4 HIGH-PROTEIN, HIGH-CALORIE ICE-CREAM PRESCRIPTION IN AN ORTHOGERIATRIC INPATIENT POPULATION

Background

At a major trauma centre in the South of Ireland, all older adults admitted with hip and other fragility fractures are co-managed by the Orthopaedic & Orthogeriatric services with an average of over 500 hip fractures a year. A recent publication by described improving calcium and protein intake by using dairy foods as a readily accessible intervention that reduces the risk of falls and fractures in aged care residents. Foods used included cheese, yoghurt and milk being described as “low cost” and “palatable”. Other dairy alternatives such as ice-cream are not used as not protein or calcium rich. In Ireland high calorie-high protein ice-cream is widely available (10g protein, 220 kcal/100g serving).

Methods

A point prevalence survey relating to the preference of calcium and/or protein rich food ‘snacks’ was completed on 20 inpatients in hospital with a hip or other fragility fracture.

Survey Questions: (1) Would an additional calcium and/or protein rich food snack be acceptable to you?; (2) Which food snack would you prefer: a serving of milk, cheese, yogurt, or ice-cream?; (3) What time would you prefer to eat an additional snack? Morning, afternoon, or evening?

Results

The majority of participants (95%; 19/20) replied an additional snack would be acceptable. With reference to snack preference: 35% (7/20) would prefer a serving of yoghurt, 30% (6/20) ice-cream, 25% (5/20) cheese and only 10% (2/20) would prefer milk. The majority said they would prefer to be offered a snack in the afternoon (55%; 11/20).

Conclusion

Our inpatient population would benefit from the addition of such snacks to optimise recovery and bone health. Patient preference needs to inform any dietary or menu modifications. Following our survey, in addition to calcium and vitamin D supplementation, high-protein high-calorie ice-cream is offered and prescribed to patients if eating less than 50% of their energy dense meals.

106 MORTALITY FOLLOWING HIP FRACTURE AMONG NURSING HOME RESIDENTS

Background

Little is known about mortality following hip fracture among Nursing Home (NH) residents. Prognostic data is important to guide management, including osteoporosis treatment.

Methods

We conducted a retrospective cohort study of all patients admitted to an Irish tertiary hospital from NHs with hip fracture during the years 2017-2020 inclusive. Mortality was assessed at 90, 180 and 365 days (one-year) following admission.

Results

One patient was lost to follow up, leaving 233 in the analysis group. 147 were female. Mean age was 85. All-cause mortality was 18.03% at 90 days, 27.04% at 180 days and 37.34% at one year. One-Year Mortality (OYM) was 34.01% among females and 43.02% among males. Among those aged 90 or over, OYM was 45.59% (31/68), being 65.22% (15/23) among males and 35.56% (16/45) among females. In those aged 75 or over, OYM was 39.9% (81/203), being 48.57% (34/70) among males and 35.34% (47/133) among females. In those aged under 75, OYM was 20% (6/30). OYM was 42.31% (11/26) among those who could mobilise independently before fracture, 37.23% (51/137) among those requiring an aid, 33.9% (20/59) among those requiring assistance, and 45.45% (5/11) among those unable to mobilise. 62 Rockwood Clinical Frailty Scales (CFS) were recorded (median score 7, range 5-9). OYM was 0% (0/4) for CFS 5, 50% (8/16) for CFS 6, 31.43% (11/35) for CFS 7, 80% (4/5) for CFS 8 and 100% (0/2) for CFS 9.

Conclusion

Mortality among NH residents following hip fracture was highest in older males. While mobility before fracture was a poor predictor of mortality, CFS showed promise among a smaller sample size.

280 PERCEIVED NEED FOR A CLINICAL ETHICS SUPPORT SERVICE AT AN IRISH UNIVERSITY HOSPITAL

Background

Ethics are the set of moral principles that guide a person’s behaviour. Ethical issues are a key component of healthcare and frequently arise in the management of hospitalized older patients. To improve decision-making and reduce burden on individual hospital staff, Clinical Ethics Support Services (CESS) have been widely-integrated into care pathways internationally. However, the need for CESS has received little attention in Irish hospitals.

