Does variation of surgical technique affect native tissue anterior pelvic organ prolapse repair outcomes?

INTRODUCTION AND HYPOTHESIS

The Variation in Surgical Technique study (VaST), demonstrated the large variation in surgical techniques used in native tissue (NT) anterior pelvic organ prolapse (POP) repairs. However, there are few comparative studies of different surgical techniques. This study was aimed at exploring whether surgical technique influenced the outcomes of NT anterior POP repairs.

METHODS

The surgical techniques of 22 consultant surgeons performing NT anterior POP repairs were filmed and categorised. These surgeons performed 809 anterior repairs within the PROlapse Surgery: Pragmatic Evaluation and randomised Controlled Trial (PROSPECT). Logistical regression models were used to determine the influence of the different surgical techniques on subjective and objective outcomes, using data collected during PROSPECT.

RESULTS

In adjusted multivariate linear regression models, fascial-flap repair was associated with an improved subjective outcome (POP-SS) compared with midline plication (β = -2.50 [-4.42 to -0.57]; p = 0.01). At 12 months, separate fascial defect repair was associated with a poorer objective outcome than midline plication (OR 6.06 [1.82-3.52], p = 0.006). At 24 months, deep dissection was associated with a poorer POP-SS than superficial dissection (0.32-2.60, p = 0.0). Continuous-locking closure of the skin was also associated with improved POP-SS compared with continuous non-locking closure (12 months: β = -1.94 [-3.42 to -0.45], p = 0.01).

CONCLUSION

Surgical technique may influence the outcome of native tissue anterior POP repairs. Our results should not change practice but inform future research; to develop methods of explicitly recording surgical techniques and allow confirmation of the effect of these aspects of technique on outcome.

Accessing support and empowerment online: The experiences of individuals with diabetes

CONTEXT

The use of the internet for health information by those with long-term conditions is growing. It has been argued that this represents a form of empowerment by patients, as it enables them to control the content and flow of the information available to them. To explore this, the use of online discussion groups by those with diabetes was examined.

METHOD

Semi-structured interviews were conducted with 21 participants with type 1 and 2 diabetes and analysed using thematic analysis. Participants were recruited via online and offline routes, namely discussion boards, newsletters, and research networks related to diabetes.

RESULTS

By drawing on the advice, information, and support shared online, participants were empowered to position themselves as active participants in their own health care and to further engage with health-care professionals.

CONCLUSION

The findings indicate that forums can play a valuable role in aiding and motivating individuals in the daily management diabetes and highlight how this support is used to complement formal health services. However, more work needs to be carried out to determine to explore when and under what circumstances online support may be particularly beneficial to those with long-term conditions.

An evidence-based approach to the use of telehealth in long-term health conditions: development of an intervention and evaluation through pragmatic randomised controlled trials in patients with depression or raised cardiovascular risk

Background

Health services internationally are exploring the potential of telehealth to support the management of the growing number of people with long-term conditions (LTCs).

Aim

To develop, implement and evaluate new care programmes for patients with LTCs, focusing on two common LTCs as exemplars: depression or high cardiovascular disease (CVD) risk.

Methods

Development

We synthesised quantitative and qualitative evidence on the effectiveness of telehealth for LTCs, conducted a qualitative study based on interviews with patients and staff and undertook a postal survey to explore which patients are interested in different forms of telehealth. Based on these studies we developed a conceptual model [TElehealth in CHronic disease (TECH) model] as a framework for the development and evaluation of the Healthlines Service for patients with LTCs.

Implementation

The Healthlines Service consisted of regular telephone calls to participants from health information advisors, supporting them to make behaviour change and to use tailored online resources. Advisors sought to optimise participants’ medication and to improve adherence.

Evaluation

The Healthlines Service was evaluated with linked pragmatic randomised controlled trials comparing the Healthlines Service plus usual care with usual care alone, with nested process and economic evaluations. Participants were adults with depression or raised CVD risk recruited from 43 general practices in three areas of England. The primary outcome was response to treatment and the secondary outcomes included anxiety (depression trial), individual risk factors (CVD risk trial), self-management skills, medication adherence, perceptions of support, access to health care and satisfaction with treatment.

