: a randomised controlled trial in pathology

The aim of this study was to determine whether reporting guidelines and computerised form-based reports improve the completeness of histopathological cancer data available for patient management and population cancer registration and to evaluate the acceptability of the intervention. The study was a randomised controlled trial with a split unit design and stratified cluster randomisation. All 16 hospital pathology laboratories in Wales were randomly allocated to report either breast or colorectal resection specimens by computerised form or conventional free text. 1044 reports were analysed in the study arm, 998 in the control arm. Use of pre-defined forms led to a 28.4% (95% confidence interval (CI): 15.7-41.2%) increase in complete reporting of a minimum dataset required for cancer registration and a 24.5% (95% CI: 11.0-38.0%) increase in complete reporting of minimum data required for patient management. Form-based reporting was acceptable to pathologists and preferred by clinicians. In conclusion, guidelines and computerised forms significantly improve the quality of histopathology reporting.

A randomized trial of specialist genetic assessment: psychological impact on women at different levels of familial breast cancer risk

The aim was to compare the psychological impact of a multidisciplinary specialist genetics service with surgical provision in women at high risk and those at lower risk of familial breast cancer. Women (n=735) were randomized to a surgical consultation with (trial group) or without (control group) specialist genetic risk assessment and the possible offer of presymptomatic genetic testing. Participants completed questionnaires before and immediately after the consultation to assess anxiety, cancer worry, perceived risk, interest in genetic testing and satisfaction. Responses of subgroups of women stratified by clinicians as low, moderate, or high risk were analyzed. There were no significant main effects of study intervention on any outcome variable. Regardless of risk information, there was a statistically significant reduction in state anxiety (P<0.001). Reductions in cancer worry and perceived risk were significant for women at low or moderate risk (P<0.001) but not those at high risk, and satisfaction was significantly lower in the high risk group (P<0.001). In high risk women who received specialist genetic input, there was a marginally significant trend towards increased perceived risk. The effect of risk information on interest in genetic testing was not significant. Breast care specialists other than geneticists might provide assessments of breast cancer risk, reassuring women at reduced risk and targeting those at high risk for specialist genetic counselling and testing services. These findings are discussed in relation to the existing UK Calman-Hine model of service delivery in cancer genetics. DOI: 10.1038/sj/bjc/6600051 www.bjcancer.comCopyright 2002 The Cancer Research Campaign

Achieving safer sex with choice: studying a women's sexual risk reduction hierarchy in an STD clinic

A flexible, risk-reduction approach, as compared with a single method approach, may increase sexually transmitted disease (STD)/HIV protection for women attending STD clinics. A brief intervention was tested in an observational study of 292 STD clinic patients in three distinct cohorts. These included subjects counseled on (1) the "women's safer sex hierarchy of prevention methods" (hierarchy cohort, n = 118), including the female condom (FC), male condom (MC), diaphragm, cervical cap, and spermicides, (2) MC only (n = 62), or (3) FC (n = 112) only. We evaluate method use and level of protection achieved at 6-month follow-up among the women in the hierarchy cohort and compare the level of unprotected sex across the three cohorts, using ordinal logistic regression analyses and an imputation procedure to account for attrition. In the hierarchy cohort, the MC, FC, spermicidal film, foam, suppository, and diaphragm were used with main partners by 80%,46%, 37%, 28%, 17%, and 5% of women, respectively. Spermicides were used frequently, mainly in conjunction with condoms. As compared with hierarchy subjects, both MC cohort subjects (OR = 2.3, p = 0.01) and FC cohort subjects (OR = 1.6, p = 0.11) were more likely to report 100% unprotected sex. The tendency for subjects to move toward higher levels of protection was observed most strongly in the hierarchy group. Hierarchical-type counseling, compared with single method counseling, leads to increased protection during sex among women at high risk of STD/HIV infection and should be implemented in STD clinics.

In vitro models, in vivo models, and pharmacokinetics: what can we learn from in vitro models?

