Associations between social and behavioural factors and the risk of late stillbirth - findings from the Midland and North of England Stillbirth case-control study

OBJECTIVE

To investigate behavioural and social characteristics of women who experienced a late stillbirth compared with women with ongoing live pregnancies at similar gestation.

DESIGN

Case-control study.

SETTING

41 maternity units in the UK.

POPULATION

Women who had a stillbirth ≥28 weeks' gestation (n = 287) and women with an ongoing pregnancy at the time of interview (n = 714).

METHODS

Data were collected using an interviewer-administered questionnaire which included questions regarding women's behaviours (e.g. alcohol intake and household smoke exposure) and social characteristics (e.g. ethnicity, employment, housing). Stress was measured by the 10-item Perceived Stress Scale.

MAIN OUTCOME MEASURE

Late stillbirth.

RESULTS

Multivariable analysis adjusting for co-existing social and behavioural factors showed women living in the most deprived quintile had an increased risk of stillbirth compared with the least deprived quintile (adjusted odds ratio [aOR] 3.16; 95% CI 1.47-6.77). There was an increased risk of late stillbirth associated with unemployment (aOR 2.32; 95% CI 1.00-5.38) and women who declined to answer the question about domestic abuse (aOR 4.12; 95% CI 2.49-6.81). A greater number of antenatal visits than recommended was associated with a reduction in stillbirth (aOR 0.26; 95% CI 0.16-0.42).

CONCLUSIONS

This study demonstrates associations between late stillbirth and socio-economic deprivation, perceived stress and domestic abuse, highlighting the need for strategies to prevent stillbirth to extend beyond maternity care. Enhanced antenatal care may be able to mitigate some of the increased risk of stillbirth.

TWEETABLE ABSTRACT

Deprivation, unemployment, social stress & declining to answer about domestic abuse increase risk of #stillbirth after 28 weeks' gestation.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Gestational diabetes and the risk of late stillbirth: a case-control study from England, UK

OBJECTIVE

To explore the separate effects of being 'at risk' of gestational diabetes mellitus (GDM) and screening for GDM, and of raised fasting plasma glucose (FPG) and clinical diagnosis of GDM, on the risk of late stillbirth.

DESIGN

Prospective case-control study.

SETTING

Forty-one maternity units in the UK.

POPULATION

Women who had a stillbirth ≥28 weeks of gestation (n = 291) and women with an ongoing pregnancy at the time of interview (n = 733).

METHODS

Causal mediation analysis explored the joint effects of (i) 'at risk' of GDM and screening for GDM and (ii) raised FPG (≥5.6 mmol/l) and clinical diagnosis of GDM on the risks of late stillbirth. Adjusted odds ratios (aOR) were estimated by logistic regression adjusted for confounders identified by directed acyclic graphs.

MAIN OUTCOME MEASURES

Screening for GDM and FPG levels RESULTS: Women 'at risk' of GDM, but not screened, experienced 44% greater risk of late stillbirth than those not 'at risk' (aOR 1.44, 95% CI 1.01-2.06). Women 'at risk' of GDM who were screened experienced no such increase (aOR 0.98, 95% CI 0.70-1.36). Women with raised FPG not diagnosed with GDM experienced four-fold greater risk of late stillbirth than women with normal FPG (aOR 4.22, 95% CI 1.04-17.02). Women with raised FPG who were diagnosed with GDM experienced no such increase (aOR 1.10, 95% CI 0.31-3.91).

CONCLUSIONS

Optimal screening and diagnosis of GDM mitigate the higher risks of late stillbirth in women 'at risk' of GDM and/or with raised FPG. Failure to diagnose GDM leaves women with raised FPG exposed to avoidable risk of late stillbirth.

TWEETABLE ABSTRACT

Risk of #stillbirth in gestational diabetes is mitigated by effective screening and diagnosis.

Association between maternal sleep practices and late stillbirth - findings from a stillbirth case-control study

Objective

To report maternal sleep practices in women who experienced a stillbirth compared with controls with ongoing live pregnancies at similar gestation.

