The Role of Computed Tomography and Radiographs in the Management of Intertrochanteric Fractures

Introduction

The Intertrochanteric fracture is a common hip trauma encountered in elderly patients. There is a lack of general agreement regarding its surgical management and choice of implant. Purpose of this study to conclude the final decision matrix regarding surgical management of intertrochanteric fractures based on parameters assessed on plain radiographs and CT scan.

Materials and methods

We have retrospectively evaluated 55 patients with intertrochanteric fractures presented to our institute after informed consent with radiographs and CT scans between July 2017 to July 2018. Assessment of various parameters regarding fracture geometry and classification as well as measurement was done.

Results

Mean lateral wall thickness in present study was 20.76mm. Incidence of coronal fragments was 90.9% and absence of coronal fragment in 5 patients. We noted the cases with anterior comminution had also a posterior comminution rendered the fracture unstable in almost 20 % cases.

Conclusion

Better understanding of fracture geometry by combined used of radiograph and CT scan enhanced preoperative planning, choice of suitable implant, helps in reduction manoeuvre and improving quality of osteosynthesis.

Partial Protection From Lupus-Like Disease by B-Cell Specific Type I Interferon Receptor Deficiency

Systemic lupus erythematosus (SLE) is an autoimmune disease that can present with many different permutations of symptom presentation. A large subset of SLE patients have been shown to present with elevated interferon stimulated gene (ISG) expression, and Type I IFNs (IFNαβ) have been shown to drive disease in murine models through global IFNα Receptor (IFNAR) knockouts. However, the disease contribution of distinct immune cell subsets in response to constitutively increased levels of IFNαβ is not fully understood. We utilized a B-cell specific IFNAR knockout (BΔIFNAR) on the B6.Nba2 spontaneous-lupus background to determine the contribution of IFNαβ stimulated B cells in disease. We found that IFNαβ signaling in B cells is driving increased splenomegaly, increased populations of activated B cells, and increased populations of germinal center (GC) B cells, memory B cells, and plasma blasts/cells, but did not affect the development of glomerulonephritis and immune-complex deposition. IFNAR expression by B cells also drove production of anti-chromatin IgG, and anti-dsDNA and -nRNP IgG and IgG_2C auto-antibody levels, as well as increased Bcl2 expression, affecting GC B cell survival in B6.Nba2 mice.

A case-control study of epidemiological factors associated with leptospirosis in South Gujarat region

BACKGROUND

The current study was planned to identify the epidemiological factors associated with leptospirosis in South Gujarat region using neighborhood controls.

METHODS

A total of 100 cases of leptospirosis occurred in South Gujarat region during the year 2012 were selected using simple random sampling. Three neighbors of the selected cases formed the controls (n = 300). A pretested structured questionnaire was used for data collection and data were analyzed using Epi Info 2007.

RESULTS

There was significant association of illiteracy (odds ratio [OR] =1.82, 95% confidence interval [CI] =1.14-2.89), working in waterlogged fields during the reference season (OR = 4.6, 95% CI = 1.6-17.9), swimming/bathing in canals, open air defecation practices, storage of cow dung in or surrounding house, residence in the house made up of cow dung walls, households with access of food to rodents, injuries over hands/foot during the endemic season (OR = 3, 95% CI = 1.8-4.8), and history of skin disease during the endemic season (OR = 4.2, 95% CI = 2-8.5), with leptospirosis. Only 10% of individuals had gumboots for protection. A total of 83 (83%) cases and 240 (80%) controls had taken oral doxycycline chemoprophylaxis (P > 0.05). Cases had taken chemoprophylaxis for a median 4 weeks (range: 1-8) while controls had taken the same for median 8 weeks (range = 1-8) (P < 0.002).

CONCLUSIONS

Although the commonly established factors appear to be associated with leptospirosis, the role of host factors seems to play a more important role in determining susceptibility to leptospirosis in exposed individuals.

Memory deficits associated with khat (Catha edulis) use in rodents

Khat products and chewing practices are common in East Africa, Middle East for centuries with concomitant socio-economic and public health repercussions. We assessed memory deficits associated with khat use in rodents. Young male CBA mice, 5-7 weeks old (n = 20), weighing 25-35 g were used. Mice were treated with either 40, 120 or 360 mg/kg body weight (bw) methanolic khat extract, or 0.5 ml saline for 10 days. Spatial acquisition, reversal and reference memory were assessed using modified Morris Water maze (MMWM). Mice treated with 40 mg/kg khat extract had longer (t4 = 4.12 p = 0.015) and t4 = 2.28 p = 0.065) escape latency on first and second day during reversal relative to the baseline. Under 120 mg/kg khat dose, the escape latency was shorter (t4 = -2.49 p = 0.05) vs (t3 = -2.5 p = 0.05) on third and fourth day. Further, treatment with 360 mg/kg khat extract resulted in significantly longer time (49.13, 33.5, 40.2 and 35.75) vs. (23.5 s), compared to baseline. Mice treated with khat or control preferred the target quadrant post acquisition while differential pattern was seen during reversal phase. Mice treated with 40 or 120 mg/kg khat showed significant preference for target quadrant. Substantial time (19.9) was spent in the old target compared to the new (16.9 s) by animals treated with highest dose however, the difference was not significant. There is a biological plausibility that chronic khat use may induce memory deficits and impair cognitive flexibility. The differential patterns of memory deficits may reflect the differences in dose effect as well as time dependent impairment.