Methods

A cross-sectional analysis of the ethical situation and CESS readiness at a tertiary hospital in Ireland was collected from July-October 2021 and in February 2022 via hard copies and online collection (SurveyMonkey). Both clinical (medicine, nursing other patient care role) and non-clinical (administrative, clerical, ICT, HR, general support staff and management) staff participated. Descriptive statistics were assessed taking the valid percentages, mean 5-item Likert scores and Friedman Test mean rank for ten ranked statements.

Results

In total, 199 people (13% response rate) completed the survey. Staff were largely (76%) clinical and the majority were qualified >10 years (57%). In all, 78% reported that ethical issues arise in the role (83% clinical staff, 59% non-clinical staff). Most (63%) were unsure who to contact about ethical concerns, instead seeking informal advice from colleagues (>90%). The majority of participants were interested in additional ethical training, especially on decision-making capacity (mean interest 4.18 out of 5), strategies for working with challenging patient/family situations (4.07 out of 5) and end-of-life care (4.06 out of 5). Out of ten options assessed, participants preferenced the development of a formal clinical ethics committee over education and training or the provision of educational materials.

Conclusion

Ethical issues commonly arise when caring for older hospitalized patients. This study found a perceived need and widespread interest in additional education as well as formal approaches to develop a hospital-based CESS, centred around a formal committee structure.

32 SIMULATION-BASED EDUCATION FOR ACUTE STROKE

Background

Acute stroke requires efficient multi-disciplinary collaboration to deliver time-sensitive treatment in a prompt and effective manner. The European Stroke Organization (ESO) recommends simulation-based education (SBE) for stroke care. Studies have shown SBE improves door-to-needle times, which predict better patient outcomes.

SimStars was a competition, run by the National Doctors Training and Planning leads for the South-SouthWest Hospitals Group, to develop in-situ SBE scenarios.

We developed a SBE program for acute stroke in an Irish teaching hospital.

Methods

Medical doctors and nursing staff are included in the SBE scenario as candidates/target learners. Patients are played by role-players. Anonymised data and neuroimaging from real patients is utilized to maximize fidelity to real life. Other participants, such as paramedics, can be included to facilitate scenarios as required.

Candidates are briefed before each scenario. Clear learning objectives are set. All participants are provided with a script outlining their roles. Candidates are appraised using standard evaluation forms. A de-brief is undertaken to reinforce learning objectives.

Results

We qualified for the final of SimStars by establishing a SBE program for acute stroke, including a video of a simulated scenario that can be utilized for demonstration purposes. 100% of candidates who have participated in the SBE program so far have stated that it made a valuable contribution to their learning in the field of stroke care.

Conclusion

Stroke has been described as an exemplar of how SBE may benefit training along an entire clinical pathway. Scenarios can be adapted to cover an endless variety of stroke-related situations. SBE has been shown to improve hyper-acute clinical pathway performance and outcomes.

The politics of COVID-19 on the island of Ireland

Background

Political systems are the means through which the science of public health achieves its objectives. This is a qualitative study of public health policies for COVID-19 in Northern Ireland and the Republic of Ireland that seeks to establish if inter-jurisdictional commitments have led to co-ordination and co-operation on the island of Ireland.

Methods

10 indicators from the OxCGRT codebook directed data collection with directed qualitative content analysis supporting comprehensive reading of policy documents. Cross-case and within-case analysis of policy alignment and divergence across ten OxCGRT indicators was undertaken.

Results

Closing Schools Republic of Ireland: 12th March 2020 Northern Ireland: 23rd March 2020; Workplace Closing - Republic of Ireland: 12th and 15th March and 24th March 2020. Northern Ireland: 20th March 2020 followed by mandatory closure on 28th March 2020. Cancelling events and mass gatherings (St Patrick's Day, 17th March)-Republic of Ireland: 9th March 2020-Northern Ireland: 9th March 2020;Lockdown/Shelter-in-place policies. Republic of Ireland: 27th March 2020- Northern Ireland: 28th March 2020; Restrictions on Internal Movement Republic of Ireland: 27th March 2020 Northern Ireland: 28th March 2020. Physical Distancing Measures -Republic of Ireland: 2-metres 24th March 2020 Northern Ireland: 2 metres 23rd March 2020. Mandatory Face Masks in Enclosed Spaces-Republic of Ireland: 10th August 2020 -Northern Ireland: 10th August 2020.

