Neurological outcome of severe cystic periventricular leukomalacia

OBJECTIVE

To determine the neurological outcome of a cohort of premature babies having ultrasound diagnoses of severe cystic periventricular leukomalacia.

METHODOLOGY

All neonatal intensive care unit admissions born at less than 35 weeks gestation or weighing less than 1500 g underwent serial cranial ultrasounds. Those developing severe bilateral cystic periventricular leukomalacia (12 patients) were then followed clinically to a mean age of 27.3 months.

RESULTS

Ten of the 12 patients fulfilling strict ultrasound criteria survived. All had a major neurological handicap, all having spastic quadriparesis and visual impairments, with most suffering global developmental delay and epilepsy.

CONCLUSIONS

Severe bilateral cystic periventricular leukomalacia results in major permanent handicap. It is currently impossible to identify most patients with this condition while they are being ventilated. Non-ultrasound techniques are needed to diagnose the condition earlier, and to give guidance to management.

Triangulation in clinical practice

The aim of the article is to clarify the research term 'triangulation'. Examples are given to illustrate the use of triangulation in clinical practice. The strength of using triangulation in both the design and analysis stages are highlighted.

Neutron diffraction of a complex of 1,8-bis(dimethylamino)naphthalene with 1,2-dichloromaleic acid

A neutron study of the crystalline complex of 1,8-bis(dimethylamino)naphthalene (DMAN) with 1,2-dichloromaleic acid (ClMH2) has been carried out at 100 K using the Laue time-of-flight technique. The moieties are planar. The neutron data indicate that both [N—H...N]+ and [O—H...O]− hydrogen bonds in the complex are asymmetric. There are significant differences between the neutron and X-ray temperature factors, C—H, N—H and O—H bond lengths. There is a strong correlation between the neutron and X-ray temperature factors for non-H atoms and no correlation for H-atom temperature factors. According to the neutron data the involvement of a given H atom in a weak C—H...O hydrogen bond can be correlated with the ratio of equivalent temperature factors of the H and non-H atoms to which they are attached.

A novel set of uncoordinated mutants in Caenorhabditis elegans uncovered by cold-sensitive mutations

A set of uncoordinated (Unc) cold-sensitive (cs) mutants was isolated at a stringent condition of 11 degrees C. About half of the 13 independently isolated cs-Unc mutants were alleles of three X-linked Unc mutants that exhibited the "kinker" phenotype. The remaining four isolates identified new mutants that exhibited "kinker," "coiler," or severe paralytic phenotypes. The temperature-sensitive period (TSP) for each gene was determined. As a homozygous or heterozygous dominant, unc-125 exhibited a TSP throughout all stages of development. Its severe paralysis was immediately observed upon a shift down to 11 degrees C and reversed upon a shift up to 23 degrees C. The reversible thermolability of the unc-125 gene product indicated that it may function in a multicomponent process involved in neuro-excitation.

Hip fracture and elderly patients

The recent report by the Audit Commission (1995) United They Stand concerns the range of care provided for elderly people with fractured hips. The report indicates that most of the 57 000 people in England and Wales who currently fracture a hip each year are elderly; further more, the increasing demographic profile (Coleman et al, 1993) suggests that the number will double in the next 20 years. These patients currently cost the health service £250 million annually for hospital treatment alone. Over 95% of these fractures are repaired surgically, allowing the patient to walk again within a day or two and leave hospital within a few weeks. Moreover, 80% of these patients also suffer from medical conditions which are common in old age and require care from physicians specializing in the care of the elderly.

Late generalized tuberculosis: unusual features of an often overlooked disease

Late generalized tuberculosis--ie, disseminated tuberculosis occurring long after the primary infection-- is an often unrecognized cause of severe illness in patients with relative immunocompromise, such as the elderly, alcoholics, or those with chronic illnesses. It has become increasingly recognized in the elderly as a cause of a gradual debilitating illness, often with vague constitutional symptoms. We describe three cases of late generalized tuberculosis in patients seen on a single medical service over a 6-month period. Each case presents a unique features of extrapulmonary tuberculosis that escaped diagnosis for some time, and each of these elderly patients had a protracted and wasting illness. We present these cases and the ensuing discussion to reemphasize to clinicians that late generalized tuberculosis may be experiencing increased prevalence among the elderly and that diagnosis requires a heightened suspicion. A history of past tuberculosis infection is not always present, but the diagnosis should be entertained in any elderly patient with a chronic debilitating illness.