Design

Prospective case‐control study.

Setting

Forty‐one maternity units in the United Kingdom.

Population

Women who had a stillbirth after ≥ 28 weeks’ gestation (n = 291) and women with an ongoing pregnancy at the time of interview (n = 733).

Methods

Data were collected using an interviewer‐administered questionnaire that included questions on maternal sleep practices before pregnancy, in the four weeks prior to, and on the night before the interview/stillbirth.

Main outcome measures

Maternal sleep practices during pregnancy.

Results

In multivariable analysis, supine going‐to‐sleep position the night before stillbirth had a 2.3‐fold increased risk of late stillbirth [adjusted Odds Ratio (aOR) 2.31, 95% CI 1.04–5.11] compared with the left side. In addition, women who had a stillbirth were more likely to report sleep duration less than 5.5 hours on the night before stillbirth (aOR 1.83, 95% CI 1.24–2.68), getting up to the toilet once or less (aOR 2.81, 95% CI 1.85–4.26), and a daytime nap every day (aOR 2.22, 95% CI 1.26–3.94). No interaction was detected between supine going‐to‐sleep position and a small‐for‐gestational‐age infant, maternal body mass index, or gestational age. The population‐attributable risk for supine going‐to‐sleep position was 3.7% (95% CI 0.5–9.2).

Conclusions

This study confirms that supine going‐to‐sleep position is associated with late stillbirth. Further work is required to determine whether intervention(s) can decrease the frequency of supine going‐to‐sleep position and the incidence of late stillbirth.

Tweetable abstract

Supine going‐to‐sleep position is associated with 2.3× increased risk of stillbirth after 28 weeks’ gestation.

Plain Language Summary

Stillbirth, the death of a baby before birth, is a tragedy for mothers and families. One approach to reduce stillbirths is to identify factors that are associated with stillbirth. There are few risk factors for stillbirth that can be easily changed, but this study is looking at identifying how mothers may be able to reduce their risk.

In this study, we interviewed 291 women who had a stillbirth and 733 women who had a live‐born baby from 41 maternity units throughout the UK. The mothers who had a stillbirth were interviewed as soon as practical after their baby died. Mothers who had a live birth were interviewed during their pregnancies at the same times in pregnancy as when the stillbirths occurred. We did not interview mothers who had twins or who had a baby with a major abnormality.

Mothers who went to sleep on their back had at least twice the risk of stillbirth compared with mothers who went to sleep on their left‐hand side. This study suggests that 3.7% of stillbirths after 28 weeks of pregnancy were linked with going to sleep lying on the back. This study also shows that the link between going‐to‐sleep position and late stillbirth was not affected by the duration of pregnancy after 28 weeks, the size of the baby, or the mother's weight. Women who got up to the toilet once or more at night had a reduced risk of stillbirth.

This is the largest of four similar studies that have all shown the same link between the position in which a mother goes to sleep and stillbirth after 28 weeks of pregnancy. Further studies are needed to see whether women can easily change their sleep position in late pregnancy and whether changing the position a mother goes to sleep in reduces stillbirth.

Tweetable abstract

Supine going‐to‐sleep position is associated with 2.3× increased risk of stillbirth after 28 weeks’ gestation.

This paper includes Author Insights, a video abstract available at https://vimeo.com/rcog/authorinsights14967

Measuring the impact of venous leg ulcers on quality of life

OBJECTIVE

To identify health-related quality-of-life (HRQoL) issues in patients with venous leg ulcers, with the aim of generating items for a treatment outcome measure.

METHOD

Thirty-eight patients with venous leg ulcers were interviewed by a psychologist using a semi-structured guide; they also completed a HRQoL questionnaire (modified Skindex). Data from the questionnaire were examined to explore the impact of venous leg ulcers on patients' lives. Interview transcripts were analysed using qualitative methods to identify additional venous leg ulcer-specific HRQoL items.

