External ocular trauma in instrumental and normal deliveries

OBJECTIVE

To compare the occurrence of external ocular trauma in instrumental and normal deliveries.

DESIGN

Prospective controlled study.

SETTING

University Hospital of Wales, Cardiff.

SUBJECTS

133 babies born consecutively with the use of forceps and 133 control babies born without instrumentation to women matched for parity.

INTERVENTIONS

External ocular examination.

MAIN OUTCOME MEASURES

The presence within 24 h of birth of corneal oedema, corneal abrasion, conjunctival chemosis, subconjunctival haemorrhage and lid oedema.

RESULTS

Lid oedema and multiple minor external ocular trauma occurred in 52 and 22 babies, respectively, in the instrumental delivery group and in 13 and 8 babies, respectively in the control group (P less than 0.001). Corneal abrasion occurred in two babies and corneal oedema in one baby after forceps delivery but in none of the control group. No more serious injuries occurred. All injuries resolved without long term sequelae.

CONCLUSION

The frequency of sight threatening corneal trauma in instrumental deliveries is low. Specialist ophthalmic screening of these babies is not justified.

Risk prediction in medicine and surgery: ethical and practical considerations

Risk prediction is a subject of increasing clinical interest, and publications in this area are likely to have an important influence on patient care in the near future. A multiplicity of risk prediction systems, many of them computer-based, will raise a number of ethical and practical questions. These questions need to be addressed by the originators of systems, the editors of journals, practising clinicians, and the lay public.

Mortality associated with captopril and enalapril: a report from the DHSS Hypertension Care Computing Project

In 1986, the Committee on Safety of Medicines published a report suggesting that enalapril may have an adverse effect on renal function. The prescription event monitoring scheme subsequently published figures on adverse drug reactions and mortality for patients treated with enalapril. They concluded that enalapril did not have an adverse effect on renal function and survival. Similar data were not available for captopril, as the drug was marketed before prescription event monitoring had been developed. In the Department of Health and Social Security (DHSS) Hypertension Care Computing Project (DHCCP), 368 hypertensive patients treated with captopril and 371 treated with enalapril were followed for an average of 3.1 and 1.6 years, respectively. Thirty-two patients died; none had renal failure as an underlying cause of death. The death rate was similar in both drug groups, at 17.5 (enalapril) and 24.0 (captopril) per 1000 patient-years. The present report shows that, for patients treated for high blood pressure, the relative risk of mortality with captopril compared with enalapril was 1.37, an insignificant difference (95% confidence interval 0.63, 2.98).

Precision of Larsen grading of radiographs in assessing progression of rheumatoid arthritis in individual patients

A study was designed to evaluate observer variation in the assessment of radiographic deterioration of individual patients using the Larsen grading system. Radiographs of hands and feet of 52 patients were assessed by three observers. Each patient had paired films taken one year apart which were assessed together for change in score. To assess within-observer variation each set of films was read twice by all observers. The average progression was 11.6 (SD 9.0). Analysis of the source of variation showed the single observer replication SD to be 3.7 but that for different observers to be 5.5. This may be interpreted as indicating that to achieve 95% confidence of detecting a true change an increase in Larsen score of 8 is required if the same observer assesses or up to 11 if a different observer assesses.

A randomized study of a domiciliary antenatal care scheme: the effect on hospital admissions

A preliminary randomized study has been made of a domiciliary management scheme which incorporates telephonic fetal heart rate monitoring for women with high-risk pregnancies. In this paper we report effects of the scheme on the pattern of hospital admissions. Sixty women were randomized 2:1 for domiciliary surveillance or for conventional hospital care, with 40 and 17 records finally available for analysis. The groups were well matched for maternal, obstetric and socio-economic characteristics. In the domiciliary group, 21 (53%) of the women avoided hospital admission altogether, the admission rate was more than halved, and the mean proportion of the time spent in hospital was reduced from 50% to 16% of the observation period. The women who received domiciliary care were generally satisfied with the scheme. Our study confirms expectations that carefully planned domiciliary surveillance can reduce the number and duration of hospital admissions.