Trial results

Depression trial

In total, 609 participants were randomised and the retention rate was 86%. Response to treatment [Patient Health Questionnaire 9-items (PHQ-9) reduction of ≥ 5 points and score of < 10 after 4 months] was higher in the intervention group (27%, 68/255) than in the control group (19%, 50/270) [odds ratio 1.7, 95% confidence interval (CI) 1.1 to 2.5;p = 0.02]. Anxiety also improved. Intervention participants reported better access to health support, greater satisfaction with treatment and small improvements in self-management, but not improved medication adherence.

CVD risk trial

In total, 641 participants were randomised and the retention rate was 91%. Response to treatment (maintenance of/reduction in QRISK®2 score after 12 months) was higher in the intervention group (50%, 148/295) than in the control group (43%, 124/291), which does not exclude a null effect (odds ratio 1.3, 95% CI 1.0 to 1.9;p = 0.08). The intervention was associated with small improvements in blood pressure and weight, but not smoking or cholesterol. Intervention participants were more likely to adhere to medication, reported better access to health support and greater satisfaction with treatment, but few improvements in self-management.

The Healthlines Service was likely to be cost-effective for CVD risk, particularly if the benefits are sustained, but not for depression. The intervention was implemented largely as planned, although initial delays and later disruption to delivery because of the closure of NHS Direct may have adversely affected participant engagement.

Conclusion

The Healthlines Service, designed using an evidence-based conceptual model, provided modest health benefits and participants valued the better access to care and extra support provided. This service was cost-effective for CVD risk but not depression. These findings of small benefits at extra cost are consistent with previous pragmatic research on the implementation of comprehensive telehealth programmes for LTCs.

Trial registration

Current Controlled Trials ISRCTN14172341 (depression trial) and ISRCTN27508731 (CVD risk trial).

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Integration, influence and change in public health: findings from a survey of Directors of Public Health in England

BACKGROUND

Following the Health and Social Care Act in England, public health teams were formally transferred from the NHS to local authorities in April 2013.

METHODS

Online survey of Directors of Public Health (DsPH) in local authorities in England (n = 152) to investigate their experience within local government 1 year on. Tests of association were used to explore relationships between the perceived integration and influence of public health, and changes in how the public health budget was being spent.

RESULTS

The organization of and managerial arrangements for public health within councils varied. Most DsPH felt that good relationships had been established within the council, and the move had made them more able to influence priorities for health improvement, even though most felt their influence was limited. Changes in commissioning using the public health budget were already widespread and included the de-commissioning of services.

CONCLUSIONS

There was a widespread feeling amongst DsPH that they had greater influence since the reforms, and that this went across the local authority and beyond. Public health's influence was most apparent when the transfer of staff to local government had gone well, when collaborative working relationships had developed, and when local partnership groups were seen as being effective.

"I Always Vet Things": Navigating Privacy and the Presentation of Self on Health Discussion Boards Among Individuals with Long-Term Conditions

Background

The ethics of research into online communities is a long-debated issue, with many researchers arguing that open-access discussion groups are publically accessible data and do not require informed consent from participants for their use for research purposes. However, it has been suggested that there is a discrepancy between the perceived and actual privacy of user-generated online content by community members.

Objective

There has been very little research regarding how privacy is experienced and enacted online. The objective of this study is to address this gap by qualitatively exploring the expectations of privacy on Internet forums among individuals with long-term conditions.

Methods

Semistructured interviews were conducted with 20 participants with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and 21 participants with type 1 and 2 diabetes mellitus, and were analyzed using thematic analysis. Participants were recruited via online and offline routes, namely forums, email lists, newsletters, and face-to-face support groups.

Results

The findings indicate that privacy online is a nebulous concept. Rather than individuals drawing a clear-cut distinction between what they would and would not be comfortable sharing online, it was evident that these situations were contextually dependent and related to a number of unique and individual factors.

Conclusions

Interviewees were seen to carefully manage how they presented themselves on forums, filtering and selecting the information that they shared about themselves in order to develop and maintain a particular online persona, while maintaining and preserving an acceptable level of privacy.