Conclusions

The historical and constitutional politics of the island of Ireland is the obstacle to an all-island response to COVID-19 and this has almost certainly been compounded by Brexit. Defying the odds, however, this study has demonstrated substantial public health policy alignment brought about through ongoing dialogue and co-operation between the health administrations in each jurisdiction.

Key messages

Historical and constitutional politics of the island of Ireland is the obstacle to an all-island response to COVID-19. Even pandemics cannot overcome realpolitik.

Predictors of in-hospital mortality post hip fracture in Ireland 2013-2017

Background

Hip fractures are associated with considerable mortality, morbidity and healthcare expenditure. There are approximately 3,500 hip fractures in Ireland per annum with this figure set to increase considerably over the coming years due to the ageing population. Internationally, mortality following hip fracture is approximately 10% at 1 month and 30% at 1 year, with less than half of survivors regaining their preoperative level of function. The authors aimed to identify the determinants of in-hospital mortality post hip fracture in the Republic of Ireland 2013-2017, with specific reference to the Irish Hip Fracture Standards.

Methods

A secondary analysis of 15,603 patients in the Irish hip fracture database was conducted.

Results

31% (n = 4,769) were male and 69% (n = 10,807) were female. Mean age for males was 75 years (SD 13.5) and 79 years for females (SD 10.5). The largest proportion of hip fractures occurred in the 80-89 age category, with 72.3% (n = 4,600) of these being female. Median in-hospital mortality was 4.7% (n = 711) (Range 2.7-6.2). Univariate logistic regression revealed 11 statistically significant predictors of in-hospital mortality; however, only 4 remained statistically significant on multivariate analysis [mobilised day of/after surgery (OR 1.46, 95% CI 1.25-1.70, p < 0.000), pre-fracture mobility (OR 0.84, 95% CI 0.79-0.89, p < 0.000), gender (OR 0.56, 95% CI 0.41-0.76, p < 0.000) and age (OR 1.05, 95% CI 1.03-1.06, p < 0.000)].

Conclusions

Older males with poor pre-fracture mobility who were not mobilised the day of/after surgery had the highest risk of in-hospital mortality. The ability to be mobilised on the day of/after surgery is a good composite measure of both patient and organisational factors in hip fracture care. This research supports the inclusion of mobilisation on the day of/after surgery as a new formal best practice standard.

Key messages

Patients not mobilised on the day of/after surgery are 46% more likely to die in hospital. In-hospital mortality of 4.7% in Ireland is comparable internationally. None of the IHFSs significantly influenced in-hospital mortality after multivariate analysis, but may well affect other outcomes such as ability to return home.

Identifying the superior measure of rapid fibrosis for predicting premature cirrhosis after liver transplantation for hepatitis C

BACKGROUND

Hepatitis C virus (HCV) recurrence post liver transplant is universal, with a subgroup of patients developing rapid hepatic fibrosis. Various clinical definitions of rapid fibrosis (RF) have been used to identify risks for rapid progression, but their comparability and efficacy at predicting adverse outcomes has not been determined.

METHODS

Retrospective data analysis was conducted on 100 adult patients with HCV who underwent liver transplantation at a single center. We measured year 1 fibrosis progression (RF defined as METAVIR F score ≥ 1 at 1-year liver biopsy), time to METAVIR F2-stage fibrosis, and fibrosis rate (calculated using liver biopsies graded by METAVIR scoring F0-4; fibrosis rate = fibrosis stage/year post transplant). RF was defined as ≥ 0.5 units/year.

