Urinary tract infection during pregnancy: a risk factor for cerebral palsy?

Exposure to Paracetamol in Early Pregnancy and the Risk of Developing Cerebral Palsy: A Case-Control Study Using Serum Samples

OBJECTIVE

To investigate whether maternal paracetamol use in early pregnancy is associated with cerebral palsy (CP) in offspring.

STUDY DESIGN

We conducted a registry and biobank-based case-control study with mother-child pairs. We identified CP cases (n = 322) born between 1995 and 2014 from a nationwide CP-registry. Randomly selected controls (n = 343) and extra preterm controls (n = 258) were obtained from a birth registry. For each mother, a single serum sample from early pregnancy (gestation weeks 10-14) was retrieved from a biobank and analyzed for serum concentrations of paracetamol, categorized into unexposed (<1 ng/ml), mildly exposed (1-100 ng/ml), and highly exposed (>100 ng/ml), and in quartiles. Analyses were performed using logistic regression and adjusted for potential confounders. Separate analyses were conducted including only those children born preterm and only those born term.

RESULTS

Of the 923 participants, 36.8% were unexposed, 53.2% mildly exposed, and 10% highly exposed to paracetamol. Overall, prenatal exposure to paracetamol was not associated with CP. Sensitivity and subgroup analyses showed no clear associations between paracetamol and CP across strata of term/preterm birth as well as subtypes of CP.

CONCLUSIONS

The present study does not support an association between intrauterine exposure to paracetamol in early pregnancy and the risk of CP. However, it is important to stress that the exposure estimate is based on a single serum sample.

Sensing and Artificial Intelligent Maternal-Infant Health Care Systems: A Review

Currently, information and communication technology (ICT) allows health institutions to reach disadvantaged groups in rural areas using sensing and artificial intelligence (AI) technologies. Applications of these technologies are even more essential for maternal and infant health, since maternal and infant health is vital for a healthy society. Over the last few years, researchers have delved into sensing and artificially intelligent healthcare systems for maternal and infant health. Sensors are exploited to gauge health parameters, and machine learning techniques are investigated to predict the health conditions of patients to assist medical practitioners. Since these healthcare systems deal with large amounts of data, significant development is also noted in the computing platforms. The relevant literature reports the potential impact of ICT-enabled systems for improving maternal and infant health. This article reviews wearable sensors and AI algorithms based on existing systems designed to predict the risk factors during and after pregnancy for both mothers and infants. This review covers sensors and AI algorithms used in these systems and analyzes each approach with its features, outcomes, and novel aspects in chronological order. It also includes discussion on datasets used and extends challenges as well as future work directions for researchers.

Maternal Infection During Pregnancy and Risk of Cerebral Palsy in Children: A Systematic Review and Meta-analysis

BACKGROUND AND AIM

The association between maternal infection during pregnancy and the risk of cerebral palsy has been previously reported. However, their results were relatively inconsistent. This systematic review and meta-analysis were carried out to investigate the association between maternal infection during pregnancy and the risk of cerebral palsy in children.

METHODS

PubMed, Scopus, and Web of Sciences databases were searched from inception to October 28, 2019. Heterogeneity was assessed using the I² value. In case of substantial heterogeneity (I² > 50%), a random effects model was applied, otherwise, a fixed effects model was used. The pooled associations were expressed as relative risks (RRs) and 95% confidence intervals (CIs). Publication bias and quality of studies included in the systematic review were checked using the Egger's regression test and Newcastle-Ottawa Scale (NOS), respectively.

RESULTS

Thirty-seven studies were included in the systematic review. Among them, 21 studies were eligible for the meta-analysis. The pooled RR of cerebral palsy risk was 2.50 (95% CI 1.94, 3.21; I² = 88.7%, P < .001) among children born to mothers who had any infection during pregnancy. The risk was increased to 2.85 (95% CI 1.96, 4.15; I² = 75.9%, P < .001) when the mother was diagnosed with chorioamnionitis. Publication bias tests suggested no evidence of potential publication bias and 76% of the studies included in the meta-analysis were of high quality (NOS ≥ 6).