"You get to know the people and whether they're talking sense or not": Negotiating trust on health-related forums

The internet is increasingly being used as a source of health advice and information by individuals with long term conditions (LTCs). Specifically, online forums allow people to interact with others with similar conditions. However, it is not clear how online health information is assessed by those with LTCs. This study aims to address this gap by exploring how individuals with contested and uncontested LTCs utilise internet forums. Semi-structured interviews were conducted with 20 participants with ME/CFS and 21 participants with type 1 and 2 diabetes and analysed using thematic analysis. Participants were recruited via online and offline routes, namely forums, email lists, newsletters, and face-to-face support groups. The findings indicate that the use of online forums was a complex and nuanced process and was influenced by a number of individual and illness-specific factors. Participants trusted those with similar experiences and perspectives as themselves, while also valuing conventional biomedical information and advice. By accessing support online, forum users were able to draw on a personalised form of support based on the lived experiences of their peers. However, the role of digital literacy in developing and maintaining online relationships must be acknowledged.

•

The use of online forums by individuals with LTCs is a complex and nuanced process.

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Participants trust those with similar experiences and perspectives as themselves.

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Users can access a personalised form of support based on the experiences of peers.

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Role of digital literacy in developing online relationships must be acknowledged.

Abstract P6-04-10: Clinicopathological and molecular characteristics of pleomorphic invasive lobular carcinoma of breast

Background: Pleomorphic invasive lobular carcinoma (PILC) is described as a distinct morphological variant of invasive lobular carcinoma (ILC) but its clinical behavior is not well characterized. PILCs have loss of E-cadherin similar to ILCs but have distinct morphological features like nuclear contour irregularity, a single prominent nucleolus, increased hyperchromasia and more frequent mitoses. In addition, some studies have reported that PILCs have acquired further molecular alterations such as gain of HER2/neu, amplification of c-myc and loss of p53. To the best of our knowledge there have been no studies evaluating Phosphoinositide 3 kinase/Akt/mammalian (or mechanistic) target of rapamycin (PI3K/Akt/mTOR) pathway in PILC. We hypothesize that there is increased activation of PI3K/Akt/mTOR pathway in PILC compared to ILC. Activation of the PI3k/Akt/mTOR pathway was evaluated by quantifying protein expression of phosphatase and tensin homolog (PTEN) and phosphorylated-S6 kinase1 (p-S6K1). PTEN is a negative regulator of the PI3K pathway and its loss/decreased expression (by mutation or allelic imbalance) activates downstream signaling. Loss (or decrease) of PTEN expression has been reported to be associated with PI3K pathway activation in more than 50% of ER+ breast tumors. Since PI3K pathway can be activated by other mechanisms in addition to PTEN loss, we hypothesized that evaluation of pS6K1 may predict activation of this pathway more than PTEN protein expression alone.

Methods: We conducted a retrospective translational study at the University of Arizona Cancer Center. Our Pathology database was searched to identify PILCs from 2012-2014. Two investigators reviewed the pathology reports independently and abstracted clinocopathological data. Formalin-fixed paraffin embedded (FFPE) primary PILCs were stained for PTEN and pS6K1 expression. Expression of PTEN and pS6K1 was quantified by long score methodology as low (≤ 10), moderate (11-50) or high (≥ 50) expression.

Results: We identified 19 patients with PILC. All tumors were either moderately (n=10) or poorly differentiated (n=9). Estrogen receptor (ER) was positive in all, progesterone receptor (PR) was positive in 11(52%) and HER2 was negative in all tumors. Proliferation index (Ki67) was elevated in all tumors (median 32%, range 20-70%). Lymph nodes were involved with metastatic carcinoma in 7 patients (negative in 9 and unknown in 3). The 21-gene recurrence score assay (Oncotype Dx) was performed in 10 patients and demonstrated higher scores (median 23, range 6-36) with the majority being in the intermediate or high range (8/10). Expression of PTEN and p-S6K1 was quantified on 10 FFPE tumor tissues. PTEN expression was high in all while pS6K1 was high in 8 and low in 2 tumors.

Conclusion: PILCs are a biologically distinct group of ILC. Clinicopathological characteristics suggest they would have a more clinically aggressive behavior (higher grade, high proliferative index and 21 gene recurrence score). In addition, our results indicate that PI3k/Akt/mTOR pathway in activated in majority of these tumors and that PTEN is not the key regulator of this pathway. Genomic profiling is currently underway to further analyze other causes of pathway activation.

Citation Format: Segar J, Baker AF, MacKerricher W, Nagle R, Livingston R, Clarke K, Ley M, Viscusi R, Gonzalez V, LeBeau L, Chalasani P. Clinicopathological and molecular characteristics of pleomorphic invasive lobular carcinoma of breast. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-04-10.