Mortality preventable by medical intervention: ethnic and regional differences in Texas

An examination of mortality from 12 causes of death was tabulated for the state of Texas for residents in the Lower Rio Grande Valley; for residents of border counties; for residents of Dallas, Harris, and Tarrant counties, along with residents of east Texas from 1980 to 1989. The ninth revised edition of the International Classification of Diseases was used to categorize causes of mortality. The mortality data were obtained from mortality data tapes obtained from the Texas Department of Health and archived at the University of Texas School of Public Health. From 1980 to 1989, an average of 1543 deaths per year was attributed to these 12 selected causes in Texas. Thirty-two percent of deaths were due to hypertensive heart disease, 30% to pneumonia and bronchitis, 11% to cervical cancer, and 6% to rheumatic fever. Pneumonia and bronchitis were the leading causes of death among those aged 15 to 44 years.

Small area variation in the utilization of mental health services: implications for health planning and allocation of resources

OBJECTIVE

To determine the variables associated with utilization of mental health services and to develop a planning model to predict service utilization that incorporates these factors.

METHOD

A regression analysis of service utilization and demographic characteristics was used to assess the relative importance of alternative service, supply of psychiatrists and demographics in explaining variations of services use. A model using socioeconomic factors was applied to the population to predict need.

RESULTS

The percentage of divorced males was the only factor significantly and positively correlated with the utilization of hospital inpatient and provincial psychiatric beds. Predicted need exceeds utilization in 7 out of 10 areas for all services.

CONCLUSIONS

Small area variations in inpatient psychiatric utilization is correlated with community characteristics, not supply of psychiatrists or utilization of alternative services. A model has been developed using census data to allocate resources according to need.

Elevated protease activities in human amnion and chorion correlate with preterm premature rupture of membranes

OBJECTIVES

The mechanism(s) of preterm premature rupture of fetal membranes resulting in preterm birth remains unknown. Studies suggest that fetal membranes are susceptible to weakening by protease attack and that collagenases may be active at the site of rupture. In this study fetal membranes from women delivered after preterm premature rupture of membranes were compared with control membranes and analyzed qualitatively and quantitatively for protease activities.

STUDY DESIGN

Fourteen membranes from women with preterm premature rupture of membranes and nine membranes from women delivered preterm without premature rupture of membranes or otherwise normal women delivered at term vaginally or by cesarean section were studied. Zymogram gel electrophoresis with gelatin incorporation was used to assess the number and apparent molecular weights of protease activities. Functional and quantitative studies of protease activity were measured by fluorescent substrate cleavage.

RESULTS

Zymogram gel electrophoresis studies demonstrated the presence of five to seven different protease bands in preterm premature rupture of membranes samples, whereas control membranes demonstrated only one to three protease bands. Fluorescent studies of protease activity demonstrated a 10- to 40-fold increase in activity in membranes from women with preterm premature rupture of membranes compared with normal control membranes. Studies with protease inhibitors suggest that most of the activity is due to metalloproteinases.

CONCLUSION

In membranes from women with preterm premature rupture of membranes there appears to be a general increase in the amount of protease activity and increased numbers of putatively different proteases. Increased activity or deregulated protease control may mediate preterm premature rupture of membranes and be a potentially remediable cause of preterm birth.

Prevention of premature birth by screening and treatment for common genital tract infections: results of a prospective controlled evaluation

OBJECTIVE

Our purpose was to analyze (1) the effects of prevalent lower reproductive tract infections and (2) the effect of systematic diagnosis and treatment to reduce risks of early pregnancy loss (< 22 weeks), preterm premature rupture of membrances, and overall preterm birth.

STUDY DESIGN

A prospective, controlled treatment trial was conducted on 1260 women. During the first 7 months of the program (observation, phase I), women were examined at initiation of prenatal care for a panel of lower genital tract microorganisms and bacterial vaginosis. Women were followed up with reexaminations at 22 to 29 weeks and after 32 weeks' gestation. The recommended treatments of the Centers for Disease Control (i.e., 300 mg of clindamycin orally twice daily for 7 days for bacterial vaginosis) were used for infected women during the second 8 months of the study (treatment, phase II). Data were analyzed according to intent to treat by means of univariate and multivariate methods.