CONCLUSION

This systematic review and meta-analysis provides evidence that maternal infection during pregnancy may be associated with an increased risk of cerebral palsy in children.

Neonatal white matter damage and the fetal inflammatory response

In 1962 a long-recognized pathologic abnormality in neonatal brains characterized by multiple telencephalic focal white matter necroses was renamed periventricular leukomalacia (PVL) and the authors inappropriately asserted that their entity was caused by anoxia. They also failed to include three other white matter histologic abnormalities. In this essay, we identify the breadth of white matter pathology, especially in very preterm newborns, and show that none of the four histologic expressions of white matter damage, including focal necrosis, are associated with hypoxemia or correlates as hypotension, but are instead associated with markers of fetal or perinatal inflammation, particularly in preterm babies. We begin with the background needed to evaluate the evidence.

Fetal neuroprotective mechanism of maternal magnesium sulfate for late gestation inflammation: in a rodent model

Background: Maternal administration of magnesium sulfate (Mg) is used in humans to protect the fetal brain during preterm delivery. We sought to determine the neuroprotective mechanism of Mg in a rat model of late gestation maternal inflammation.Methods: Pregnant rats at 20 d of gestation (20 total, four groups, N = 5 in each group) received i.p. LPS or saline. Dams were randomized for s.c. saline or Mg supplementation 2 h prior and following the LPS/saline injections. Dams were sacrificed 4 h following the last treatment. Fetal brains were collected from the four treatment groups. Fetal brain caspase 3 active form, NF-kB p65, neuronal nitric oxide synthase (phospho-nNos), and proinflammatory cytokines levels were determined by western blot.Results: Maternal LPS at e20 significantly (p < .01) increased fetal brain caspase 3 active form (af) (0.27 ± 0.02 versus 0.15 ± 0.06u), NFkB (0.23 ± 0.01 versus 0.13 ± 0.01u), and phospho-nNOS (0.22 ± 0.01 versus 0.12 ± 0.01u) and fetal brain proinflammatory cytokines (IL-6 0.21 ± 0.01 versus 0.11 ± 0.01 u; TNFα 0.29 ± 0.01 versus 0.15 ± 0.01u), compared with control fetuses. Mg treatment significantly (p < .05) reduced fetal brain caspase 3 af (0.16 ± 0.01u), NFkB p65 (0.11 ± 0.01u), phospho-nNOS (0.1 ± 0.01u), as well as brain proinflammatory cytokines (IL-6 0.07 ± 0.01u; TNFα 0.15 ± 0.01u) to levels similar to controls.Conclusion: Maternal inflammation-induced fetal brain injury at late gestation may be mediated by the activation of inflammatory response, oxidative stress, and apoptosis. Maternal Mg may attenuate the injury by inhibition of these putative pathways.

The complex aetiology of cerebral palsy

Cerebral palsy (CP) is the most prevalent, severe and costly motor disability of childhood. Consequently, CP is a public health priority for prevention, but its aetiology has proved complex. In this Review, we summarize the evidence for a decline in the birth prevalence of CP in some high-income nations, describe the epidemiological evidence for risk factors, such as preterm delivery and fetal growth restriction, genetics, pregnancy infection and other exposures, and discuss the success achieved so far in prevention through the use of magnesium sulfate in preterm labour and therapeutic hypothermia for birth-asphyxiated infants. We also consider the complexities of disentangling prenatal and perinatal influences, and of establishing subtypes of the disorder, with a view to accelerating the translation of evidence into the development of strategies for the prevention of CP.