Acne vulgaris, probiotics and the gut-brain-skin axis: from anecdote to translational medicine

Acne vulgaris has long been postulated to feature a gastrointestinal mechanism, dating back 80 years to dermatologists John H. Stokes and Donald M. Pillsbury. They hypothesised that emotional states (e.g. depression and anxiety) could alter normal intestinal microbiota, increase intestinal permeability, and contribute to systemic inflammation. They were also among the first to propose the use of probiotic Lactobacillus acidophilus cultures. In recent years, aspects of this gut-brain-skin theory have been further validated via modern scientific investigations. It is evident that gut microbes and oral probiotics could be linked to the skin, and particularly acne severity, by their ability to influence systemic inflammation, oxidative stress, glycaemic control, tissue lipid content, and even mood. This intricate relationship between gut microbiota and the skin may also be influenced by diet, a current area of intense scrutiny by those who study acne. Here we provide a historical background to the gut-brain-skin theory in acne, followed by a summary of contemporary investigations and clinical implications.

Reverse halo sign on chest imaging in a renal transplant recipient

Without proper treatment, the mortality of pulmonary mucormycosis is nearly 100%. Although the diagnosis is often made histologically, it can be suspected when patients have a reverse halo sign on computed tomography (CT) of the chest, along with the right clinical findings. We describe the case of a woman 7 months post renal transplant who presented with fevers, malaise, and chest pain. Her chest CT revealed a round, focal area of ground-glass attenuation surrounded by a complete rim of consolidation in the left upper lobe, consistent with the reverse halo sign. Pulmonary mucormycosis was diagnosed by transbronchial lung biopsy. She was successfully treated with combined medical and surgical therapies. In the context of this case, we provide a brief review of the diagnosis of pulmonary mucormycosis, with a focus on radiographic and pathologic findings.

Naked mole-rats: behavioural phenotyping and comparison with C57BL/6 mice

Naked mole-rats (NMR) live underground in large eusocial colonies in East Africa. They are extremely long-lived, some individuals having a lifespan of over 30 years. This has attracted research into longevity and possibly neurodegenerative disorders. However, very little is known about their basic behaviour, particularly in tests commonly used to characterise the behaviour of the laboratory rat and mouse, for which there is an enormous database. Recently the authors carried out comprehensive behavioural phenotyping on NMRs, comparing them on most tasks directly with C57BL/6 mice, the strain for which there is the largest behavioural database. The NMR colony had been obtained from the wild originally, but housed in an animal facility for about two years. Large inter-species differences in behaviour were seen between the mice and the NMRs. The latter had generally poor sensorimotor function, including cutaneous sensation, strength and even grasp reflexes. They were often reluctant to enter or head-dip into small holes that mice readily entered. Their vision (generally considered to be very poor) was sufficient to distinguish the two zones of a light-dark box. Although, as expected, the NMRs were capable of burrowing and digging, when individually housed they did not shred cotton material to make nests. Shredding was seen in a colony cage containing a queen, but no nests were made there even when a nesting box was provided. In cognitive testing, although, unlike mice and rats, they did not spontaneously alternate in a T-maze, they learnt rewarded alternation and a cued position task well. This study demonstrates how behaviour uniquely reflects the natural environment in which these unusual animals have evolved and live, and provides baseline data for future work.

Synthesis and Antibacterial and Antifungal Studies of Novel Nitrogen Containing Heterocycles from 5-Ethylpyridin-2-ethanol

A novel series of chalcones, pyrimidines and imidazolinone is described; chalcones (4a-o) were prepared from the lead molecule 4-[2-(5-ethylpyridin-2-yl)ethoxy]benzaldehyde. Pyrimidine (5a-o) derivatives were prepared from the reaction of chalcones and guanidine nitrate in alkali media. Imidazolinones (6a-o) were synthesized from reaction of pyrimidine and oxazolone derivatives (prepared by Erlenmeyer azlactone synthesis). The structures of the synthesized compounds were assigned on the basis of elemental analysis, IR, (1)H and (13)C NMR spectral data. All the products were screened against different strains of bacteria and fungi. Most of these compounds showed better inhibitory activity in comparison to the standard drugs.

Whole blood cytokine attenuation by cholinergic agonists ex vivo and relationship to vagus nerve activity in rheumatoid arthritis

OBJECTIVE

The central nervous system regulates innate immunity in part via the cholinergic anti-inflammatory pathway, a neural circuit that transmits signals in the vagus nerve that suppress pro-inflammatory cytokine production by an alpha-7 nicotinic acetylcholine receptors (alpha7nAChR) dependent mechanism. Vagus nerve activity is significantly suppressed in patients with autoimmune diseases, including rheumatoid arthritis (RA). It has been suggested that stimulating the cholinergic anti-inflammatory pathway may be beneficial to patients, but it remains theoretically possible that chronic deficiencies in this pathway will render these approaches ineffective.

METHODS

Here we addressed the hypothesis that inflammatory cells from RA patients can respond to cholinergic agonists with reduced cytokine production in the setting of reduced vagus nerve activity.

RESULTS

Measurement of RR interval variability (heart rate variability, HRV), in RA patients (n = 13) and healthy controls (n = 10) revealed that vagus nerve activity was significantly depressed in patients. Whole blood cultures stimulated by exposure to endotoxin produced significantly less tumour necrosis factor in samples from RA patients as compared to healthy controls. Addition of cholinergic agonists (nicotine and GTS-21) to the stimulated whole blood cultures however significantly suppressed cytokine production to a similar extent in patients and healthy controls.

CONCLUSION

These findings suggest that it is possible to pharmacologically target the alpha7nAChR dependent control of cytokine release in RA patients with suppressed vagus nerve activity. As alpha7nAChR agonists ameliorate the clinical course of collagen induced arthritis in animals, it may be possible in the future to explore whether alpha7nAChR agonists can improve clinical activity in RA patients.