In vitro pharmacokinetic models of infection can make an important contribution to the study of the pharmacodynamic properties of an antibacterial agent. In conjunction with animal and human pharmacodynamic evaluations, they provide data to allow for the optimization of drug dosing regimens. In vitro models can be used simply to describe the effect of a drug on a bacterial population as well as to provide data for more-analytical studies, including hypothesis testing. Analytical study designs provide information on the pharmacodynamic parameter best related to the chosen outcome, as well as its magnitude. Factors such as the characteristics of the model (method of drug removal, inoculum density, and growth phase), doses simulated, species and susceptibility range of bacteria, and methods and analytical tools used to measure antibacterial effect will have an effect on the conclusions drawn. In vitro models have an important future role in ensuring antibiotic efficacy and in reducing the risks of resistance.

Vascular closure devices and the risk of vascular complications after percutaneous coronary intervention in patients receiving glycoprotein IIb-IIIa inhibitors

Vascular closure devices offer advantages over traditional means of obtaining hemostasis after percutaneous coronary intervention (PCI) in terms of patient comfort and time to ambulation. We investigate whether such devices also reduce the risk of vascular complications in selected patient populations. We conducted a retrospective analysis of all patients who underwent PCI at our institution between January 1998 and December 1999. Of 3,151 consecutive patients, 3,027 were eligible to receive vascular closure devices. Of these, 1,485 received a closure device and 1,409 received glycoprotein IIb-IIIa antagonists. The overall vascular complication rate, as defined by the need for surgical repair or transfusion, or the development of arteriovenous fistula, pseudoaneurysm, or large hematoma, was 4.20%. By univariate analysis, the use of closure devices was associated with a lower vascular complication rate (3.03% vs 5.52%; p = 0.002) and a shorter length of hospital stay (2.77 vs 3.97 days, p <0.001). Multivariate analysis showed a significant reduction in vascular complications with closure devices (odds ratio 0.59, p = 0.007). For the subgroup of patients receiving glycoprotein IIb-IIIa antagonists, the use of closure devices was associated with an even more pronounced reduction in the risk of vascular complications (odds ratio 0.45, p <0.008). Thus, the use of closure devices in selected patients undergoing PCI is associated with a low rate of vascular complications and decreased length of stay. This benefit was most marked for patients receiving glycoprotein IIb-IIIa antagonists.

The Peritraumatic Distress Inventory: a proposed measure of PTSD criterion A2

OBJECTIVE

Meeting criterion A2 for the diagnosis of posttraumatic stress disorder (PTSD) in DSM-IV requires that an individual have high levels of distress during or after the traumatic event. Because of the paucity of valid and reliable instruments for assessing such responses, the authors developed a 13-item self-report measure, the Peritraumatic Distress Inventory, to obtain a quantitative measure of the level of distress experienced during and immediately after a traumatic event.

METHOD

The cross-sectional study group comprised 702 police officers and 301 matched nonpolice comparison subjects varying in ethnicity and gender who were exposed to a wide range of critical incidents.

RESULTS

The Peritraumatic Distress Inventory was found to be internally consistent, with good test-retest reliability and good convergent and divergent validity. Even after controlling for peritraumatic dissociation and for general psychopathology, the authors found that Peritraumatic Distress Inventory scores correlated with two measures of posttraumatic stress symptoms.

CONCLUSIONS

The Peritraumatic Distress Inventory holds promise as a measure of PTSD criterion A2. Future studies should prospectively examine the ability of the Peritraumatic Distress Inventory to predict PTSD and its associated biological and cognitive correlates in other trauma-exposed groups.

The role of symptomatic colds in asthma exacerbations: Influence of outdoor allergens and air pollutants

BACKGROUND

Both air pollutants and respiratory viral infections have been recognized to be important triggers of asthma exacerbations, but the possible interaction of these has not been assessed in an epidemiologic study.

OBJECTIVE

In this study, we aimed to assess the possible associations of symptomatic colds with outdoor allergens and air pollutants in exacerbating asthma.

METHODS

A total of 57 adults and children with asthma participated in a 1-year study in Vancouver, British Columbia. Diary cards recording symptoms of asthma and colds, medication usage, and peak expiratory flow rates were completed twice daily. Outdoor air pollutant levels and levels of pollen and fungal spores were measured. Levels were examined for associations with exacerbations of asthma with symptoms of a cold, as compared with asthma exacerbations with no cold symptoms and colds in the absence of asthma exacerbations.