The Development of Extremely Preterm Infants Born to Women Who Had Genitourinary Infections During Pregnancy

Gestational genitourinary infections, which have been associated with neurodevelopmental impairments among infants born near term, have not been studied among very preterm infants. The mothers of 989 infants born before 28 weeks of gestation were interviewed about urine, bladder, or kidney infections (UTIs) and cervical or vaginal infections (CVIs) during pregnancy, as well as other exposures and characteristics, and their charts were reviewed for the Extremely Low Gestational Age Newborns (ELGAN) Study (2002-2004). At 2 years of age, these infants underwent a neurodevelopmental assessment. Generalized estimating equation logistic regression models of developmental adversities were used to adjust for potential confounders. Infants born to women who reported a UTI were less likely than were others to have a very low Mental Development Index (adjusted odds ratio = 0.5; 95% confidence interval: 0.3, 0.8), whereas infants born to women who reported a CVI were more likely than others to have a low Psychomotor Development Index (adjusted odds ratio = 1.7; 95% confidence interval: 1.04, 2.7). In this high-risk sample, maternal gestational CVI, but not UTI, was associated with a higher risk of impaired motor development at 2 years of age. The apparent protective effect of UTI might be spurious, reflect confounding due to untreated asymptomatic bacteriuria among women who were not given a diagnosis of UTI, or reflect preconditioning.

Cerebral palsy: causes, pathways, and the role of genetic variants

Cerebral palsy (CP) is heterogeneous with different clinical types, comorbidities, brain imaging patterns, causes, and now also heterogeneous underlying genetic variants. Few are solely due to severe hypoxia or ischemia at birth. This common myth has held back research in causation. The cost of litigation has devastating effects on maternity services with unnecessarily high cesarean delivery rates and subsequent maternal morbidity and mortality. CP rates have remained the same for 50 years despite a 6-fold increase in cesarean birth. Epidemiological studies have shown that the origins of most CP are prior to labor. Increased risk is associated with preterm delivery, congenital malformations, intrauterine infection, fetal growth restriction, multiple pregnancy, and placental abnormalities. Hypoxia at birth may be primary or secondary to preexisting pathology and international criteria help to separate the few cases of CP due to acute intrapartum hypoxia. Until recently, 1-2% of CP (mostly familial) had been linked to causative mutations. Recent genetic studies of sporadic CP cases using new-generation exome sequencing show that 14% of cases have likely causative single-gene mutations and up to 31% have clinically relevant copy number variations. The genetic variants are heterogeneous and require function investigations to prove causation. Whole genome sequencing, fine scale copy number variant investigations, and gene expression studies may extend the percentage of cases with a genetic pathway. Clinical risk factors could act as triggers for CP where there is genetic susceptibility. These new findings should refocus research about the causes of these complex and varied neurodevelopmental disorders.

Maternal lipopolysaccharide alters the newborn oxidative stress and C-reactive protein levels in response to an inflammatory stress

Maternal infection is associated with oxidative stress (OS) and inflammatory responses. We have previously shown that maternal exposure to lipopolysaccharide (LPS) at E18 alters the subsequent offspring immune response. As immune responses are mediated, in part, by OS, we sought to determine if maternal inflammation during pregnancy programs offspring OS and C-reactive protein (CRP) levels. Pregnant Sprague-Dawley rats received intraperitoneal (i.p.) injections of saline or LPS at 18 days' gestation (n = 4), and pups delivered spontaneously at term. At postnatal day 24, male and female offspring received i.p. injection of LPS. Serum lipid peroxides formation (PD) and CRP levels were determined before and at 4 h following the LPS injection. Pups of LPS-exposed dams had significantly higher basal OS (PD 29.4 ± 5.4 v. 10.1 ± 4.8 nmol/ml) compared with controls. In response to LPS, CRP levels (20.4 ± 2.8 v. 5.7 ± 1.0 ng/ml) were significantly higher among pups of LPS-exposed dams than controls. Prenatal maternal exposure to LPS increases baseline OS levels in neonates and CRP levels in response to LPS. These results suggest that maternal inflammation during the antenatal period may induce long-term sequelae in the offspring that may predispose to adult disease.