RESULTS

Skindex scores indicated that older patients had worse HRQoL (p<0.05), as did those with pain and non-healing ulcers. Ulcer duration and size did not correlate with HRQoL. Interviews revealed the following effects of ulceration: pain (80.5%); itching (69.4%); altered appearance (66.7%); loss of sleep (66.6%); functional limitation (58.3%); and disappointment with treatment (50%). Based on the interview transcripts, items were generated and discussed with an expert panel, with a view to including them in a venous leg ulcer-specific HRQoL questionnaire.

CONCLUSION

Disease-specific HRQoL outcome measures should be considered when evaluating treatments for venous leg ulcers.

A single-centre study of 1000 consecutive peribulbar blocks

PURPOSE

To assess the efficacy and safety of the peribulbar block as practised by anaesthetists in a District General Hospital and also to assess the effect of using the 'painless local' subconjunctival injection on the pain of the peribulbar block.

METHOD

Audit data collected from 1000 consecutive patients undergoing peribulbar blocks with 2% lignocaine were analysed. Efficacy was assessed by visual rating scores for operative pain, eye movement, intraocular pressure and reinjection rate, and safety by looking at complications. Comparison of pain of injection scores was used to assess the effect of the 'painless local' injection. Visual rating scores for pain were analysed using the Mann-Whitney U-test.

RESULTS

Akinesia was achieved in 79% of blocks and operative pain scores were very low (median = 0, IQR = 0). All complications recorded were minor and there were no sight- or life-threatening events. The 'painless local' injection given to 499 patients resulted in significantly lower visual rating scores for pain of injection (p<0.05).

CONCLUSION

These data suggest that the peribulbar block is a safe and effective method of providing anaesthesia for eye surgery provided that it is taught methodically and practised by experienced staff. The 'painless local' injection reduces the pain experienced during administration of this block.

Emergency surgery: atavistic refuge of the general surgeon?

A prospective audit of emergency soft-tissue surgery for an eight-week period revealed that general surgical emergency operations were more than twice as common as those undertaken in other soft-tissue specialties. The audit reveals that emergency general surgery needs an increase in resources, an increase in available staff and an increase in the role of the consultant general surgeon on call. An alternative solution would be to admit soft-tissue emergencies by specialty and develop specialist emergency services.

Audit of bloodborne virus infections in injecting drug users in general practice

Two hundred and ninety patients attending a single general practice in Edinburgh were known to have used illegal drugs, 145 of whom were identified as past or present injectors. Data on bloodborne virus infections and immunisation against hepatitis B virus (HBV) were gathered during 1998, attempts were made to improve the level of testing for bloodborne viruses and immunisation against HBV, and follow up was carried out between October 1999 and February 2000. One hundred and fifteen patients were studied in detail. Evidence of previous HBV infection was found in 31 of 71 tested in 1998 (44%) and 40 of 99 tested at follow up (40%). In 1998 54 out of the 75 tested for hepatitis C antibodies (72%) were positive compared with 73 out of 108 (68%) at follow up. Twenty-six of the 80 tested for HIV antibodies were positive in 1998 (33%) and 26 of 105 at follow up (25%). Large numbers of injecting drug users in our study were found to be not immune to hepatitis B and required immunisation. An abbreviated protocol for immunisation was devised, including post vaccination checks and boosting as necessary. Hepatitis C testing was requested after counselling in most cases, resulting in important and positive interventions. Prevention opportunities for all three bloodborne viruses were identified.

Validation of a new noncontact catheter system for electroanatomic mapping of left ventricular endocardium

BACKGROUND

Improvements in cardiac mapping are required to advance our understanding and treatment of arrhythmias. This study validated a new noncontact multielectrode array catheter and accompanying analysis system to provide electroanatomic mapping of the entire left ventricular (LV) endocardium during a single beat.