Khat (Catha edulis) lowers plasma luteinizing hormone (LH) and testosterone secretion, but increases cortisol levels in male rabbits

AIM

This study investigated the effects of fresh khat extract on specific circulating hormones in male rabbits.

MATERIALS AND METHODS

A total of 25 male New Zealand White rabbits were divided into five groups each comprising five animals. The first four groups were fed four doses (1.5 g/kg, 4.5 g/kg, 13.5 g/kg and 40.5 g/kg body weight) of khat extract twice a week for 5 weeks while the last group, serving as control, was fed only normal saline via intragastric tube. Blood samples were collected at 15 min interval for up to 3 h after khat extract administration and plasma assayed for luteinizing hormone (LH), testosterone and cortisol levels using radioimmunoassay technique.

RESULTS

Khat extract at all doses significantly lowered (P<0.05) LH pulse frequency, area under LH curve, mean plasma LH and mean plasma testosterone levels. Plasma cortisol levels were significantly elevated (P<0.05) in khat-treated rabbits in a dose-dependent manner.

CONCLUSION

This study demonstrates that khat may impair reproductive function in male rabbits by interfering with sex hormone profiles.

Effect of Catha edulis (khat) on behaviour and its potential to induce seizures in Sprague Dawley rats

BACKGROUND

Khat is a plant whose young shoots and leaves are habitually used in Eastern Africa and the Arabian Peninsula as a drug of recreation. Although it is used without any control in these regions, it contains two controlled substances, cathinone (schedule I) which is present in fresh khat and cathine (schedule VI) which is a degradation product of cathinone abundant in old khat.

OBJECTIVE

To determine the effect of khat on locomotor behaviour and seizures in rats.

DESIGN

Experimental study.

SETTING

University of Nairobi.

SUBJECTS

Adult male rats in groups of six were given fresh khat, old khat, methylphenidate and saline at varying doses and observed over three hours.

RESULTS

Fresh khat at low doses and old khat at high doses stimulated locomotor activity. High doses of fresh and old khat induced stereotype behaviour and seizures.

CONCLUSION

The results show that khat stimulates locomotor and stereotypic behavioural activity and can induce seizures; results similar to those observed with amphetamine analogs.

"Mitotic drive" of expanded CTG repeats in myotonic dystrophy type 1 (DM1)

In myotonic dystrophy type 1 (DM1), an expanded CTG repeat shows repeat size instability in somatic and germ line tissues with a strong bias toward further expansion. To investigate the mechanism of this expansion bias, 29 DM1 and six normal lymphoblastoid cell lines (LBCLs) were single-cell cloned from blood cells of 18 DM1 patients and six normal subjects. In all 29 cell lines, the expanded CTG repeat alleles gradually shifted toward further expansion by "step-wise" mutations. Of these 29 cell lines, eight yielded a rapidly proliferating mutant with a gain of large repeat size that became the major allele population, eventually replacing the progenitor allele population. By mixing cell lines with different repeat expansions, we found that cells with larger CTG repeat expansion had a growth advantage over those with smaller expansions in culture. This growth advantage was attributable to increased cell proliferation mediated by Erk1,2 activation, which is negatively regulated by p21(WAF1). This phenomenon, which we designated "mitotic drive" , is a novel mechanism which can explain the expansion bias of DM1 CTG repeat instability at the tissue level, on a basis independent of the DNA-based expansion models. The lifespans of the DM1 LBCLs were significantly shorter than normal cell lines. Thus, we propose a hypothesis that DM1 LBCLs drive themselves to extinction through a process related to increased proliferation.

Mechanism of action of cathinone: the active ingredient of khat (Catha edulis)

OBJECTIVE

To review the current understanding of the mechanism of action of cathinone, the active ingredient of khat.

DATA SOURCE

Published experimental studies on the nature and action and effect of cathinone on the central nervous system both in animals and humans.

DATA EXTRACTION

Data was taken from work published on the mechanism of action of cathinone and also from work where the action of cathinone and amphetamine was compared.

DATA SYNTHESIS

Data from various studies on cathinone was compared for common themes with regards to its action and similarity with the known mechanism of action of amphetamine.

CONCLUSION

The experimental work shows that cathinone is a liable substance, structually related to amphetamine, and similarly to amphetamine, increases the levels of dopamine in the brain by acting on the cathecholaminergic synaspes. Hence the psychostimulant effect of khat can be accounted for by the mechanism of cathinone, which is considered to be its main active ingredient.

Multicentre evaluation of a commercial test for the rapid diagnosis of Clostridium difficile-mediated antibiotic-associated diarrhoea

An immunoassay for the detection of Clostridium difficile toxin A in stool samples (Clearview C. DIFF A; Unipath, UK) was evaluated against the cell cytotoxicity assay using 407 stool samples from patients suspected to have, or considered at risk of, antibiotic-associated diarrhoea. Of the samples tested, 98 were positive and 280 were negative by both tests (sensitivity 83.1%, specificity 96.9%). Following resolution of the 29 discrepant results, the sensitivity and specificity of the immunoassay were 91% and 98%, respectively, and the sensitivity for the cell cytotoxicity assay was calculated as 91.5%, with a specificity of 99%. The Clearview C. DIFF A test proved to be a rapid simple assay for the detection of Clostridium difficile toxin A in stool samples. The test was equally suited to single or batch testing, required minimal sample handling, and provided results within 30 min of applying the sample to the test unit.

UK study of intrapartum care for low risk primigravidas: a survey of interventions

STUDY OBJECTIVE

To determine the extent of intrapartum intervention received by primigravidas.

DESIGN

Cross sectional survey of NHS hospitals in the UK.

SETTING

One hundred and one randomly selected hospital maternity units.

PARTICIPANTS

Forty consecutive primigravid women, judged to be at low risk at the start of labour, in each hospital.