RESULTS

Multivariate analysis revealed that donor age and peak HCV viral load were significant risks for RF, when fibrosis rate was used to define RF. Advanced donor age was a risk for rapid progression to F2-stage fibrosis, whereas genotype 2 or 3 HCV infection was protective. Fibrosis rate had the strongest correlation with time to cirrhosis development (P < 0.0001, r = -0.76) and was the most accurate predictor of rapid graft cirrhosis (P < 0.0001, area under the curve 0.979, sensitivity 100%, specificity 94%).

CONCLUSION

Different measures of RF progression identify different risks for RF and are not directly comparable. Fibrosis rate was the most accurate predictor of rapid graft cirrhosis.

Post-liver transplantation multicentric Castleman disease treated with valganciclovir and weaning of immunosuppression

Multicentric Castleman disease is a lymphoproliferative disorder which when seen in the setting of HIV/AIDS is often associated with human herpes virus 8 (HHV-8) infection. We describe the case of a HIV-negative man who developed HHV-8-associated multicentric Castleman disease 11 years after liver transplantation. The patient presented with fevers and weight loss. Physical examination revealed enlarged cervical, axillary and inguinal lymph nodes. Widespread lymphadenopathy was confirmed on computed tomography (CT) scanning. Histology of an enlarged lymph node showed a polymorphous infiltrate with mature plasma cells, plasmacytoid lymphocytes and occasional blasts within the cortex and paracortex. The diagnosis of Castleman disease was confirmed by the finding of numerous HHV-8-immunopositive cells around the regressed lymph node follicles and the detection of HHV-8 on plasma PCR. Although the conventional treatment for this condition has been combination chemotherapy, in the post-transplant context it was decided to treat the patient with valganciclovir and cessation of immunosuppression. His symptoms resolved rapidly and repeat plasma PCR done 3 months after starting treatment was negative for HHV-8. A follow-up CT scan showed a dramatic reduction in the size and amount of lymphadenopathy. After 15 months of treatment, he remains well with no evidence of graft dysfunction or rejection.

Intravascular large B cell lymphoma: an elusive cause of pyrexia of unknown origin diagnosed postmortem

Intravascular large B cell lymphoma (IVLBCL) is a rare cause of pyrexia of unknown origin. Because of its protean clinical manifestations, diagnosis is elusive and is often made postmortem. We report here a case of IVLBCL that evaded diagnosis despite multiple investigations in vivo for pyrexia of unknown origin over a 5&#x2010;month period.

Safety and Effectiveness of Telemedicine for Neurology Outpatients

Background and Aims

Patients often wait many months to see a neurologist for the first time. With the introduction of targets for maximum waiting times there is a need for novel approaches. Real time telemedicine by videolink (VL) is one such method and we aimed to replicate this in Aberdeen.

Methods

Patients were seen by VL by two Irish-based neurologists, one experienced in telemedicine, the other not. A senior trainee neurologist present with some of the patients validated the telemedicine diagnosis and management with his own face-to-face (FF) assessment. Satisfaction was assessed by questionnaires. Numbers requiring investigations and review were recorded as were representations to neurology over six months.

Results

Forty-four patients were seen. Satisfaction was higher and review rates were similar to previous cohorts seen by FF and VL. There was no difference between the two neurologists. There was complete diagnostic agreement between the VL and FF neurologists. There was a diagnostic change in a single patient after six months follow-up.

Conclusion

Neurology consultation using VL is safe and effective as well as acceptable, and the necessary skills were acquired rapidly by a telemedicine-naive neurologist. Telemedicine using VL can contribute to waiting list reduction, and is likely to be most useful in rural areas.

WITHDRAWN: Prophylactic corticosteroids for preterm birth

BACKGROUND

Respiratory distress syndrome is a serious complication of prematurity causing significant immediate and long-term mortality and morbidity.

OBJECTIVES

The objective of this review was to assess the effects of corticosteroids administered to pregnant women to accelerate fetal lung maturity prior to preterm delivery.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register was searched.

SELECTION CRITERIA

Randomised and quasi-randomised trials of corticosteroid drugs capable of crossing the placenta compared with placebo or no treatment in women expected to deliver preterm as a result of either spontaneous preterm labour, prelabour rupture of the membranes preterm, or elective preterm delivery.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed by one reviewer.