A randomised study of a domiciliary antenatal care scheme: maternal psychological effects

The Cardiff Integrated Antenatal Care Scheme (CIACS) places emphasis on home-centred care for selected women with a high-risk pregnancy. The Scheme is intended to make better use of midwifery and obstetric resources, and it provides a new type of care where close surveillance is required. A randomised controlled trial was undertaken in which anxiety levels were compared between two groups of women with an identified high-risk pregnancy. Sixty-five women were eligible for entry to the study. Five refused randomisation and 60 were randomised 2:1 either to care under the CIAC Scheme (domiciliary group n = 40) or to conventional hospital antenatal care (conventional group n = 17). Zung depression and STAI 'trait' levels conducted at weekly intervals were similar in both groups whilst 'state' levels were 34.05 (SD 9.24) in the domiciliary group and 41.05 (SD 9.93) in the conventional care group (P less than 0.01). It is suggested that the observed difference is due to the greater security provided by the home environment coupled with individual support from a midwife.

The effects of anti-hypertensive drugs on sexual function in men and women: a report from the DHSS Hypertension Care Computing Project (DHCCP)

One thousand, two hundred and eighty-five men and 1,080 women being followed in the DHSS Hypertension Care Computing Project answered the questions on sexual activity included in a self-administered questionnaire. In men, both impotence and sexual inactivity were increased in patients receiving hydralazine. No gross excess of these complaints could be determined in patients receiving either beta-adrenoceptor blocking drugs or methyldopa, nor was failure of ejaculation increased with these drugs. The survey could not exclude any deterioration in sexual function occurring uniformly across all treatment groups. However, the rates of complaint were similar in men taking a diuretic alone, a beta-adrenoceptor blocking drug alone and those taking the combination of these two drug groups. In women with hypertension, frequency of sexual intercourse and the achievement of orgasm was not associated with the giving of hydralazine, beta-adrenoceptor blocking drugs or methyldopa.

Beta adrenoceptor blockade is associated with increased survival in male but not female hypertensive patients: a report from the DHSS Hypertension Care Computing Project (DHCCP)

The DHCCP is a multicentre observational study of patients being treated for hypertension in the United Kingdom. The influence of the type of anti-hypertensive therapy on survival was examined in 2,697 patients followed from 1971 with 206 deaths up to November 1981. Patients were classified by three types of treatment after one year in the project: betablockers (1,387), methyldopa (452) and others (667), (70% on diuretics only). The data were analysed both for all patients and for a subset excluding patients with previous ischaemic heart disease by all cause and IHD age-adjusted rates and life table analysis. Men on beta blockers had lower rates for total mortality, when compared with men on methyldopa (64% of the methyldopa rate, P less than 0.05) and when compared with men on other treatments (76% of the other treatment rate, P less than 0.1). The results for IHD mortality were similar. This improved survival of men in the beta blocker group was also found in the subset with no prior history of IHD. The benefit of beta blockers was not apparent in women: the lowest rates were observed for women on methyldopa, but the confidence limits for the ratios of relative rates were wide. Adjustment for blood pressure and cigarette smoking using the Cox proportional hazards model did not substantially modify the ratios of the mortality rates for the treatment groups. A sub-group analysis showed the reduction in all cause and IHD mortality associated with beta blockers was mainly due to the effect in non-smoking men.(ABSTRACT TRUNCATED AT 250 WORDS)

Treated blood pressure, rather than pretreatment, predicts survival in hypertensive patients. A report from the DHSS Hypertension Care Computing Project (DHCCP)