MAIN OUTCOME MEASURES

Seven groups of interventions or monitoring procedures were identified from the first, second, and third stages of labour: fetal monitoring, vaginal examinations, artificial rupture of membranes, augmentation of labour, pain relief, type of delivery, and episiotomy. Data were collected during 1993.

MAIN RESULTS

Ninety eight hospitals took part in the study and data were collected on 3160 low risk primigravidas. Seventy four per cent of these women had continuous cardiotocography. The proportion of women having restrictive or invasive fetal monitoring showed appreciable geographical variation for both the first and second stages of labour. Using the criterion of a vaginal examination every four hours and allowing for the length of each woman's labour, 72% had more vaginal examinations than expected; there was a significant geographical variation in the number of women receiving more than five examinations. Fifty three per cent had artificial rupture of membranes; the procedure was performed over a wide range of cervical dilatations (0 cm-10 cm). Thirty eight per cent of labours were augmented, most commonly by intravenous syntocinon; the procedure showed significant geographical variation. Twenty eight per cent had a spinal block or epidural analgesia for the relief of pain; this intervention varied by geographical region only for the second stage of labour. Over one quarter of the women required instrumental delivery. Forty six per cent had an episiotomy; the frequency of this intervention varied substantially by region. There were no infant deaths. Twelve babies were recorded at birth as having a congenital anomaly.

CONCLUSIONS

The rates of several interventions seem high for this low risk group and there was substantial geographical variation in the use of six interventions. Clinical trials are needed to evaluate the optimum criteria for using these interventions from which guidelines should be drawn up by local groups and the Royal College.

Evaluation of risk factors for Alzheimer's disease in elderly east Africans

A number of biological risk factors have been implicated for Alzheimer's disease (AD). The investigation of prevalence rates of AD in crosscultural populations has much potential in validating these factors. We previously assessed brain amyloid beta (A beta) protein deposition and other lesions associated with AD as possible markers for preclinical AD in elderly nondemented East Africans. In further analysis, we demonstrate that 17-19% of elderly East African subjects without clinical neurological disease exhibited neocortical A beta deposits and minimal neurofibrillary changes at necropsy that was qualitatively and quantitatively similar to that in an age-matched elderly control sample from Cleveland, OH. A beta deposits varied from numerous diffuse to highly localized neuritic plaques and were predominantly reactive for the longer A beta 42 species. In parallel studies, we evaluated another recently implicated factor in AD, the apolipoprotein E genotype. We found relatively high frequencies of the apolipoprotein E-epsilon 4 allele in elderly nondemented East Africans. The frequencies were comparable to those in other African populations but higher than in subjects from developed countries. Our limited study suggests that elderly East Africans acquire cerebral lesions found in AD subjects but the apolipoprotein E-epsilon 4 allele may not be a highly specific factor for the disease among East Africans.

Plasma luteinizing hormone levels in response to gonadotropin-releasing hormone agonist and clonidine in Trypanosoma congolense-infected female goats

Trypanosomiasis, a parasitic disease of humans and animals, occurs over a wide area of Africa and imposes a large socioeconomic burden on the people. In the present study, we investigated whether trypanosomiasis-induced reproductive disorders were due to pituitary or hypothalamic dysfunction by determining plasma luteinizing hormone (LH) response to gonadotropin-releasing hormone (GnRH) agonist or clonidine in Trypanosoma congolense-infected female goats. With GnRH agonist administration, the total amount of LH secreted over a 140-min sampling period on day 23 and day 60 postinfection was consistently higher (71 and 21%, respectively) in infected goats compared to controls. In contrast, clonidine administration to infected goats on day 28 and day 69 postinfection failed to significantly alter the LH pulse frequency or the mean LH pulse amplitude over a 80-min sampling period. The results, especially the lack of response to clonidine, indicate that trypanosomiasis impairs GnRH release from the hypothalamus.

Apolipoprotein E polymorphism in elderly east Africans

Current advances have shown the apolipoprotein E (APOE)-epsilon 4 allele to be highly associated with late-onset familial and sporadic Alzheimer's disease (AD) in Western populations. The association of APOE allele frequencies and dementia remain unknown in populations from developing countries. We recently initiated a project to examine APOE frequencies in non-demented and demented elderly East Africans. Blood DNA collected from two hospital-based populations showed that the APOE allele frequencies in a group of non-demented 67 Tanzanians over the age of 65 years were found to be 14% for epsilon 2, 61% for epsilon 3 and 25% for epsilon 4. By comparison, the frequency of APOE-epsilon 4 in an age-matched demented group was also 25%. Assessment of APOE genotypes in the group of elderly Kenyan subjects from Nairobi also revealed high frequencies of the epsilon 4 allele with no clear difference in frequency between demented and non-demented subjects. Our preliminary observations suggest that elderly East Africans with no apparent clinical AD possess relatively high APOE-epsilon 4 allele frequencies compared to normal ageing subjects from Western countries including African-Americans. These results appear similar to those reported in a recent study in Nigerian Africans where a lack of correlation between APOE-epsilon 4 allele frequency and Alzheimer type of dementia was noted, and imply that APOE-epsilon 4 allele may not necessarily be a risk factor in some populations of Africa.

Standards for ultrasound fetal growth velocity

OBJECTIVES

An ultrasound study to establish the nature and limits of fetal growth in a low risk population from 22 weeks of gestation until term.

DESIGN

Prospective, longitudinal ultrasound study of 274 low risk pregnancies involving organised scanning schedules with all measurements performed by one observer using the same equipment.