Leadership for health commissioning in the new NHS

PURPOSE

The purpose of this paper is to explore the early experiences of those involved with the development of Clinical Commissioning Groups (CCGs), examining how the aspiration towards a "clinically-led" system is being realised. The authors investigate emerging leadership approaches within CCGs in light of the criterion for authorisation that calls for "great leaders".

DESIGN/METHODOLOGY/APPROACH

Qualitative research was carried out in eight case studies (CCGs) across England over a nine-month period (September 2011 to May 2012) when CCGs were in their early development. The authors conducted a mix of interviews (with GPs and managers), observations (at CCG meetings) and examined associated documentation. Data were thematically analysed.

FINDINGS

The authors found evidence of two identified approaches to leadership - positive deviancy and responsible guardianship - being undertaken by GPs and managers in the developing CCGs. Historical experiences and past ways of working appeared to be influencing current developments and a commonly emerging theme was a desire for the CCG to "do things differently" to the previous commissioning bodies. The authors discuss how the current reorganisation threatens the guardianship approach to leadership and question if the new systems being implemented to monitor CCGs' performance may make it difficult for CCGs to retain creativity and innovation, and thus the ability to foster the positive deviant approach to leadership.

ORIGINALITY/VALUE

This is a large scale piece of qualitative research carried out as CCGs were beginning to develop. It provides insight into how leadership is developing in CCGs highlighting the complexity involved in these roles.

TElehealth in CHronic disease: mixed-methods study to develop the TECH conceptual model for intervention design and evaluation

OBJECTIVE

To develop a conceptual model for effective use of telehealth in the management of chronic health conditions, and to use this to develop and evaluate an intervention for people with two exemplar conditions: raised cardiovascular disease risk and depression.

DESIGN

The model was based on several strands of evidence: a metareview and realist synthesis of quantitative and qualitative evidence on telehealth for chronic conditions; a qualitative study of patients' and health professionals' experience of telehealth; a quantitative survey of patients' interest in using telehealth; and review of existing models of chronic condition management and evidence-based treatment guidelines. Based on these evidence strands, a model was developed and then refined at a stakeholder workshop. Then a telehealth intervention ('Healthlines') was designed by incorporating strategies to address each of the model components. The model also provided a framework for evaluation of this intervention within parallel randomised controlled trials in the two exemplar conditions, and the accompanying process evaluations and economic evaluations.

SETTING

Primary care.

RESULTS

The TElehealth in CHronic Disease (TECH) model proposes that attention to four components will offer interventions the best chance of success: (1) engagement of patients and health professionals, (2) effective chronic disease management (including subcomponents of self-management, optimisation of treatment, care coordination), (3) partnership between providers and (4) patient, social and health system context. Key intended outcomes are improved health, access to care, patient experience and cost-effective care.

CONCLUSIONS

A conceptual model has been developed based on multiple sources of evidence which articulates how telehealth may best provide benefits for patients with chronic health conditions. It can be used to structure the design and evaluation of telehealth programmes which aim to be acceptable to patients and providers, and cost-effective.

Under-representation of women on governing bodies: women general practitioners on Clinical Commissioning Groups in England

Recently formed Clinical Commissioning Groups in the English National Health Service have important responsibility for commissioning local health and care services. Women are under-represented on the governing bodies of these significant primary care based organizations despite the fact that they constitute almost half of the general practitioner workforce in England. This essay examines some of the reasons for this under-representation including the predominance of women in the salaried and part-time sector of general practice and gendered management styles within the National Health Service. It is argued that the under-representation of women on Clinical Commissioning Group governing bodies matters in terms of social justice, representation of the broader community and role models.

Views of NHS commissioners on commissioning support provision. Evidence from a qualitative study examining the early development of clinical commissioning groups in England

OBJECTIVE

The 2010 healthcare reform in England introduced primary care-led commissioning in the National Health Service (NHS) by establishing clinical commissioning groups (CCGs). A key factor for the success of the reform is the provision of excellent commissioning support services to CCGs. The Government's aim is to create a vibrant market of competing providers of such services (from both for-profit and not-for-profit sectors). Until this market develops, however, commissioning support units (CSUs) have been created from which CCGs are buying commissioning support functions. This study explored the attitudes of CCGs towards outsourcing commissioning support functions during the initial stage of the reform.