A group of hypertensive patients (n = 2855) with an untreated diastolic blood pressure greater than or equal to 90 mmHg were followed in the Department of Health and Social Security (DHSS) Hypertension Care Computing Project (DHCCP) for periods of up to 10 years. During this period 191 of these patients died. Survival was assessed in relation to pretreatment blood pressure levels and blood pressure achieved during treatment. The blood pressure during treatment was a useful predictor of mortality, but the pretreatment pressure was not. After adjusting for age, mortality was particularly related to the height of the systolic and diastolic blood pressure during the second and third years of treatment. In men, age-standardized 5-year mortality was greater than 10% in those with a first year treated systolic pressure greater than 150 mmHg or a diastolic pressure greater than 95 mmHg. In women, age standardized 5-year mortality was greater than 5% with the same levels of treated blood pressure. The longest survival occurred with the lowest bands of treated pressure, i.e. systolic pressure less than 140 and diastolic pressure less than 90 mmHg; the 5-year mortality being less than 7% in men and less than 3% in women. Treated systolic and diastolic pressures were useful in predicting death from ischaemic heart disease (IHD).

The relationship between a low treated blood pressure and IHD mortality: a report from the DHSS Hypertension Care Computing Project (DHCCP)

The suggestion that treating blood pressure to below a certain level may increase IHD mortality is controversial. We investigated the influence of treated blood pressure on mortality in the DHSS Hypertension Care Computer Project. Mortality was examined by quintiles of treated diastolic blood pressure (DBP) in 2,145 patients treated for a minimum period of one year and subsequently followed for an average of four years. One hundred and seventy five patients died; 71 from IHD. In men and women all cause mortality increased with level of treated DBP. In men IHD mortality showed a U-shaped distribution with an age-adjusted rate of 15.2 per 1,000 person years in the lowest fifth (DBP less than 86 mmHg) comparable to that of 15.6 per 1,000 in the upper (DBP greater than or equal to 103 mmHg). A similar pattern could not be established in women due to very few IHD deaths. IHD mortality was further examined separately for men by prior history of IHD. An increase in IHD deaths in the lowest fifth of treated blood pressure was found for men both with and without a history of IHD. No similar pattern of IHD mortality was obtained for untreated DBP or treated systolic pressure. However, we cannot exclude the possibility that the risk of low treated DBP is secondary to ischaemic heart disease.

Amoxycillin-clavulanic acid (Augmentin) versus metronidazole as prophylaxis in hysterectomy: a prospective, randomized clinical trial

In order to determine the most effective regimen for the prevention of infection after elective hysterectomy, 300 patients were randomly assigned to receive three perioperative doses of either amoxycillin-clavulanic acid (1.2 g intravenous) or metronidazole (1 g suppository). Of the 280 patients who were assessable 138 were given amoxycillin-clavulanic acid and 142 received metronidazole; 268 underwent abdominal hysterectomy and 12 had vaginal hysterectomy. Patients in the amoxycillin-clavulanic acid group had significantly less infectious morbidity (13.8%) than those in the metronidazole group (33.1%). There were also statistically significant differences in favour of amoxycillin-clavulanic acid with respect to operative site infection, duration of hospital stay, need for postoperative antimicrobials, and surgery for operative site infection. But for one isolate of Bacteroides fragilis, all pathogens isolated from wound infections in the metronidazole group were aerobes. No anaerobes were isolated from patients in the amoxycillin-clavulanic acid group. The results suggest that prophylaxis for hysterectomy should consist of an agent, or combination of agents, with activity against both aerobic and anaerobic bacteria. Amoxycillin-clavulanic acid fulfils this criterion and appears to be effective and safe.

Significant changes in Ritchie scores

A study was designed to establish the reliability of assessing joint tenderness in rheumatoid arthritis. Reliability both within and between observers was measured and the 95% confidence intervals (CI) for a change in score calculated. Forty-two patients were assessed by two metrologists over a 14-week period using three subjects per week. Results showed close agreement within and between metrologists. The 95% CI for repeat measures by the same metrologist was +/- 8.5 and +/- 12 by a different metrologist. Taking a change of 5 in the score as clinically significant, the 95% CI for a clinically significant change would be +/- 14 with one observer and +/- 17 when a different observer repeated the assessment. It is recommended that other centres should establish their own CI for a change in scores when undertaking clinical trials.