METHODS AND RESULTS

A 9F 64-electrode balloon array catheter with an inflated size of 1.8x4.6 cm was used to simultaneously record electrical potentials generated by the heart and locate a standard electrophysiology (EP) catheter within the same chamber. By use of the recorded location of the EP-catheter tip, LV geometry was determined. Array potentials served as inputs to a high-order boundary-element method to produce 3360 potential points on the endocardial surface translatable into electrograms or color-coded activation maps. Three methods of validation were used: (1) driven electrodes in an in vitro tank were located; (2) waveforms generated from the array catheter were compared with catheter contact waveforms in canine LV; and (3) sites of local LV endocardial activation were located and marked with radiofrequency lesions. Tank testing located a driven electrode to within 2.33+/-0.44 mm. Correlation of timing and morphology of computed versus contact electrograms was 0.966. Radiofrequency lesions marked 17 endocardial pacing sites to within 4.0+/-3.2 mm.

CONCLUSIONS

This new system provides anatomically accurate endocardial isopotential mapping during a single cardiac cycle. The locator component enabled placement of a separate EP catheter to any site within the mapped chamber.

Intratester and intertester reliability and criterion validity of the parallelogram and universal goniometers for active knee flexion in healthy subjects

BACKGROUND AND PURPOSE

A new parallelogram goniometer was designed by the Rehabilitation Centre of the Royal Ottawa Health Care Group in 1983. The advantage of using such a goniometer is that the clinician is not required to estimate the joint axis of rotation when taking a measurement. The parallelogram goniometer has obtained a good intratester and intertester reliability when measuring active range of motion of hip abduction on eight individuals with hip pathologies. However, the validity of the parallelogram goniometer has not been examined. The purposes of this study were to examine the intratester and intertester reliability and the criterion validity of the parallelogram and universal goniometers for active knee flexion on healthy individuals.

SUBJECTS

Sixty healthy university students (44 females and 16 males; mean age of 20.6 yrs.) participated to this study.

METHODS

Measurements with the universal and parallelogram goniometers were taken in two different positions, the smaller and larger angles of active knee flexion. All measurements were taken by two trained testers. A radiograph was taken in both positions to serve as the 'gold standard'. The sequence of the measurements and radiographs were randomly selected. The intra and intertester reliability of both goniometers were established by calculating the intraclass correlation coefficients (ICCs) using the repeated-measures ANOVA. The criterion validity was examined by calculating Pearson product-moment correlation coefficients (tau) between each goniometric and radiologic measurements. A 0.05 level of significance was chosen for each statistical test.

RESULTS

Intratester reliability ranged from good to excellent for the small angles (ICC = 0.85 and 0.87) and the large angles (ICC = 0.91 and 0.96) when using the parallelogram goniometer. Intertester reliability was fair for the small angles of flexion (ICC = 0.43 to 0.52) and good to excellent for the large angles of flexion (ICC = 0.82 to 0.88). The parallelogram goniometer was found to have greater validity when measuring the large angles of knee flexion (r = 0.73 and 0.77) compared to the small angles of knee flexion (r = 0.33 and 0.41). Similar results of reliability and validity were obtained with the universal goniometer.

CONCLUSION

The results of this study have clinical importance. The use of the parallelogram goniometer was found to be as reliable and valid as the universal goniometer when measuring active knee flexion. However, the parallelogram goniometer offered clinicians the advantages of obtaining precise angular measurements with fewer adjustments, and a faster application technique. Further studies on the parallelogram goniometer are necessary among individuals presenting with altered range of motion at different joints.

Transesophageal echocardiography: Diagnostic and clinical applications in the evaluation of the stroke patient

OBJECTIVES

Transesophageal echocardiography (TEE) is superior to transthoracic echocardiography (TTE) in diagnosing cardiac abnormalities that may result in cerebral embolism. The clinical importance of these abnormalities is unclear.

METHODS

We classified 96 consecutive stroke patients into high- or low-risk groups for cardioembolism based on historical criteria. The presence of left atrial thrombus, atrial smoke, patent foramen ovale, atrial septal aneurysm, and plaque in the ascending aorta was assessed with TEE. Stroke type and other possible stroke mechanisms were evaluated.