Assessment of urinary infection management during prenatal care in pregnant women attending public health care units in the city of Rio de Janeiro, Brazil

The aim of this study was to assess the sociodemographic risk factors for urinary tract infection and the inadequacy of antenatal care, according to the Kotelchuck index, in pregnant women in the city of Rio de Janeiro. A cross-sectional study was conducted with 1,091 pregnant women, 501 with urinary tract infection, in the public health antenatal care units in Rio de Janeiro, Brazil, in 2007-2008. Demographic and socioeconomic data, obstetric history and adequacy of antenatal care were collected by interviews and antenatal care card. Inadequacy management of urinary tract infection was evaluated by professional performance, health services and women dimensions. Chi-square and multivariate logistic regression were used to compare groups and to identify associated factors with management of urinary tract infection. Pregnant teenagers, anemic and diabetic pregnant women and quality of prenatal partially adequate or inadequate were those with higher odds of urinary tract infection. In the overall assessment, 72% had inadequate management of urinary tract infection. Inadequate management of urinary tract infection was associated with brown skin color compared to white skin color. In the assessment of health professional performance, inadequacy management of urinary tract infection was more common in pregnant women with low weight and overweight and obesity. According to pregnant women evaluation, primiparous women have lower odds of inadequacy management of urinary tract infection compared to those with one or more children.

Congenital cerebral palsy and prenatal exposure to self-reported maternal infections, fever, or smoking

OBJECTIVE

The objective of the study was to investigate the association between maternal self-reported infections, fever, and smoking in the prenatal period and the subsequent risk for congenital cerebral palsy (CP).

STUDY DESIGN

We included the 81,066 mothers of singletons born between 1996 and 2003 who participated in the Danish National Birth Cohort. Children were followed up through December 2008. Information on maternal infections, fever, smoking, and other demographic and lifestyle factors during pregnancy were reported by mothers in computer-assisted telephone interviews in early and midgestation. We identified 139 CP cases including 121 cases of spastic CP (sCP) as confirmed by the Danish National Cerebral Palsy Register. Cox proportional hazards regression models were used to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).

RESULTS

Self-reported vaginal infections were associated with an increased risk of CP and sCP (aHR, 1.52; 95% CI, 1.04-2.24; and aHR, 1.73; 95% CI, 1.16-2.60, respectively) and particularly untreated vaginal infections were associated with an increased risk of sCP (aHR, 1.95; 95% CI, 1.16-3.26). Fever was associated with the risk of CP (aHR, 1.53; 95% CI, 1.06-2.21). Smoking 10 or more cigarettes per day during pregnancy was also associated with sCP (aHR, 1.80; 95% CI, 1.10-2.94). There was a modest excess in risk for children exposed to both heavy smoking and vaginal infections. No other self-reported infections were significantly associated with CP.

CONCLUSION

Self-reported vaginal infections, fever, and smoking 10 or more cigarettes per day during pregnancy were associated with a higher risk of overall CP and/or sCP.

Placental-mediated increased cytokine response to lipopolysaccharides: a potential mechanism for enhanced inflammation susceptibility of the preterm fetus

BACKGROUND

Cerebral palsy is a nonprogressive motor impairment syndrome that has no effective cure. The etiology of most cases of cerebral palsy remains unknown; however, recent epidemiologic data have demonstrated an association between fetal neurologic injury and infection/inflammation. Maternal infection/inflammation may be associated with the induction of placental cytokines that could result in increased fetal proinflammatory cytokine exposure, and development of neonatal neurologic injury. Therefore, we sought to explore the mechanism by which maternal infection may produce a placental inflammatory response. We specifically examined rat placental cytokine production and activation of the Toll-like receptor 4 (TLR4) pathway in response to lipopolysaccharide exposure at preterm and near-term gestational ages.

METHODS

Preterm (e16) or near-term (e20) placental explants from pregnant rats were treated with 0, 1, or 10 μg/mL lipopolysaccharide. Explant integrity was assessed by lactate dehydrogenase assay. Interleukin-6 and tumor necrosis alpha levels were determined using enzyme-linked immunosorbent assay kits. TLR4 and phosphorylated nuclear factor kappa light chain enhancer of activated B cells (NFκB) protein expression levels were determined by Western blot analysis.