MAIN RESULTS

Eighteen trials including data on over 3700 babies were included. Antenatal administration of 24 milligrams of betamethasone, of 24 milligrams of dexamethasone, or two grams of hydrocortisone to women expected to give birth preterm was associated with a significant reduction in mortality (odds ratio 0.60, 95% confidence interval 0.48 to 0.75), respiratory distress syndrome (odds ratio 0.53, 95% confidence interval 0.44 to 0.63) and intraventricular haemorrhage in preterm infants. These benefits extended to a broad range of gestational ages and were not limited by gender or race. No adverse consequences of prophylactic corticosteroids for preterm birth have been identified.

AUTHORS' CONCLUSIONS

Corticosteroids given prior to preterm birth (as a result of either preterm labour or elective preterm delivery) are effective in preventing respiratory distress syndrome and neonatal mortality. However there is not enough evidence to evaluate the use of repeated doses of corticosteroids in women who remain undelivered, but who are at continued risk of preterm birth.(This abstract has been prepared centrally.).

WITHDRAWN: Interventions for preventing or improving the outcome of delivery at or beyond term

BACKGROUND

Perinatal mortality and morbidity is increased in pregnancies of more than 42 weeks that are otherwise low risk.

OBJECTIVES

The objective of this review was to assess the effects of interventions aimed at either reducing the incidence or improving the outcome of post-term pregnancy.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register was searched.

SELECTION CRITERIA

Randomised and quasi-randomised trials of interventions involving the intention to induce labour at a specified gestational age.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed by one reviewer. Study authors were contacted for additional information.

MAIN RESULTS

Twenty-six trials of variable quality were included. There were four trials of routine early pregnancy ultrasound, two of nipple stimulation, nineteen of routine versus selective induction of labour and one of antenatal fetal monitoring. Routine early pregnancy ultrasound reduced the incidence of post-term pregnancy (odds ratio 0.68, 95% confidence interval 0.57 to 0.82). Breast and nipple stimulation at term did not affect the incidence of post-term pregnancy (odds ratio 0.52, 95% confidence interval 0.28 to 0.96). Routine induction of labour reduced perinatal mortality (odds ratio 0.20, 95% confidence interval 0.06 to 0.70). This benefit is due to the effect of induction of labour after 41 weeks. Routine induction of labour had no effect on caesarean section.

AUTHORS' CONCLUSIONS

Routine early pregnancy ultrasound examination and subsequent adjustment of delivery date appear to reduce the incidence of post-term pregnancy. Routine induction of labour after 41 weeks gestation appears to reduce perinatal mortality. There is not enough evidence to evaluate the effects of breast and nipple stimulation, or tests of fetal wellbeing.(This abstract has been prepared centrally.).

Effects of human placental lactogen on the expression of CD163 and CD14 on human monocytes in culture

The effect of human placental lactogen (hPL), a member of the somatomammotrophin family, on the regulation of the scavenger receptor molecules CD14 and CD163 on human monocytes cultured for 48h was investigated. Cells were cultured in the presence or absence of the hormone and also in the presence or absence of IFN-gamma and dexamethasone. Monocytes cultured in the presence of hPL showed a significant increase in the expression of CD14 in both males and females compared to background. When IFN-gamma and dexamethasone were added to the cultures, CD14 expression was decreased and was not rescued by the presence of hPL. hPL alone had no effect on the expression of CD163 on cultured monocytes from either gender, although cells cultured in the presence of IFN-gamma and dexamethasone showed a profound increase in their expression of CD163. This expression was augmented further by the presence of hPL in the cultures over a 48-h period. These results support the hypothesis of a potential role of this hormone in the regulation of the innate immune response.