DESIGN

The research took place between September 2011 and June 2012. We used a case study research design in eight CCGs, conducting in-depth interviews, observation of meetings and analysis of policy documents.

SETTING/PARTICIPANTS

We conducted 96 interviews and observed 146 meetings (a total of approximately 439 h).

RESULTS

Many CCGs were reluctant to outsource core commissioning support functions (such as contracting) for fear of losing local knowledge and trusted relationships. Others were disappointed by the absence of choice and saw CSUs as monopolies and a recreation of the abolished PCTs. Many expressed doubts about the expectation that outsourcing of commissioning support functions will result in lower administrative costs.

CONCLUSIONS

Given the nature of healthcare commissioning, outsourcing vital commissioning support functions may not be the preferred option of CCGs. Considerations of high transaction costs, and the risk of fragmentation of services and loss of trusted relationships involved in short-term contracting, may lead most CCGs to decide to form long-term partnerships with commissioning support suppliers in the future. This option, however, limits competition by creating 'network closure' and calls into question the Government's intention to create a vibrant market of commissioning support provision.

Accountable to whom, for what? An exploration of the early development of Clinical Commissioning Groups in the English NHS

OBJECTIVE

One of the key goals of the current reforms in the English National Health Service (NHS) under the Health and Social Care Act, 2012, is to increase the accountability of those responsible for commissioning care for patients (clinical commissioning groups (CCGs)), while at the same time allowing them a greater autonomy. This study was set out to explore CCG's developing accountability relationships.

DESIGN

We carried out detailed case studies in eight CCGs, using interviews, observation and documentary analysis to explore their multiple accountabilities.

SETTING/PARTICIPANTS

We interviewed 91 people, including general practitioners, managers and governing body members in developing CCGs, and undertook 439 h of observation in a wide variety of meetings.

RESULTS

CCGs are subject to a managerial, sanction-backed accountability to NHS England (the highest tier in the new organisational hierarchy), alongside a number of other external accountabilities to the public and to some of the other new organisations created by the reforms. In addition, unlike their predecessor commissioning organisations, they are subject to complex internal accountabilities to their members.

CONCLUSIONS

The accountability regime to which CCGs are subject to is considerably more complex than that which applied their predecessor organisations. It remains to be seen whether the twin aspirations of increased autonomy and increased accountability can be realised in practice. However, this early study raises some important issues and concerns, including the risk that the different bodies to whom CCGs are accountable will have differing (or conflicting) agendas, and the lack of clarity over the operation of sanction regimes.

Roles and identities in transition: boundaries of work and inter-professional relationships at the interface between telehealth and primary care

Shifting the balance of care towards home and community is viewed as requiring interventions which enhance or complement primary care. Technology-based interventions are seen as key to the future in this work. Telehealthcare implicates a new agenda for inter-professional working across boundaries of healthcare. One such interface is between telehealthcare professionals and professionals located in primary care. This study reports the findings from a qualitative study forming part of a broader project examining the potential of developing and implementing telehealth interventions to support patients with long-term conditions. Semi-structured interviews were undertaken with telehealth nurse care managers, practice nurses and general practitioners in their respective work settings (39 interviews with 62 participants). Observation was undertaken at a telehealth call centre. The research took place between April 2010 and March 2011. Thematic analysis of qualitative data was undertaken. Telehealth nurse care managers' interviews suggested narrative constructions of new roles and identities to fit telehealth work, combining a holistic ideal and retro-appeal with 'traditional' values of nursing, which distinguished and distanced them from counterparts in general practices. Practice nurses and general practitioners were ambivalent and often sceptical about the contribution of telehealth to long-term condition work. Practice nurses' accounts suggested a sense of protectiveness about maintaining boundaries around established remits of managing long-term conditions; general practitioners, having devolved much of the care of long-term conditions to nurses, were keen to retain their positions as gatekeepers to resources. Perceptions of shifts of professional roles, new ways of working and how they are valued form a relevant contextual element to the introduction of telehealth interventions. A pre-emptive view and response to how professionals understand and approach increasingly complex and multi-faceted roles within primary care is likely to prepare and facilitate the introduction and integration of telehealth innovations into existing patient services.