RESULTS

At both e16 and e20, lactate dehydrogenase levels were unchanged by treatment with lipopolysaccharide. After exposure to lipopolysaccharide, the release of interleukin-6 and tumor necrosis alpha from e16 placental explants increased by 4-fold and 8-9-fold, respectively (P < 0.05 versus vehicle). Conversely, interleukin-6 release from e20 explants was not significantly different compared with vehicle, and tumor necrosis alpha release was only 2-fold higher (P < 0.05 versus vehicle) following exposure to lipopolysaccharide. Phosphorylated NFκB protein expression was significantly increased in the nuclear fraction from placental explants exposed to lipopolysaccharide at both e16 and e20, although TLR4 protein expression was unaffected.

CONCLUSION

Lipopolysaccharide induces higher interleukin-6 and tumor necrosis alpha expression at e16 versus e20, suggesting that preterm placentas may have a greater placental cytokine response to lipopolysaccharide infection. Furthermore, increased phosphorylated NFκB indicates that placental cytokine induction may occur by activation of the TLR4 pathway.

N-acetyl-cysteine (NAC) attenuates LPS-induced maternal and amniotic fluid oxidative stress and inflammatory responses in the preterm gestation

OBJECTIVE

Maternal infection is associated with oxidative stress and inflammation. We sought to determine whether N-acetyl-cysteine can decrease maternal oxidative stress and the inflammatory response in preterm gestation.

STUDY DESIGN

Pregnant rats 16 days, were treated with (1) lipopolysaccharide, (2) N-acetyl-cysteine 120 minutes after lipopolysaccharide, or (3) saline solution (intraperitoneal). Six hours after lipopolysaccharide administration, serum lipid peroxide formation (LPO), tumor necrosis factor-α, interleukin-6, and interleukin-1β levels in maternal serum and amniotic fluid were determined.

RESULTS

Lipopolysaccharide significantly increased maternal serum lipid peroxide formation (24-118.5 nmol/mL; P < .05), and maternal serum and amniotic fluid tumor necrosis factor-α, interleukin-6, and interleukin-1β. N-acetyl-cysteine treatment after lipopolysaccharide significantly attenuated lipid peroxide formation (47.5 nmol/mL) and proinflammatory cytokines response in maternal serum and amniotic fluid.

CONCLUSION

Maternal and amniotic fluid oxidative stress and inflammatory stimulation are attenuated by N-acetyl-cysteine even when administered after lipopolysaccharide. These results suggest that N-acetyl-cysteine may protect the fetus from adverse sequelae associated with inflammatory stimulation.

Prophylactic maternal n-acetylcysteine before lipopolysaccharide suppresses fetal inflammatory cytokine responses

OBJECTIVE

Maternal infection or inflammation may induce fetal inflammatory responses and potentially fetal brain injury. We sought to determine whether prophylactic n-acetylcysteine (NAC), a known antiinflammatory, may modulate the fetal cytokine response to maternal lipopolysaccharide (LPS).

STUDY DESIGN

Pregnant Sprague Dawley rats (20/21 days = 0.95 gestation; n = 35) received intraperitoneal NAC (300 mg/kg) or saline at time 0 and LPS (500 microg/kg) or saline at 30 minutes. An additional group received NAC following saline. At 6 hours, rats were killed and interleukin (IL)-6, IL-1 beta, and IL-10 levels were determined in fetal and maternal blood.

RESULTS

Following maternal LPS, fetal blood IL-6 (median [25th, 75th] 50 [27, 50] to 2072 [448, 4853] pg/mL) and IL-1 beta (74 [10, 139] to 391 [284, 797] pg/mL) significantly increased. NAC before LPS significantly reduced the fetal IL-6 and IL-1 beta response. Fetal IL-10 was not attenuated by any treatment. NAC attenuated both maternal pro- and antiinflammatory responses to LPS.

CONCLUSION

Maternal NAC suppressed fetal and maternal inflammatory responses to maternal LPS. These results suggest that prophylactic NAC may protect the fetus from maternal inflammation.

Maternal N-acetylcysteine suppresses fetal inflammatory cytokine responses to maternal lipopolysaccharide

OBJECTIVE

Evidence suggests that maternal infections may induce fetal inflammatory responses. Because cytokine actions may be mediated by oxidative stress, we determined whether N-acetylcysteine, an antioxidant, can blunt fetal inflammatory responses to maternal lipopolysaccharide.