RESULTS

Left atrial thrombus occurred only in the high-risk group. Patent foramen ovale, atrial septal aneurysm, and most cases of left atrial smoke occurred in the presence of another embolic source or were associated with a stroke related to hypertensive small vessel disease. Protruding atherosclerotic plaque in the ascending aorta and aortic arch was the most significant cause of stroke diagnosed by TEE because it frequently occurred in those without other risk factors for stroke. TEE identified aortic plaque in one and left atrial smoke in two patients with lacunar infarction without risk factors for small vessel disease.

CONCLUSIONS

TEE should be considered in both lacunar and nonlacunar stroke that occur in the absence of stroke risk factors, although optimal management of most TEE findings is yet to be determined.

A numerical analysis of the geniculocortical input to striate cortex in the monkey

Using data that are available in various publications, a quantitative analysis has been made of the geniculocortical input to layer IVC of the macaque striate cortex. The data suggest that only 1.3-1.9% of the excitatory, or asymmetric synapses in layer IVC alpha of striate cortex are provided by the neurons of the magnocellular layers of the LGN. This amounts to only 18-40 of the 1000-2100 asymmetric synapses that the average layer IVC alpha neuron receives. The parvicellular afferents to layer IVC beta, on the other hand, provide 3.7-8.7% of the asymmetric synapses formed by the average layer IVC beta neuron, or 37-191 synapses to each neuron. If it is assumed that the boutons in the geniculocortical axonal plexuses are evenly spread, it can be calculated that the input to an individual layer IVC neuron is provided by some 24 axonal plexuses. This is regardless of whether the neuron lies in layer IVC alpha or in IVC beta. This calculation suggests that a single axonal plexus provides not more than one or two of the excitatory synapses received by an individual layer IVC alpha neuron, and between one and eight excitatory synapses for a layer IVC beta neuron. Consequently, it is unlikely that the response properties of a particular cortical neuron are dominated by its input from a single geniculate neuron. Since the geniculocortical input essentially determines the response properties of neurons in layer IV of macaque striate cortex, it is surprising that this input amounts to such a small number of synapses to an individual neuron, although we obtained a somewhat similar result in our earlier quantitative analysis of the geniculate input to the striate cortex of the cat (Peters and Payne, 1993). But it has to be questioned whether the low values obtained are correct. Interestingly, the geniculocortical input to cortex has been largely neglected in favor of analyses of intracortical circuitry, but in view of the basic importance of this afferent input, it is suggested that more quantitative data about it should be generated, so that a better assessment can be made of its extent.

Early syphilis. Relationship to sex, drugs, and changes in high-risk behavior from 1987-1990

A case-control study was conducted to evaluate two main questions: 1) which specific sex- and drug-use behaviors are associated with the acquisition of early syphilis; and 2) whether changes in sex- and drug-use behaviors from 1987-1990 associated with acquisition of early syphilis. Risk factors associated with significant odds ratio were greater than four sex partners and lack of condom use in the past 3 months. Crack use within the past 3 months was the only specific drug-related risk factor with a significantly elevated odds ratio. However, a number of risk factors associated with both sex and drugs had significantly elevated odds ratios: number of drug-using partners, number of partners exchanging sex for drugs and money, and number of partners with whom the respondent shares sex and drugs. Risk estimates for early syphilis were uniformly higher for women as compared with men. Women appeared to be at higher risk of syphilis than men when engaged in the same high-risk activities. From 1987-1990, there was a significant change from lower-risk to higher-risk behaviors among patients. Patients showed an increase in their number of sex partners, in drug use, and in other high-risk activities. Increasing rates of syphilis can be attributed to a particular set of sex- and drug-related behaviors, and an increase in the adoption of these behaviors has probably contributed significantly to the increased rate of early syphilis in Trenton, NJ, during the period from 1987-1990.

Family correlates of a 10-year pulmonary health trend in cystic fibrosis

In this study, 33% of the variance in the 10-year trend of forced expiratory volume in 1 second (FEV1), used as an index of pulmonary health, was explained by differences in family characteristics at the start of the study. Balanced family coping, a family emphasis on personal growth, and compliance with treatment for 91 children with cystic fibrosis were assessed at the start of the study and the FEV1 was observed at every clinic visit over the next 10 years. When both parents' coping emphasized family integration, support for self, and medical consultation, the FEV1 trend was better. Compliance with daily chest physical therapy and with quarterly clinic visits was associated with a better FEV1 trend. Poorer FEV1 trend was associated with active social involvement of family members. Older patients and patients whose parents worked more hours outside the home had lower compliance. These findings support the importance of encouraging families to balance their resources between the child's health needs and family needs.