RESULTS

Growth velocity charts have been created for a number of ultrasound parameters including estimated fetal weight, by applying appropriate statistical methods to the serial data. The rates of growth of the biparietal diameter, femur length, abdominal area and estimated weight each have characteristic patterns demonstrating maximal growth rates at different gestations.

CONCLUSIONS

Appropriately derived and calculated ultrasound fetal growth velocity standards have been established. These data are suitable for the evaluation of ultrasonically estimated fetal growth rates in the prediction of adverse perinatal outcome and the further investigation of the role of the intrauterine environment in the origin of adult disease.

Neonatal cerebral arterial flow velocity waveforms in term infants with and without metabolic acidosis at delivery

To define the effects of acid base status at delivery on neonatal cerebral artery flow velocity waveform patterns obtained using Doppler ultrasound during the first week of life, a longitudinal comparative study of neonates born at term with and without evidence of metabolic acidosis in the umbilical artery was undertaken. Eighty-two appropriate for gestational age infants delivered after uncomplicated pregnancies with non-acidotic umbilical artery blood gases and in whom no neonatal complications were noted were studied to establish reference values of neonatal cerebral arterial vascular resistance index (RI) in normal term infants during the first week of life. A further 189 infants were grouped according to the presence and severity of metabolic acidosis at delivery, and also the presence of high risk features in the antenatal period. In the normal non-acidotic infants, over the first 24 h of life, there was a significant fall in the cerebral arterial resistance index (RI) in all the vessels examined, after which a steady state value was attained with no significant changes in vascular resistance index being noted during the remainder of the study period. The fall in RI between 12 and 24 h of age was consistent in all study groups. Infants with metabolic acidosis at delivery had blood flow patterns compatible with decreased resistance to flow in both anterior and middle cerebral arteries which persisted throughout the first week of life. This reduction in cerebral vascular resistance was most marked in those infants with severe metabolic acidosis. The majority of severely acidotic infants had a benign clinical outcome in the first week of life and all infants had normal cerebral ultrasound scans during the neonatal period. These findings suggest that metabolic acidosis at birth is associated with changes in neonatal cerebral arterial vascular resistance during the first week of life, and in the presence of benign clinical course the significance of this observation with regard to neurodevelopmental outcome requires evaluation.

Are 'notched' uterine arterial waveforms of prognostic value for hypertensive and growth disorders of pregnancy?

In a case-control controlled study of 86 women identified as having bilaterally 'notched' uterine arterial waveform patterns at 18 weeks, the presence of bilateral 'notched' uterine arterial waveforms at that time was associated with the subsequent development of hypertension and small-for-gestational-age infants, but the predictive value was poor. For those women in whom the bilateral uterine 'notches' were observed to persist to 24 weeks, the relative risk of developing proteinuric hypertension increased 14 times, and in these women the positive predictive value for the subsequent development of hypertension increased to 58.6% when compared with their matched controls. The identification of women with persistent bilateral uterine 'notches' provides a means of identifying women at significant risk of hypertensive and growth disorders at a stage when therapeutic intervention aimed at limiting the severity of the disease and its associated complications could be commenced.

Neonatal cerebral Doppler flow velocity waveforms in the pre-term infant with cerebral pathology

In a longitudinal study of 217 infants delivering at < 37 completed weeks gestation, Doppler flow velocity waveforms were obtained, and resistance index (RI) values calculated from the middle (MCA) and anterior (ACA) cerebral arteries during the first 10 days of life. Sixty infants demonstrated ultrasound evidence of cerebral pathology, of which five cases were congenital, and an additional 13 cases were complicated by patent ductus arteriosus during the study period. The Doppler data obtained during the first week of life from the remaining 42 infants who developed cerebral pathology, and 15 infants who had evidence of metabolic acidosis at delivery without ultrasound evidence of cerebral pathology were compared with local reference data obtained from non-acidotic infants with normal cranial ultrasound from 24 h of age. In those infants who had evidence of minor periventricular haemorrhage alone (Grade I/II PVH), there was no significant difference between the ACA or MCA RI during the study period compared with the reference data. In those groups of infants who demonstrated major PVH (Grade III/IV) or persistent periventricular flares, the ACA and MCA RI was found to be consistently significantly higher than the reference group throughout the study period. In those infants who developed ultrasound evidence of periventricular cystic leukomalacia (PVCL), the MCA RI was significantly lower than the reference data between 48 and 72 h of age, there being no significant difference in the ACA RI. The Doppler findings in those infants with evidence of metabolic acidosis at delivery (umbilical arterial pH < 7.20; BD > 8 mmol/l) but with normal ultrasound findings were similar to those infants who developed PVCL, namely a significant fall in MCA RI between 48 and 72 h of life, with no significant difference in the ACA RI during the study period. These findings suggest that variable changes in cerebral vascular resistance occur with the evolution of, or as a consequence of the development of cerebral pathology in the pre-term infant, and these changes of increased and decreased vascular resistance are discussed. Further investigation of the changes occurring in the cerebral circulation in the early neonatal period of infants who develop PVCL is required to clarify the vascular changes taking place, but if the findings of this study are confirmed, this technique may provide a means of identifying infants at risk of developing ischaemic cerebral pathology at an early stage when it may be possible to initiate therapeutic intervention to limit the cerebral damage.