STUDY DESIGN

Sprague Dawley near-term rats (n = 16) received intraperitoneal lipopolysaccharide (100 microg/kg) at 30 minutes and saline solution or N-acetylcysteine (300 mg/kg) at 150 minutes. An additional group received N-acetylcysteine before and after lipopolysaccharide administration. At 6 hours, rats were killed, and fetal and maternal blood cytokines were determined.

RESULTS

After maternal lipopolysaccharide administration, fetal blood interleukin-6 markedly increased (3 +/- 2 to 1265 +/- 574 pg/mL); N-acetylcysteine that was given before or before and after lipopolysaccharide administration reduced fetal interleukin-6 response to control levels. A similar trend was observed for interleukin-1beta. No effect of N-acetylcysteine on fetal interleukin-10 levels was observed.

CONCLUSION

Maternal N-acetylcysteine inhibits fetal cytokine responses to maternal lipopolysaccharide, even when given 2 hours after lipopolysaccharide injection. These results suggest that N-acetylcysteine may protect the fetus from sequelae of maternal inflammation.

N-acetyl-cysteine suppresses amniotic fluid and placenta inflammatory cytokine responses to lipopolysaccharide in rats

OBJECTIVE

Maternal infections may induce placental, amniotic and, potentially, fetal inflammatory responses. As cytokine responses may be mediated by oxidative stress, we determined whether the antioxidant N-acetyl-cysteine (NAC), can attenuate maternally induced amniotic and placental cytokine responses to maternal infection (modeled by lipopolysaccharide [LPS]).

STUDY DESIGN

Gestation day 18 pregnant rats were (1) treated with LPS (100 microg/kg, body weight; intraperitoneally) alone; (2) pretreated with NAC (300 mg/kg body weight; intraperitoneally) 30 minutes before LPS; (3) posttreated with NAC 120 minutes after LPS; or (4) treated with NAC 30 minutes before and 120 minutes after LPS. Six hours after LPS administration, maternal serum and amniotic fluid interleukin-6 (IL-6) and IL-10 levels, and placental IL-6 messenger RNA levels were determined.

RESULTS

LPS increased maternal serum IL-6 (50 +/- 25 to 3444 +/- 584 pg/mL) and IL-10 (40 +/- 20 to 958 +/- 339 pg/mL) and amniotic fluid IL-6 (59 +/- 25 to 891 +/- 128 pg/mL). Pretreatment and/or posttreatment with NAC attenuated IL-6 in the maternal serum and amniotic fluid and IL-10 in the amniotic fluid. LPS also induced placental IL-6 messenger RNA that was inhibited by treatment with NAC before and after LPS.

CONCLUSION

NAC inhibition of inflammatory responses may protect the fetus from potential long-term sequelae.

Antibiotics for Life-Threatening Illness

Infection is a common reason for seeking treatment in the emergency department. Appropriate and timely therapy for these patients is critical. The therapy of most infectious presentations in the emergency department is empiric, with little information published about the infectious etiology and/or pathogen(s). Optimal antibiotic therapy in these patients involves the selection of the appropriate agent(s), the proper dosing regimen, timely administration, and close therapeutic monitoring. To make these decisions, health care providers must be aware of the appropriate diagnostic criteria, likely pathogens for the suspected site of infection, the latest antimicrobial products, and current antimicrobial resistance patterns and trends. Health care providers are also charged with the task of avoiding unnecessary or inappropriate antimicrobial therapy to prevent or slow further bacterial pathogen resistance. Bacterial meningitis, urinary tract infection, and community-acquired pneumonia are the most commonly seen emergency department infectious presentations.