Aortic plaque in patients with brain ischemia: diagnosis by transesophageal echocardiography

We evaluated 183 patients with brain ischemia for an embolic source, using transesophageal echocardiography with extensive imaging of the thoracic aorta. There were mobile, frond-like projections of aortic plaque in seven (4%) patients. The plaque originated on a wide base on the posterior aspect of the ascending aorta at its junction with the transverse arch in six patients, and on the aortic root in one. The acute event was a cerebral infarction in five patients, and a transient ischemic attack in two. This type of aortic plaque could be a previously underdiagnosed source of cerebral embolism that is now easily visualized by transesophageal echocardiography.

The Hungerford shooting incident

Thirty people sustained gunshot injuries on one afternoon in Hungerford, a small rural town in Berkshire. Fourteen people died at the scene of the shootings and three of the 16 patients who were admitted to hospital subsequently died. We describe the management of the 14 patients admitted to Princess Margaret Hospital, Swindon.

Eccentric fixation with macular scotoma

People with macular scotoma tend to read and visually scan more slowly than others with equivalently reduced visual acuity but intact central fields. We measured fixation eye movements and considered the contribution of fixation variability and centripetal eye drift to poor visual performance. These factors might confound efforts to consistently use an optimum retinal locus outside of the macula. We measured monocular horizontal and vertical eye movements using a search coil eyetracker while subjects with naturally occurring central scotomata or control subjects with simulated scotomata eccentrically fixated a single character that was sized to their visual acuity. Motivated subjects with long-standing stable maculopathies were chosen to estimate attainable performance limits. During attempts to eccentrically fixate, an ubiquitous foveal pursuit or centripetal drift tendency was not found; rather a pattern of drift was idiosyncratic from subject to subject. This finding was confirmed by an analysis of eye drift of 32 eyes with long-standing bilateral macular scotomata. Moreover, the eye drift speeds (15-200 minarc/sec) were too low to be of functional significance. Drift speeds during eccentric fixation with a visible target were not significantly different than those after the target was extinguished; however, drift speeds were greater than during foveal fixation. This suggests that the fovea has a specialized control of slow eye movements. Fixation variability increased with scotoma size for both simulated and real scotomata, with an abrupt rise when scotomata diameters exceeded 20 degrees C. A significant minority of subjects (39%) adopted two or more distinct preferred retinal loci (PRL) during fixation. Multiple PRL were also more likely if scotoma size exceeded 20 degrees C. Reasonably steady fixation is thus attainable when central scotoma sizes are smaller than approximately 20 degrees C.

Laxatives after hemorrhoidectomy

Thirty patients undergoing a standard Milligan-Morgan hemorrhoidectomy were used for a randomized study of the addition of postoperative laxatives or wheat fiber to the diet. Seventeen patients received wheat fiber; 13 were given a laxative regime of sterculia, magnesium sulfate, and mineral oil. There were no differences between the two groups in preoperative or postoperative bowel habits. Patients receiving wheat fiber had a shorter postoperative hospital stay four days (three to five) vs. five days (three to six), median (range), P less than .01, and suffered less pain after defecation on the day of discharge from the hospital (P less than .05). Fecal leakage or soiling was seen less frequently with wheat fiber than in patients receiving the laxative regime (5/17 vs. 10/13, P less than .05). The authors conclude that wheat fiber added to the diet will produce a satisfactory bowel habit after hemorrhoidectomy, with a lower incidence of fecal leakage and reduced pain after defecation than the usual laxative regime.