Neonatal cerebral Doppler flow velocity waveforms in the uncomplicated pre-term infant: reference values

In a longitudinal study of 217 infants delivering at < 37 completed weeks gestation, Doppler flow velocity waveforms were obtained and resistance index (RI) values calculated from the middle (MCA) and anterior (ACA) cerebral arteries during the first 10 days of life. One hundred thirty-seven of these infants were non-acidotic at delivery and during the early neonatal period, and had normal cerebral ultrasound scans throughout the study period. These infants formed the reference group. In three gestational subgroups considered (< or = 32 weeks, 33-34 weeks, > or = 35 weeks) from the reference group, the median RI for both the ACA and MCA was noted to fall significantly during the first 12 h of life (P < 0.01 for all groups). For infants delivering at > or = 33 weeks gestation, both MCA and ACA RI values reached a steady state with no significant change in the median value for the remainder of the study period. For infants delivering at < or = 32 weeks, there was a further significant fall in both the MCA and ACA RI between 12 and 24 h of life (P < 0.05), after which a steady state value was reached. During the first 12 h of life the RI for both vessels was significantly higher in infants delivering at < or = 32 weeks compared to the more mature infants (P < 0.01), but for the remainder of the study period, there were no significant differences in RI values between the gestational subgroups.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk of preterm delivery in pregnant women with group B streptococcal urinary infections or urinary antibodies to group B streptococcal and E. coli antigens

OBJECTIVE

To establish whether there is an association between preterm delivery and either group B streptococcal urinary infection or the presence of urinary antibodies to group B streptococcal or E. coli antigens.

DESIGN

A prospective study with urine culture and antibody measurement performed at the first antenatal visit and at 28 weeks gestation.

SETTING

Ninewells Hospital, Dundee.

SUBJECTS

Two thousand and forty-three women registering consecutively at an antenatal clinic.

MAIN OUTCOME MEASURE

Delivery at less than 37 weeks gestation.

RESULTS

No increase in preterm delivery was observed in women with positive urine cultures for group B streptococci either at booking or at 28 weeks, even when confirmed by positive repeat cultures. Preterm delivery was more common in women with elevated urinary antibodies to E. coli antigens at booking (relative risk 1.81, 95% CI 1.22-2.68, P = 0.005) and at 28 weeks (relative risk 2.36, 95% CI 1.60-3.48, P < 0.0001) and to group B streptococcal antigens at 28 weeks (relative risk 2.24, 95% CI 1.46-3.43, P = 0.0003).

CONCLUSIONS

These data do not support previous reports that positive urine cultures for group B streptococci are associated with an increased risk of preterm delivery. Our report of an association between elevated levels of urinary antibodies and preterm delivery is a new finding consistent with the possibility that a local inflammatory response to uro-genital infection may be important in stimulating the onset of preterm labour. The results suggest that screening for urinary antibodies at 28 weeks gestation might help to identify a group of women at increased risk of prematurity.

Nitric oxide: a new biological messenger molecule

Nitric oxide, a recently discovered gaseous biological messenger molecule, has been found to play a fundamental regulatory role in the body. It is involved in the cardiovascular, immune, reproductive, and digestive physiology and its presence in the brain indicates that it will have a neuronal function as well. Several areas of research suggest that low levels or absence of nitric oxide may be the underlying cause of some forms of essential hypertension and impotence, while over-production could be the cause of neuronal damage, septic shock, and immune-related tissue damage.

Prevalence of HIV among childbearing women and women having termination of pregnancy: multidisciplinary steering group study

OBJECTIVE

To determine the prevalence of HIV among pregnant women, in particular those whose behaviour or that of their partners put them at "low risk" of infection.

DESIGN

Voluntary named or anonymous HIV testing of pregnant women during 21 months (November 1988 to July 1990).

SUBJECTS AND SETTING

All women who planned to continue their pregnancy and attended clinics serving the antenatal populations of Edinburgh and Dundee. All women admitted for termination of pregnancy to gynaecology wards serving the pregnant populations of Dundee and outlying rural areas.

MAIN OUTCOME MEASURES

Period prevalence of HIV antibody positivity.

RESULTS

91% of antenatal clinic attenders and 97% of women having termination of pregnancy agreed to HIV testing on a named or anonymous basis. HIV period prevalences for antenatal clinic attenders and women having termination of pregnancy tested in Dundee were 0.13% and 0.85% respectively, and for antenatal clinic attenders tested in Edinburgh 0.26%. For those at "low risk" rates for antenatal clinic attenders and women having termination of pregnancy in Dundee were 0.11% and 0.13%, and for antenatal clinic attenders in Edinburgh 0.02%. In Dundee HIV prevalence among women having a termination of pregnancy (0.85%) was significantly greater than that among antenatal clinic attenders (0.13%).

CONCLUSIONS

HIV infection is undoubtedly occurring among women at "low risk," and it is clear that a policy of selective testing of those at only "high risk" is inadequate for pregnant women living in areas of high prevalence such as Edinburgh and Dundee. Moreover, when studying pregnant populations in such areas there is the need to include those having a termination of pregnancy.

Cerebral pathology in the very low birthweight infant: predictive value of peripartum metabolic acidosis

One-hundred-and-three infants with a birthweight of less than 1500 g and delivering at a gestation of less than 32 weeks were examined by serial cranial ultrasound scans. A capillary blood sample was drawn for blood gas analysis within 1 h of birth in all cases. The subsequent development of intracranial pathology was found to be significantly associated with gestation at delivery (P less than 0.01), birthweight (P less than 0.01) and base deficit within 1 h of birth (P less than 0.001). For infants with a base deficit of greater than 5.0 mmol/l within the first hour of life, the sensitivity for predicting the subsequent development of cerebral pathology was 51.5% with a specificity of 97.3%, and a positive predictive value of 97.1%. This relationship between a metabolic acidosis within 1 h of birth and the subsequent development of cerebral pathology held for both major and minor degrees of pathology, but was stronger in those infants developing major cerebral pathology. The study suggests that improved surveillance of the very preterm infant during labour and at birth with the aim of reducing the incidence of metabolic acidosis at birth, may help to reduce subsequent intracranial pathology, and thereby perinatal and long-term morbidity.