Childhood poisoning in Wales: experience of the Welsh National Poisons Unit (1984)

In 1984, 60% of all the enquiries made to the Welsh National Poisons Unit in Cardiff concerned children under 15, and 86% of the latter concerned children under 5. Nearly 60% of requests for information in childhood poisoning were about non-medicinal products and this contrasts with hospital admissions which are more often associated with medicinal products in this age group. Seasonal variability was noted for non-medicinal products such as pesticides and plant poisoning enquiries, whereas medicinal product enquiries remained constant over the year. The pesticides enquiries were greatest in Spring while those concerning plants were significantly greater in Summer. The latter was due to increased reports of ingestion of garden plants since the number of enquiries concerning house plants remained constant. Thus availability appears to be a major determinant of the risk of poisoning with any particular product in childhood.

Relation of haemoglobin levels in first and second trimesters to outcome of pregnancy

The relation between haemoglobin (Hb) concentrations at antenatal booking and subsequent outcome was examined in 54 382 singleton pregnancies. Both high (greater than 13.2 g/dl) and low (less than 10.4 g/dl) Hb values were associated with an adverse outcome. Mothers with a booking Hb in the intermediate range (10.4-13.2 g/dl) fared best. Significant differences emerged in perinatal mortality between those with high and those with intermediate Hb levels at 13-19 weeks' gestation. The frequencies of perinatal death, low birthweight, and preterm delivery were greater with high than with intermediate Hb. There was a striking relation between booking Hb values and the subsequent frequency of hypertension (p less than 0.001). In primiparas, the frequency of subsequent hypertension ranged from 7% at Hb values under 10.5 g/dl to 42% at Hb concentrations over 14.5 g/dl.

The survival of treated hypertensive patients and their causes of death: a report from the DHSS hypertensive care computing project (DHCCP)

A prospective study has been carried out to determine the causes of death and risk factors for survival in 4994 patients referred with a diagnosis of hypertension to hospital specialist clinics and 457 patients treated by their general practitioners for this condition. At the time of entering the prospective study, 69% of the patients were already being treated for hypertension. Four hundred and eleven patients have died, and their causes of death and death rates have been compared with the rates for the population of England and Wales. Ischaemic heart disease accounted for over one-third of the deaths and stroke for one-fifth. The death rates for these conditions were two to five times those expected for men and women aged 50-59 years and up to twice the rate expected for the age group 60-69 years. Survival in these selected patients was impaired by the following independent risk indicators: cigarette smoking, previous history of myocardial infarction or stroke, diagnosis of angina, impaired renal function and raised blood sugar. The following factors were not independent positive risk factors: smoking a pipe or cigars, obesity, a low plasma potassium and an elevated serum uric acid.

Coeliac disease and malignancy

Patients with coeliac disease are at greater risk than the general population for the development of malignant neoplasms, particularly lymphomas. Of 259 histologically confirmed malignancies in 235 patients with histologically proven coeliac disease, 133 were malignant lymphomas, the predominant histological type being malignant histiocytosis and the commonest site of this lesion the small intestine. Patients with coeliac disease also have a greatly increased risk for the development of small-intestinal adenocarcinomas. Among 116 invasive non-lymphomatous malignancies there were 19 small-intestinal adenocarcinomas, compared with 0 . 23 expected from national cancer registrations adjusted for sex and age. There were also more oesophageal and pharyngeal squamous carcinomas than expected.

Nomograms for precise determination of birth weight for dates

We have derived a mathematical model (Altman and Coles, 1980) that matches closely the birth weight standards derived from the large Aberdeen survey (Thomson et al, 1968). From this, we have drawn nomograms that can be used to assess an infant's position in relation to these standards. The nomograms are easy to use and give adequate precision.