[Importance of the clinical genetics evaluation on hydrocephalus]

The aim of this study was to characterize the possibility of genetic etiology in a group of individuals with congenital hydrocephalus in which the etiology was indeterminate and to confirm that earlier diagnosed. The casuistry was composed by 16 individuals with congenital hydrocephalus. Investigation protocol included anamnesis, familial investigation, physical examination, computerized tomography or magnetic resonance image of head, vertebral column X-ray, karyotype and dysmorphological study. Results were analyzed in two groups. In Group I (3M:9F) was composed by hydrocephalus associated with unspecific signs. Group II (7 males) had findings of epectrum of L1 disease. Genetic counseling could be offered in 11 cases. These results demonstrate the great etiological heterogeneity of congenital hydrocephalus and reinforce the importance of dysmphology evaluation as an important complementary investigation.

The epidemiology and causes of cerebral palsy

Cerebral palsy is the commonest physical disability in childhood, occurring in 2.0 to 2.5 per 1000 live births. Although the total number of children with cerebral palsy has remained stable or increased slightly since 1970, there has been a consistent rise in the proportion of cerebral palsy associated with preterm and very preterm births. Known causes of cerebral palsy--whether prenatal, perinatal or postnatal--must be distinguished from risk factors or associations. Much is known about such risk factors which, alone or in combination, may indirectly result in cerebral palsy. Causes and risk factors implicated in cerebral palsy are discussed in detail, together with directions for future research.

Epidemiology of urinary tract infections: transmission and risk factors, incidence, and costs

Uropathogenic E. coli have special features that allow them to take advantage of the bladder environment. There UPEC can grow to substantial numbers in pure culture that are shed frequently into the environment and have a high probability of transmission to other hosts. A better understanding of the transmission system and the host and bacterial factors influencing transmission is essential for the identification of effective prevention strategies. Although the risk of severe morbidity among otherwise healthy populations is low, the incidence is high. Further, the potential impact of antibiotic treatment on the emergence of increasingly antibiotic-resistant UPEC (the resistant mechanisms that may be transmitted to other bowel inhabitants) is high. The benefits of successfully preventing UTI are substantial.

Epidemiology of urinary tract infections: incidence, morbidity, and economic costs

Urinary tract infections (UTIs) are considered to be the most common bacterial infection. According to the 1997 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, UTI accounted for nearly 7 million office visits and 1 million emergency department visits, resulting in 100,000 hospitalizations. Nevertheless, it is difficult to accurately assess the incidence of UTIs, because they are not reportable diseases in the United States. This situation is further complicated by the fact that accurate diagnosis depends on both the presence of symptoms and a positive urine culture, although in most outpatient settings this diagnosis is made without the benefit of culture. Women are significantly more likely to experience UTI than men. Nearly 1 in 3 women will have had at least 1 episode of UTI requiring antimicrobial therapy by the age of 24 years. Almost half of all women will experience 1 UTI during their lifetime. Specific subpopulations at increased risk of UTI include infants, pregnant women, the elderly, patients with spinal cord injuries and/or catheters, patients with diabetes or multiple sclerosis, patients with acquired immunodeficiency disease syndrome/human immunodeficiency virus, and patients with underlying urologic abnormalities. Catheter-associated UTI is the most common nosocomial infection, accounting for >1 million cases in hospitals and nursing homes. The risk of UTI increases with increasing duration of catheterization. In noninstitutionalized elderly populations, UTIs are the second most common form of infection, accounting for nearly 25% of all infections. There are important medical and financial implications associated with UTIs. In the nonobstructed, nonpregnant female adult, acute uncomplicated UTI is believed to be a benign illness with no long-term medical consequences. However, UTI elevates the risk of pyelonephritis, premature delivery, and fetal mortality among pregnant women, and is associated with impaired renal function and end-stage renal disease among pediatric patients. Financially, the estimated annual cost of community-acquired UTI is significant, at approximately $1.6 billion.