Prevalence of HIV antibody and pregnancy in Tayside, 1984-9: background to screening

OBJECTIVE

To determine age specific prevalence of HIV antibody, incidence of pregnancy, and likelihood of detection and correct assignment to risk category by antenatal screening of women known to be positive for HIV antibody, from 1984 to 1989.

DESIGN

Retrospective analysis of reproductive history and risk behaviour of women positive for HIV antibody and prediction of detection by screening on the basis of blood group samples, Guthrie tests, and rubella tests.

SETTING

City of Dundee, where the prevalence of HIV is high, since the appearance of HIV in 1984, predominantly among heterosexual intravenous drug users.

PATIENTS

All (61) women known to be positive for HIV antibody who had had clinically indicated tests, for whom case notes were available for 60.

MAIN OUTCOME MEASURES

Risk assessment according to case notes and reported to the laboratory, incidence of infection, geographical location, age, date of positive test result, and reproductive history.

RESULTS

With 61 infected women the overall minimum prevalence among women within the city of Dundee was 0.67/1000 and 2.9/1000 among women in their third decade. Of the 60 women whose reproductive history was available, 35 had 57 pregnancies, 36 of which occurred after seroconversion was known to have taken place, representing 8.7% of the total number of affected pregnancies reported for the United Kingdom. If antenatal screening for HIV had been performed between 1984 and 1989 it could not have detected positivity for HIV antibody in 25 (42%) women who had no pregnancies during this time. Among the remaining 35 women, screening samples taken for blood grouping could have identified a maximum of 34 (57%), samples taken to check rubella susceptibility a maximum of 22 (37%), and blood spots on Guthrie cards a maximum of 19 (32%). Retesting would have occurred in 14 women 33 times with samples taken for blood grouping, but three and four women would have been tested twice using samples taken for rubella testing and Guthrie cards respectively. Anonymous screening would have been unable to determine risk category as a history of intravenous drug use was known in 47 (79%) women before testing but this was increased by a further 5 (8%) who admitted to it after the test result was known.

CONCLUSION

Interpreting the results of antenatal screening programmes will be complex and will underestimate overall prevalence of HIV antibody among women; this will be exaggerated by strategies based on anonymous testing with Guthrie cards or on samples taken for rubella testing, which do not include women who have had an earlier loss of pregnancy. Only open testing with consent will permit satisfactory attribution to

Epidural analgesia and its effect on umbilical artery flow velocity waveform patterns in uncomplicated labour and labour complicated by pregnancy-induced hypertension

Umbilical artery flow velocity waveforms were obtained using continuous-wave Doppler ultrasound to examine the effect of epidural analgesia on peak systolic/least diastolic ratio (A/B ratio) in 38 women in uncomplicated labour, and 12 women with pregnancy-induced hypertension (PIH). In the uncomplicated group there was no significant change in A/B ratio after epidural analgesia, but in the PIH group there was significant correlation between the fall in mean blood pressure and the fall in A/B ratio at 30 min after induction of epidural analgesia (r = 0.85, p less than 0.001). This suggests that epidural analgesia in PIH is associated with a reduction in placental resistance and may be beneficial to the fetus.

Umbilical artery waveform analysis and biophysical profile. A comparison of two methods to identify compromised fetuses

Sixty-nine singleton high-risk pregnancies were assessed with both umbilical artery flow velocity waveform analysis and fetal biophysical profile within 10 days of delivery. An abnormal outcome, as defined as either small for gestational age at birth (SGA) or fetal distress during labour, was found in 30 babies. The peak systolic/end diastolic (A/B) ratio from the umbilical artery had a higher sensitivity (37%), specificity (92%), positive predictive value (79%) and negative predictive value (66%) than the fetal biophysical profile (27%, 82%, 53%, and 59%, respectively) in the diagnosis of abnormal outcome. Additional information from a real-time ultrasound assessment, such as the diagnosis of malformations and oligohydramnios could justify a combination of the two methods in antenatal monitoring of high-risk pregnancies.

Fetal umbilical artery flow velocity waveforms: prediction of small for gestational age infants and late decelerations in labour

The relationship between fetal umbilical artery waveform patterns and (a) small for gestational age infants or (b) late fetal heart rate (FHR) decelerations in labour was examined in 205 clinically high-risk pregnancies. All pregnancies were studied using continuous-wave Doppler Ultrasound within 7 days of delivery. Waveforms were analysed by calculating a ratio of peak systolic frequency to end diastolic frequency (A/B ratio). An abnormal Doppler result was defined as being above the 97th centile for gestation from our previously derived normal values. Abnormal Doppler results occurred in only 38% of small for gestational age (SGA) infants and in 70% of those developing late decelerations in labour. Doppler ultrasound is a poor predictor of SGA infants, but may identify a high proportion of cases at risk of developing late FHR decelerations in labour.

Effect of a new nonionic contrast agent, ioxilan, on human erythrocytes and the hemostatic and serum complement pathways

A new nonionic contrast medium (CM), ioxilan, was compared with iohexol and iopamidol. Following incubation of whole heparinized blood with CM, the morphology and osmotic fragility of erythrocytes were studied, the former by transmission electron microscopy. Effects on platelets and hemocoagulation were determined by standard hematologic procedures. Effects on serum complement were evaluated by measurement of total hemolytic complement (CH50), C3, C4 consumption and the presence in serums of C3c as determined by immunoelectrophoresis. Ioxilan affected the erythrocyte membrane less than iohexol and iopamidol: the latter two produced acanthocytes, whereas ioxilan had no effect on erythrocyte morphology; also, erythrocytes exposed to ioxilan (and iopamidol) were more resilient to hypotonic saline solutions than those exposed to iohexol. In all tests, all CM showed anticoagulant activity, albeit much less when compared with ionic CM. At equal iodine concentration, ioxilan reduced the platelet aggregation and whole blood clotting time more than did iohexol. None of the CM activated the serum complement system.