Personal Budgets, Choice and Health

Personal or individual budgets for purchasing health and social care are intended to offer more choice, control and flexibility to service users when compared with agency-directed care. They are becoming an increasingly common feature in high-income countries for purchasing personal care that often lies on the border line between health and social care. In England, they have recently been introduced explicitly for the purchasing of health care. There are some key motivations behind their introduction: they are expected to give individuals more choice about care they receive; to expand options for care; to improve outcomes; and to reduce expenditure. This paper draws from a review of the international evidence on personal budgets which identified: descriptive detail on personal budget schemes in 11 OECD countries to examine their key features and implementation processes; empirical evidence on the experiences of, and outcomes for, people using these schemes, and; empirical evidence regarding the impact of the schemes on the healthcare system, particularly with regards to resources. The paper examines the motivating factors behind personal budget schemes in light of this evidence. It concludes that there is little in the evidence to suggest that international governments' expectations for personal budget programmes are well-founded. The assumptions that they improve choice, and that more choice will in turn lead to greater autonomy and then improved outcomes at lower cost, are actually far more complex and generally unsupported by evidence.

Complementary and alternative medicine: Exploring the gap between evidence and usage

Debates over the efficacy of complementary and alternative medicine (CAM) are highly polarized and have received much publicity of late. While ‘believers’ in CAM campaign for its integration into the NHS, ‘sceptics’ call for the withdrawal of any public funding for such services. These debates take place in the context of a steady rise in CAM usage both in the UK and abroad. Critics of CAM often point to the lack of scientific evidence demonstrating its efficacy. The lack of evidence gathered by means of randomized controlled trials is often used to make the claim that CAM is no more effective than placebo. This article examines some of the debates surrounding the use of evidence-based medicine to assess the efficacy of CAM. It also explores a number of issues pertaining to CAM and the placebo response including the moral questions surrounding the knowing use of placebo as therapy. The rest of the article presents material from a qualitative study carried out in northern England on the understandings of CAM efficacy. The material shows that CAM therapists and patients do not reflect the polarities evident in the public debate in their own understanding and usage of CAM. Rather they are pragmatic pluralists with clear ideas about when CAM treatment is appropriate and often have sophisticated insights into the placebo response. The article concludes with a brief discussion of the implications of these findings for future work in the growing field of CAM research.

Hard lives and evil winds: illness aetiology and the search for healing amongst Ciskeian villagers

This paper examines the explanations for illness used by Ciskeian villagers to account for conditions ranging from diarrhoea and tuberculosis to anxiety and hypertension. Explanations recognise the links between illness and hard physical labour, poor working conditions and poverty whilst also acknowledging supernatural grounds for affliction. The healing resources available to villagers, which are outlined here, include state-run health facilities, a large number of private biomedical practitioners, a variety of indigenous therapists-including religious healers-and a store of common knowledge. In keeping with recent developments within critical medical anthropology, this paper seeks to analyse illness aetiology and health seeking behaviour within the broad social and economic context of individual lives. In Ciskei, one of South Africa's former nominally independent homelands, that context includes high levels of unemployment, dependence on migrant labour earnings and on welfare payments, lack of infrastructure such as water supply and transportation and a significant degree of economic differentiation between households. Against this backdrop, individual case studies will be examined which will illustrate how degrees of powerlessness and lack of disposable income affect both explanations of illness causation and health seeking behaviour among Ciskeian villagers.

Neural control of renal hemodynamics and function during development

This review summarizes our current understanding of the role of the renal sympathetic nervous system during development. Recent evidence suggests that renal innervation appears early during fetal life and may play an important role in promoting cellular development. It has also been observed that renal nerve stimulation decreases renal blood flow and increases renal vascular resistance in fetal sheep, but to a lesser extent than in newborn and adult sheep. Moreover, it has been shown that, contrary to previous findings in adult animals, renal nerve stimulation during alpha-adrenoceptor blockade induces renal vasodilation in fetal and newborn sheep, but not in adult sheep. Recent studies have also demonstrated that renal nerves modulate the natriuretic response to a saline load in newborn lambs and influence sodium reabsorption in near-term fetal sheep. The role of renal nerves and neuronally released norepinephrine on renin secretion in the developing kidney is discussed. Finally, it is suggested that efferent renal sympathetic nerve activity might influence fetal renal hemodynamics during stressful conditions.