The uncertainty in the activity estimate from a lung count due to the variability in chest wall thickness profile

Calibration of a lung counter requires the use of a realistic torso phantom. The depth profile of both torso phantoms' (LLNL and JAERI) chest plate covers is fixed and assumed to be equivalent to a person's chest wall; however, ultrasound measurements of humans have shown this to be an approximation. When the depth profile of a calibration phantom is different from that of a subject, then a systematic uncertainty will be introduced into the activity estimate. Monte Carlo simulation has shown that changes in the depth profile of the chest wall thickness affect the counting efficiency. Ultrasound measurements have suggested that the coefficient of variation in the depth profile of the chest wall thickness lies between 13% and 26% for male workers; therefore, the added uncertainty to an activity estimate will be an over or underestimate of about a factor of 1.07 resulting from the different depth profile. The factor will be somewhat higher for females, probably about 1.2 at the extreme. These additional uncertainties resulting from depth profile differences are small compared with other uncertainties commonly encountered in lung counting: detector positioning, deposition patterns of the activity, measurement of the chest wall thickness, etc.

The assessment of the effect of thyroid size and shape on the activity estimate using Monte Carlo simulation

Monte Carlo simulations have been used to assess the uncertainty introduced into an activity estimate of radioiodine (125I and 131I) in the thyroid when the size and shape of the gland differs from that of the calibration phantom. The detector dimensions for the 125I simulations were small (diameter 2.54 cm, thickness 0.2 cm); medium (diameter 7.62 cm, thickness 0.2 cm); large (diameter 30.48 cm, thickness 0.2 cm). The detector dimensions for the 131I simulations were small (diameter 2.54 cm, thickness 3.2 cm); medium (diameter 7.62 cm, thickness 6.4 cm); large (diameter 30.48 cm, thickness 11.0 cm). Shapes simulated have included thyroid glands with a third (pyramidal) lobe, no isthmus, and rotated lobes. Sizes simulated have been 10 g, 20 g, and 40 g. The results show that the size of the uncertainty is dependent on the detector size, the neck-to-detector distance, and the type of radioiodine being measured (i.e., 131I or 125I). The worst case bias (on contact counting) for either 125I or 131I using the different sized detectors is as follows: small is between -40% and 40%; medium is between -33% and 17%; large is between -20% and 5%. If the detectors are placed at about 15 cm from the neck the bias values drop so that the uncertainty introduced if the subject has a smaller than standard thyroid becomes insignificant and becomes much improved if the thyroid is larger than the standard. The bias values for the detectors are as follows: small is between -20% and 5%; medium is between -23% and 2%; large is between -21% and 2%.

Interventions for preventing or improving the outcome of delivery at or beyond term

BACKGROUND

Perinatal mortality and morbidity is increased in pregnancies of more than 42 weeks that are otherwise low risk.

OBJECTIVES

The objective of this review was to assess the effects of interventions aimed at either reducing the incidence or improving the outcome of post-term pregnancy.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register was searched.

SELECTION CRITERIA

Randomised and quasi-randomised trials of interventions involving the intention to induce labour at a specified gestational age.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed by one reviewer. Study authors were contacted for additional information.

MAIN RESULTS

Twenty-six trials of variable quality were included. There were four trials of routine early pregnancy ultrasound, two of nipple stimulation, nineteen of routine versus selective induction of labour and one of antenatal fetal monitoring. Routine early pregnancy ultrasound reduced the incidence of post-term pregnancy (odds ratio 0.68, 95% confidence interval 0.57 to 0.82). Breast and nipple stimulation at term did not affect the incidence of post-term pregnancy (odds ratio 0.52, 95% confidence interval 0.28 to 0.96). Routine induction of labour reduced perinatal mortality (odds ratio 0.20, 95% confidence interval 0.06 to 0.70). This benefit is due to the effect of induction of labour after 41 weeks. Routine induction of labour had no effect on caesarean section.

REVIEWER'S CONCLUSIONS

Routine early pregnancy ultrasound examination and subsequent adjustment of delivery date appear to reduce the incidence of post-term pregnancy. Routine induction of labour after 41 weeks gestation appears to reduce perinatal mortality. There is not enough evidence to evaluate the effects of breast and nipple stimulation, or tests of fetal wellbeing.

Prophylactic corticosteroids for preterm birth

BACKGROUND

Respiratory distress syndrome is a serious complication of prematurity causing significant immediate and long-term mortality and morbidity.