Epidemiology of urinary tract infections: incidence, morbidity, and economic costs

Urinary tract infections (UTIs) are considered to be the most common bacterial infection. According to the 1997 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, UTI accounted for nearly 7 million office visits and 1 million emergency department visits, resulting in 100,000 hospitalizations. Nevertheless, it is difficult to accurately assess the incidence of UTIs, because they are not reportable diseases in the United States. This situation is further complicated by the fact that accurate diagnosis depends on both the presence of symptoms and a positive urine culture, although in most outpatient settings this diagnosis is made without the benefit of culture. Women are significantly more likely to experience UTI than men. Nearly 1 in 3 women will have had at least 1 episode of UTI requiring antimicrobial therapy by the age of 24 years. Almost half of all women will experience 1 UTI during their lifetime. Specific subpopulations at increased risk of UTI include infants, pregnant women, the elderly, patients with spinal cord injuries and/or catheters, patients with diabetes or multiple sclerosis, patients with acquired immunodeficiency disease syndrome/human immunodeficiency virus, and patients with underlying urologic abnormalities. Catheter-associated UTI is the most common nosocomial infection, accounting for >1 million cases in hospitals and nursing homes. The risk of UTI increases with increasing duration of catheterization. In noninstitutionalized elderly populations, UTIs are the second most common form of infection, accounting for nearly 25% of all infections. There are important medical and financial implications associated with UTIs. In the nonobstructed, nonpregnant female adult, acute uncomplicated UTI is believed to be a benign illness with no long-term medical consequences. However, UTI elevates the risk of pyelonephritis, premature delivery, and fetal mortality among pregnant women, and is associated with impaired renal function and end-stage renal disease among pediatric patients. Financially, the estimated annual cost of community-acquired UTI is significant, at approximately $1.6 billion.

Systematic review of chorioamnionitis and cerebral palsy

In a recent meta-analysis evaluating the relationship between chorioamnionitis and cerebral palsy, we found that chorioamnionitis is a risk factor for both cerebral palsy and cystic periventricular leukomalacia (cPVL). The current paper extends the meta-analysis by including studies published in the year 2000, and by further evaluating the causes of heterogeneity among individual study results. Using a random effects model, clinical chorioamnionitis was significantly associated with both cerebral palsy (RR 1.9, 95% CI 1.5-2.5) and cPVL (RR 2.6, 95% CI 1.7-3.9). Sources of heterogeneity included widely varying practices in the diagnosis of clinical chorioamnionitis, different gestational age characteristics, and varying study year. We conclude that based on the available literature, chorioamnionitis is a risk factor for both cerebral palsy and cPVL.

Advances in prevention and treatment of cerebral palsy

In recent years there have been a number of advances in understanding of predisposing and protective factors in the development of cerebral palsy in infants. Multiple gestation births, maternal infection, and maternal and fetal thrombophilic conditions all predispose to the development of CP in the infant. Opportunities for prevention of CP may develop from an improved understanding of these factors and their mechanisms of operation. Similar progress has been made in the evaluation of treatments for CP and the effects of these treatments on the individual's impairment, function, and disability. Selective posterior rhizotomy and Botulinum toxin A are now widely used in the treatment of spasticity. The challenge remains to determine how effectively these promising interventions can alter long-term function and quality of life outcomes in children and adults with CP.

Antenatal and perinatal antecedents of moderate and severe spastic cerebral palsy

Routinely collected perinatal morbidity data were abstracted for 204 cases of moderate and severe spastic cerebral palsy and 816 matched controls. Separate analyses were conducted for cases with birth-weight > or = 2,500 g and birth-weight < 2,500 g. The presence of a congenital abnormality was an important risk factor for cerebral palsy in both groups and further analyses were conducted after dividing the groups according to presence or absence of a congenital abnormality. In the < 2,500 g group, resuscitation needed was clearly identified as a risk factor for cerebral palsy in the group with no congenital abnormalities (adjusted OR=3.4; 95% CI=1.6-7.5) while in the group with congenital abnormalities, none of the risk factors were clearly associated with an increased risk of cerebral palsy. Among the cases with birth-weight > or = 2,500 g, intrauterine hypoxia/birth asphyxia was clearly associated with an increased risk of cerebral palsy (adjusted OR=18.1; 95% CI=1.8-186) in the group with no congenital abnormalities while in the group with congenital abnormalities, none of the factors were clearly associated with an increased risk of cerebral palsy.