RESULTS

Overall, presence of bacterial vaginosis (32.5%) at enrollment was associated with pregnancy loss at < 22 weeks' gestation (relative risk 3.1, 95% confidence interval 1.4 to 6.9). Among women in the observation phase bacterial vaginosis was associated with increased risk of both preterm birth (relative risk 1.9, 95% confidence interval 1.2 to 3.0) and preterm premature rupture of membranes (relative risk 3.5, 95% confidence interval 1.4 to 8.9). Within this population (phase I) 21.9% of preterm birth overall (43.8% premature rupture of membranes) is estimated as attributable to bacterial vaginosis. Among women with bacterial vaginosis phase II (treatment) was associated with reduced preterm birth (relative risk 0.5, 95% confidence interval 0.3 to 0.9); there was a similar reduction for women with preterm premature rupture of membranes (relative risk 0.5, 95% confidence interval 0.2 to 1.4). Women with both bacterial vaginosis and trichomoniasis were at highest risk of preterm birth (28%); treatment of both conditions (phase II) reduced preterm birth (17%) but did not eliminate this risk. Earlier patient enrollment and oral antibiotic treatment were associated with reduced preterm birth.

CONCLUSIONS

This prospective, controlled trial confirms that the presence of bacterial vaginosis is associated with increased risks of pregnancy loss at < 22 weeks, preterm premature rupture of membranes, and preterm birth. Orally administered clindamycin treatment is associated with a 50% reduction of bacterial vaginosis-linked preterm birth and preterm premature rupture of membranes. Women at risk for preterm birth or preterm premature rupture of membranes because of bacterial vaginosis or common genital tract infections should be screened, treated, reevaluated for cure, and re-treated if necessary.

How consistently do RNs perform the procedure of collecting specimens for measurement of gastric pHi and CO2?

Gastric Tonometry is an important tool being used more frequently in the Intensive Care Unit (ICU). Tonometry is used to collect normal saline which has equilibrated with the stomach contents and is used in combination with a sample of arterial blood to calculate intragastric PaCO2 and intramucosal pH (pHi). These values are indicative of gastric perfusion. Correct performance of each of the 5 procedural steps to instill and then collect the normal saline is paramount for accuracy of the CO2 and pHi results. The aim of this study was to examine how consistently nurses perform the procedure. Study participants comprised two groups of 15 registered nurses (RNs) chosen at random from the nurses employed in the ICU at Liverpool Hospital (NSW, Australia). The first group of RNs were asked to answer a questionnaire before and after performing the tonometry procedure under simulated conditions. The second group were asked to perform the tonometry procedure only. Each participant was observed by one of the researchers whilst performing all of the procedural steps. Regardless of critical care experience of participants or the number of years since registration a s a nurse, error rates in performing the specimen collection/procedure were as high as 34%. This study is designed to examine the previously unaddressed area of how accurately nursing staff follow systematic instructions to collect the mucosal sample.

Lack of interaction between two antihistamines, mizolastine and cetirizine, and ethanol in psychomotor and driving performance in healthy subjects

The pharmacodynamic interaction between mizolastine, a new H1 antihistamine, and ethanol was assessed in a randomized, double-blind, three-way crossover, placebo-controlled study. Eighteen healthy young male volunteers received mizolastine 10 mg, or cetirizine 10 mg or placebo once daily for 7 days with a 1-week wash-out interval. An oral dose of ethanol or ethanol placebo, given 2 h after dosing on days 5 or 7 of each treatment period, was administered to achieve a peak blood alcohol concentration (BAC) of 0.7 g/l then maintained for 1 h by two further doses of ethanol. Driving ability and psychomotor performance were evaluated using actual and simulated driving tests, critical flicker fusion threshold (CFF), adaptive tracking and divided attention (DAT) tasks. Ethanol produced a significant decrement in all tasks up to 5.5 h after administration: an increase in steering movements of 4.6, in lateral deviation of 0.45 m, in braking reaction time of 80 ms, in driving test and DAT performance of + 3.2; and a decrease in CFF and in tracking speed of 2.6 m.s-1. Neither mizolastine nor cetirizine significantly impaired driving ability or arousal (CFF) compared with the placebo. However, both drugs significantly impaired DAT performance 6:00 h post-dose (increase of + 2.1 for mizolastine and + 2.4 for cetirizine). The tracking speed was significantly decreased 7:50 h after mizolastine administration (-1.3 m.s-1) and more consistently from 1:30 to 7:50 h after cetirizine administration (-1.4 m.s-1). No significant adverse interaction, i.e. potentiation, occurred between ethanol and either antihistamine.(ABSTRACT TRUNCATED AT 250 WORDS)