OBJECTIVES

The objective of this review was to assess the effects of corticosteroids administered to pregnant women to accelerate fetal lung maturity prior to preterm delivery.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register was searched.

SELECTION CRITERIA

Randomised and quasi-randomised trials of corticosteroid drugs capable of crossing the placenta compared with placebo or no treatment in women expected to deliver preterm as a result of either spontaneous preterm labour, prelabour rupture of the membranes preterm, or elective preterm delivery.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed by one reviewer.

MAIN RESULTS

Eighteen trials including data on over 3700 babies were included. Antenatal administration of 24 milligrams of betamethasone, of 24 milligrams of dexamethasone, or two grams of hydrocortisone to women expected to give birth preterm was associated with a significant reduction in mortality (odds ratio 0.60, 95% confidence interval 0.48 to 0.75), respiratory distress syndrome (odds ratio 0.53, 95% confidence interval 0.44 to 0.63) and intraventricular haemorrhage in preterm infants. These benefits extended to a broad range of gestational ages and were not limited by gender or race. No adverse consequences of prophylactic corticosteroids for preterm birth have been identified.

REVIEWER'S CONCLUSIONS

Corticosteroids given prior to preterm birth (as a result of either preterm labour or elective preterm delivery) are effective in preventing respiratory distress syndrome and neonatal mortality. However there is not enough evidence to evaluate the use of repeated doses of corticosteroids in women who remain undelivered, but who are at continued risk of preterm birth. (This abstract has been prepared centrally.)

Birth at home

Recently the National Birthday Trust performed a confidential survey of home births in the United Kingdom. A good response rate was obtained from midwives, who recruited two groups of women prospectively; those planned and accepted as suitable for a home delivery at 37 weeks and a matched group of similar women who were booked for hospital by 37 weeks. Some 16% of such women were transferred to hospital in late pregnancy (4%) or in labour (12%). This figure rose to 40% among the primiparous women in the survey. The survey report presents an analysis of 4,500 home births and 3,300 hospital controls. Outcomes could therefore be presented by the woman's intent or by what actually happened. In essence it seems that a woman who is appropriately selected and screened for a home birth is putting herself and her baby at no greater risk than a mother of a similar low-risk profile who is hospital booked and delivered. Home births will probably increase to 4-5% of all maternities in UK during the next decade and this needs preparatory planning.

Abnormal prenatal sonographic findings in the posterior cranial fossa: a case of Joubert's syndrome

Joubert's syndrome is a well-documented but rare disorder characterized by a variable combination of central nervous system, respiratory, renal and eye anomalies. The most significant and constant neuropathological finding is partial or complete agenesis of the cerebellar vermis. The syndrome was first described by Joubert and colleagues as a familial agenesis of the cerebellar vermis and appears to be inherited as an autosomal recessive trait. A case of Joubert's syndrome is described in which second-trimester ultrasonography demonstrated abnormal findings in the fetal posterior fossa with associated renal abnormalities. However, postnatal sonography of the posterior fossa could not confirm the prenatal findings, and the diagnosis of Joubert's syndrome was only later established by computed tomography of the neonatal brain in the knowledge of the characteristic clinical picture.

Influence of Soybean Cultivar on Reproduction of Heterodera glycines in Monoxenic Culture

Nematodes produced in monoxenic culture are used for many research purposes. To maximize the number of Heterodera glycines produced in culture, 24 soybean cultivars (maturity groups 0-8) were evaluated for host suitability. A strain of H. glycines race 3, maintained in monoxenic culture on excised soybean root tips of cv. Kent, was inoculated into 20 petri dishes of each cultivar. The highest numbers of first-generation females per petri dish were produced on cultivars Bass, Williams 82, Kent, Proto, and Chapman, and the lowest on cultivars Lambert and Chesapeake. A diapause-like period with decreased nematode production was recorded on some cultivars but not others. Six generations of cultivation on CX 366 did not affect the number of females produced. The results indicated that soybean maturity group could not be used as a parameter for selecting the optimum cultivars for nematode production, and that only J2 petri dishes needed to be counted to determine a 60-female difference per petri dish among cultivars. This study demonstrated that H. glycines populations in monoxenic culture can be more than quadrupled by selection of an appropriate soybean cultivar.