Mothering problems and child morbidity amongst "mothers with emotional disturbances"

In a study of 1,955 primigravidae who gave birth to a live singleton baby, 227 (11.6%) scored 'positive' (7+) in an antenatal Health Questionnaire enquiring into pre-pregnancy emotional disturbances. This group of mothers had more frequent depression, and this was of longer duration after their delivery compared with those scoring less than 7 (less than or equal to 6). Those scoring 7+ were less likely to breast-feed and the infants were more often ill during the first year of life. There were also differences in 'minor obstetric complications' between the two survey groups. This suggests that the application of this Health Questionnaire antenatally can identify emotionally vulnerable women, who could benefit from support and education during the antenatal period.

The predictive value of fetal breathing movements in the diagnosis of preterm labour

A real time ultrasound investigation was performed on 64 patients who presented in threatened preterm labour. Fetal breathing movements (FBM) were absent in 17 patients, all of whom were delivered within 56 h. FBM were present in 47 patients of whom five were delivered within 56 h from examination and four of these had spontaneous rupture of membranes and/or chorioamnionitis. In 33 the pregnancy continued for at least 1 week. Two of the fetuses with false negative results showed a distinct breathing pattern different from the rest of the study group. This suggests that pattern recognition of fetal breathing might improve the specificity of this investigation.

The effect of fetal heart rate on umbilical artery flow velocity waveforms

Umbilical artery flow velocity waveforms were obtained using continuous wave Doppler ultrasound in 85 normal pregnancies (25 antepartum, 60 intrapartum) to examine the relation between fetal heart rate, end systolic/end diastolic ratio (A/B ratio) and resistance index (RI). Our results demonstrated a significant negative correlation between fetal heart rate, A/B ratio and RI (in the antepartum group r = -0.49, and in the labouring group r = -0.65). It is therefore important when performing mathematical analysis of umbilical artery flow velocity profiles to make a statistical allowance for fetal heart rate.

Mortality and morbidity in infants born between 20 and 28 weeks gestation

Of 149 infants with ultrasound evidence of gestational age, born in Ninewells Hospital at between 20 and 28 weeks gestation over a 5-year period, 50 were alive at birth. Of these infants, 21 died within 1 week, a further three died within 1 month and a further two within 18 months. Of the 24 survivors, 8 (33%) have significant handicap. The obstetric factors leading to delivery and the mode of delivery are discussed.

Non-stress antenatal cardiotocography--a prospective blind study

A prospective blind study of non-stress antenatal cardiotocography was undertaken in a group of 216 'high risk' pregnancies. The 'Cardiff' scores and the outcome of the pregnancies were compared subsequently. Low scores were associated with infants that were small-for-gestational age and fetal distress in labour, while high scores were associated with normal intrauterine growth. Although antepartum cardiotocography is predictive of fetal and neonatal outcome the extent to which its availability will prevent adverse outcome appears limited.

Non-stress antenatal cardiotocography--a prospective randomized clinical trial

A randomized controlled trial examined the effects of non-stress antepartum cardiotocography on obstetric management and assessed its usefulness as a diagnostic test of fetal compromise. Daily cardiotocograph recordings were made in 396 antenatal patients at increased risk of fetal compromise but were withheld from the clinicians responsible for care in half the cases. The frequency of intrapartum fetal distress and low Apgar score was similar in the two groups. The three normally-formed perinatal deaths all occurred in the revealed group but in only one case could earlier obstetric intervention have altered the outcome. Availability of non-stress cardiotocography was not associated with an increased rate of induction of labour or caesarean section.

An assessment of perinatal mortality in twin pregnancies in Dundee

An analysis of all perinatal deaths occurring in twin pregnancies in Dundee women from 1956 to 1983 was performed. The uncorrected perinatal mortality rate fell from 116/1000 births in 1956-60 to 16/1000 births in 1981-83, this fall almost entirely taking place after 1975. Causes of death were identified using the Aberdeen Classification and a reduction in deaths in all cause groupings occurred. About half of the deaths were in the Premature, Cause Unknown group and a marked decrease in deaths in this group made the largest contribution to the improved perinatal mortality rate. This fall was partly due to a reduction in the incidence of extreme prematurity and low birth weight. Changes in obstetric management which may have influenced outcome included the introduction of routine early pregnancy ultrasound scanning, the use of tocolytic drugs, intrapartum fetal monitoring, epidural analgesia and an increase in Caesarean section rate from 2% in 1956-60 to 39% in 1981-83.

Intrauterine volume, fetal abdominal area and biparietal diameter measurements with ultrasound in the prediction of small-for-dates babies in a high-risk obstetric population

The value of fetal biparietal diameter and abdominal area, total intrauterine, intra-amniotic and placental volume measurements for predicting small-for-dates babies in a high-risk obstetric population was investigated in 130 women. A parallel planimetric area method was used to measure volume. The commonest risk factors were suspected intrauterine growth-retardation, hypertensive complications and previous poor obstetric history. The prevalence of birthweight at and below the 10th or 3rd centiles was 30 and 16% respectively. Fetal abdominal area and total intrauterine volume measurements had the highest and comparable sensitivity, specificity and positive predictive value in the detection of infants with birthweights of less than or equal to 10th and less than or equal to 3rd centiles. While these measurements are of use in consolidating the clinical diagnosis of small-for-dates fetuses (growth retardation), high false positive rates (10% and 16-17% for birthweights less than or equal to 10th centile, and less than or equal to 3rd centile respectively) make further discriminatory tests necessary for part of the population.