A study of two species of fish inoculated with spruce budworm nuclear polyhedrosis virus

Preliminary studies conducted on rainbow trout (Salmo gairdneri) and white suckers (Castostomus commersoni) exposed to spruce budworm nuclear polyhedrosis virus revealed minor histopathologic changes in various organs of each fish which were interpreted as not being significant. However, an evaluation (mean values) of the total changes in groups of fish suggested that a relationship may exist in the suckers exposed to either purified polyhedra or virions. A more extensive and definitive study must be done before any conclusions are warranted.

Mortality of young-of-the-year rainbow smelt (Osmerus mordax) in Lake Erie associated with the occurrence of Glugea hertwigi

An extensive mortality of young-of-the-year rainbow smelt (Osmerus mordax) occurred in Lake Erie during the fall of 1969. Dead and dying smelt were observed along the north shore from west of Long Point in the central basin to Port Maitland in the eastern basin. No other fish species was involved. Glugea hertwigi, a microsporidan parasite, was observed in 90% of the distressed smelt examined, and is believed to have been a major contributing factor to the mortality.

The ultrastructure of the liver of the rainbow trout: normal structure and modifications after chronic administration of a polychlorinated biphenyl Aroclor 1254

Rainbow trout (Salmo gairdneri) were fed dietary levels of 0-, 1-, 10-, and 100-ppm Aroclor 1254 for 229 to 330 days. The ultrastructural features of control livers were similar to those of other animals, but rainbow trout liver differed from mammalian liver in an apparent absence of Kupffer cells. Also small dense duct-type cells were present that formed a transition zone, combining with hepatocytes to form canaliculi; alone they formed preductules and in combination with cells of lower density they formed ductules. Microtubules were found in the vicinity of canaliculi and less frequently adjacent to the plasma membrane of other cell surfaces. They were not seen at the sinusoidal border as they are in mammalian liver. Peroxisomes lacked nucleoids. There were no ultrastructural liver changes in the 1-ppm group. The most frequently encountered alterations in both the 10- and 100-ppm groups were those involving the nucleus. These included irregular and bizarre nuclear outlines, separation of nucleolar components, and large nuclear pseudoinclusions. Other frequently encountered changes were slight increases in smooth endoplasmic reticulum, altered rough endoplasmic reticulum, increased lysosomes, reduced and altered glycogen, increased lipid, and hypoxic vacuoles. Seen also were concentric membrane arrays, myelin figures in intercellular spaces and Golgi cisternae, and bundles of fine tubules throughout the cytoplasm.

Chronic oral exposure of rainbow trout (Salmo gairdneri) to a polychlorinated biphenyl (Aroclor 1254): pathological effects

Groups of eight rainbow trout (Salmo gairdneri) were fed rations containing 0 ppm, 1 ppm, 10 ppm and 100 ppm of the polychlorinated biphenyl, Aroclor 1254, over a period of up to 330 days. Growth rates were unaffected by these levels. Pathological changes were found in the kidneys of 13 fish on the polychlorinated biphenyl ration. Foci of nephrosis with cellular or granular cast formation were seen. The greatest number of cases occured in fish at the 10 ppm concentration. An increase in the number of hepatocytes per unit area was related to the greater concentration of polychlorinated biphenyls in the diet. A reduction in the amount of white pulp in the spleen was observed in 23 of 27 fish on the 10 ppm and 100 ppm diets. The fish with nephrosis had reduced splenic white pulp and lowered white cell counts. Fish fed the 1 ppm and 10 ppm levels had mean tissue residues of 1.4 and 2.3 ppm polychlorinated biphenyl respectively. Fish on the 100 ppm ration had a mean value of 80.1 ppm polychlorinated biphenyl content.

Disseminated intravascular coagulation in mink

Images

Distemper in Raccoons Characterized by Giant-Cell Pneumonitis

Images

Plasmacytoma with Amyloidosis in a Nutria A Case Report

A fatal neoplastic disease in a nutria is described. The salient features were proliferation of plasma cells and amyloidosis. A comparison is made with the lesions of viral plasmacytosis of mink and multiple myeloma of man.

A Hepatitis-Nephritis Disease of Nutria (Myocastor Coypus) of Probable Viral Etiology

Images