RESULTS

Of 130 asthma exacerbations, 47% were associated with cold symptoms (accounting for 44% of episodes of colds). Asthma exacerbations with colds were associated with higher levels of sulfur dioxide, and nitric oxide during March to November in comparison with asthma exacerbations without cold symptoms (P <.018). Cold-symptom days overall were more common in winter and were significantly associated with lower temperatures, lower ozone levels, and higher sulfur dioxide, nitrogen dioxide, nitrogen oxide (NO and NO(x)), and carbon monoxide levels.

CONCLUSIONS

Asthma exacerbations are commonly associated with cold symptoms. These episodes are associated with higher levels of sulfur dioxide and nitrogen oxides from March to November in comparison with asthma exacerbations without cold symptoms.

Percutaneous coronary intervention and subsequent endovascular beta-radiation brachytherapy in a 14-year-old with repaired anomalous left coronary artery from pulmonary artery

Anomalous origin of the left coronary artery from pulmonary artery (ALCAPA) is a rare congenital anomaly. Re-establishment of the dual coronary system is the standard treatment, although the long-term outcome after surgical repair is not well defined. We report a case in which coronary stenting was performed to treat left anterior descending artery lesions eight months after surgical repair of ALCAPA. The patient then developed rapid in-stent restenosis within three months, which was successfully treated by rotational atherectomy, balloon angioplasty, and catheter-based beta-radiation brachytherapy. Follow-up angiograms after three and six months showed no recurrent in-stent restenosis. This represents the first report of coronary stenting in the setting of ALCAPA, and the first report of catheter-based intracoronary radiation therapy in a pediatric patient.

Dependence of 13C NMR chemical shifts on conformations of rna nucleosides and nucleotides

Cross-polarization magic-angle spinning solid-state NMR spectroscopy has been used to investigate the dependence of (13)C sugar chemical shifts on specific conformational parameters of a variety of ribonucleotides and ribonucleosides. Solid-state NMR is a valuable tool for nucleoside and nucleotide structural studies since it provides the means to acquire spectra that correspond to single conformations, as opposed to (13)C solution NMR methods. The distinct effects of sugar puckering on the C1', C4', and C5' resonances of C2' endo (S type) and C3' endo (N type) furanoid conformations allow us to separate them into two groups. Further analysis of each group reveals an additional dependence of the C1' and C5' resonances on the glycosidic and C4'-C5' exocyclic torsion angles, respectively. However, it is found that the glycosidic conformation cannot independently be determined from sugar (13)C chemical shift data. The statistical methods of exploratory data analysis and discriminant analysis are used to construct two canonical coordinates-linear combinations of chemical shifts which give the statistically optimal determination of the conformation from the NMR data.

Topical and systemic therapies for the aging face

Many cosmeseuticals and drugs are available to treat and augment therapy for the aging face. Patients frequently have misconceptions about the use of these agents, and it is important that today's cosmetic surgeon know how to maximize the benefits while minimizing side effects. The role of retinoids, antioxidants, hydroxy acids, bleaching agents, moisturizers, and sunscreens are reviewed as they relate to skin rejuvenation.

Factors associated with sudden death of individuals requiring restraint for excited delirium

The purpose of this article is to identify and rank factors associated with sudden death of individuals requiring restraint for excited delirium. Eighteen cases of such deaths witnessed by emergency medical service (EMS) personnel are reported. The 18 cases reported were restrained with the wrists and ankles bound and attached behind the back. This restraint technique was also used for all 196 surviving excited delirium victims encountered during the study period. Unique to these data is a description of the initial cardiopulmonary arrest rhythm in 72% of the sudden death cases. Associated with all sudden death cases was struggle by the victim with forced restraint and cessation of struggling with labored or agonal breathing immediately before cardiopulmonary arrest. Also associated was stimulant drug use (78%), chronic disease (56%), and obesity (56%). The primary cardiac arrest rhythm of ventricular tachycardia was found in 1 of 13 victims with confirmed initial cardiac rhythms, with none found in ventricular fibrillation. Our findings indicate that unexpected sudden death when excited delirium victims are restrained in the out-of-hospital setting is not infrequent and can be associated with multiple predictable but usually uncontrollable factors.

Detection of Crohn's strictures--the use of an 'Endo-marble'

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