Herpes zoster brachial plexus neuritis

This is the first report of brachial plexus inflammation associated with clinical herpes zoster paresis. A 78-year-old female with a 3-week history of herpes zoster of the C4, C5, and C6 dermatomes developed left upper arm monoplegia. She died from an acute myocardial infarction. Post-mortem provided a rare opportunity to study the neuropathology of herpes zoster motor involvement. Histology of the brachial plexus showed extensive lymphocytic infiltration, myelin breakdown, and preservation of axons without vasculitis. The cervical spinal cord showed perivascular lymphocytic cuffing and no anterior horn necrosis. We suggest, the brachial plexus inflammation was a distal extension of a dorsal ganglionitis. Brachial plexus neuritis may be a direct cause of reversible upper limb paresis in herpes zoster. We demonstrate the motor neuropathy is an inflammatory demyelinative process consistent with the recovery observed in a number of patients. We postulate post-herpetic neuralgia may be related to an ongoing inflammatory process.

Chemical modification of a cloned glutathione S-transferase from Schistosoma japonicum: evidence for an essential histidine residue

Diethylpyrocarbonate (DEP) inhibits the catalytic activity of a cloned glutathione S-transferase from Schistosoma japonicum (Sj26GST) with a second-order rate constant of 474 M-1 min-1 at pH 7.0 and 25 degrees C. There is an accompanying increase in absorbance at 242 nm due to the formation of N-carbethoxyhistidyl derivatives. There was no evidence that tyrosine or cysteine residues were modified by DEP treatment nor did the enzyme undergo any major conformational change. Activity can be restored by treating the DEP-modified enzyme with hydroxylamine and the pH curve for inactivation indicates involvement of a residue with a pKa of 7.3. Complete inactivation of Sj26GST requires the modification of six histidine residues per subunit. Statistical analysis of residual enzyme activity versus number of groups modified showed that of the six modifiable groups, only one is critical for activity. Substrate protection suggests that this essential histidine residue is at or near the active site.

A method for recovery and counting of nematode cysts

A technique was developed in the early 1980's for recovery and quantification of Heterodera glycines (soybean cyst nematode) cysts from soil and soybean roots. Cysts were collected on sieves and counted on lincd filter paper. This technique could be applied to other particles of similar dimension and density.

Biochemical properties of cloned glutathione S-transferases from Schistosoma mansoni and Schistosoma japonicum

cDNA clones encoding a 28-kDa subunit glutathione S-transferase (GST) from Schistosoma mansoni (Sm28GST) and a 26-kDa subunit GST from Schistosoma japonicum (Sj26GST) have been expressed in bacterial systems. The recombinant proteins were purified to homogeneity by batch-wash glutathione-agarose affinity chromatography and their biochemical properties investigated. Gel filtration chromatography indicated that both recombinant GSTs are homodimeric proteins. Resolution of Sm28GST and Sj26GST by chromatofocusing in the ranges pH 9-6 and pH 7-4 gave pI estimates of 7.4 and 5.0, respectively. Kinetic analyses suggested that both Sm28GST and Sj26GST operate via a sequential bisubstrate catalytic mechanism. Sm28GST and Sj26GST displayed a mosaic of mammalian Alpha-, Mu- and Pi-type substrate specificities and inhibitor sensitivities. However, multivariate analysis suggests that Sm28GST has an overall catalytic homology with mammalian Mu class GSTs, whilst the enzymatic properties of Sj26GST appear to constitute a hybridisation of Mu and Alpha class features. Both recombinant GSTs interact with a range of hydrophobic ligands including haematin and related compounds, bile acids and several anthelmintics. Sm28GST and Sj26GST possess relatively limited selenium-independent glutathione peroxidase activities, but are able to catalyse the glutathione conjugation of members of the trans,trans-alka-2,4-dienal, trans-alk-2-enal and 4-hydroxyalk-2-enal series of reactive carbonyls (known secondary products of lipid peroxidation).