Ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: a secondary analysis of the PITCHES trial

OBJECTIVE

To evaluate whether a particular group of women with intrahepatic cholestasis of pregnancy (ICP), based on their presenting characteristics, would benefit from treatment with ursodeoxycholic acid (UDCA).

DESIGN

Secondary analysis of the PITCHES trial (ISRCTN91918806).

SETTING

United Kingdom.

POPULATION OR SAMPLE

527 women with ICP.

METHODS

Subgroup analyses were performed to determine whether baseline bile acid concentrations or baseline itch scores moderated a woman's response to treatment with UDCA.

MAIN OUTCOME MEASURES

Bile acid concentration and itch score.

RESULTS

In women with baseline bile acid concentrations less than 40 μmol/l, treatment with UDCA resulted in increased post-randomisation bile acid concentrations (geometric mean ratio 1.19, 95% CI 1.00-1.41, P = 0.048). A test of interaction showed no significance (P = 0.647). A small, clinically insignificant difference was seen in itch response in women with a high baseline itch score (-6.0 mm, 95% CI -11.80 to -0.21, P = 0.042), with a test of interaction not showing significance (P = 0.640). Further subgroup analyses showed no significance. Across all women there was a weak relationship between bile acid concentrations and itch severity.

CONCLUSIONS

There was no subgroup of women with ICP in whom a beneficial effect of treatment with UDCA on bile acid concentration or itch score could be identified. This confirms that its routine use in women with this condition for improvement of bile acid concentration or itch score should be reconsidered.

TWEETABLE ABSTRACT

PITCHES: No group of women with ICP has been found in whom UDCA reduces bile acid concentrations or pruritus.

An international comparison of retinopathy of prematurity grading performance within the Benefits of Oxygen Saturation Targeting II trials

Purpose

To investigate whether the observed international differences in retinopathy of prematurity (ROP) treatment rates within the Benefits of Oxygen Saturation Targeting (BOOST) II trials might have been caused by international variation in ROP disease grading.

Methods

Groups of BOOST II trial ophthalmologists in UK, Australia, and New Zealand (ANZ), and an international reference group (INT) used a web based system to grade a selection of RetCam images of ROP acquired during the BOOST II UK trial. Rates of decisions to treat, plus disease grading, ROP stage grading, ROP zone grading, inter-observer variation within groups and intra-observer variation within groups were measured.

Results

Forty-two eye examinations were graded. UK ophthalmologists diagnosed treat-requiring ROP more frequently than ANZ ophthalmologists, 13.9 (3.49) compared to 9.4 (4.46) eye examinations, P=0.038. UK ophthalmologists diagnosed plus disease more frequently than ANZ ophthalmologists, 14.1 (6.23) compared to 8.5 (3.24) eye examinations, P=0.021. ANZ ophthalmologists diagnosed stage 2 ROP more frequently than UK ophthalmologists, 20.2 (5.8) compared to 12.7 (7.1) eye examinations, P=0.026. There were no other significant differences in the grading of ROP stage or zone. Inter-observer variation was higher within the UK group than within the ANZ group. Intra-observer variation was low in both groups.

Conclusions

We have found evidence of international variation in the diagnosis of treatment-requiring ROP. Improved standardisation of the diagnosis of treatment-requiring ROP is required. Measures might include improved training in the grading of ROP, using an international approach, and further development of ROP image analysis software.

Caesarean section surgical techniques: 3 year follow-up of the CORONIS fractional, factorial, unmasked, randomised controlled trial

BACKGROUND

The CORONIS trial reported differences in short-term maternal morbidity when comparing five pairs of alternative surgical techniques for caesarean section. Here we report outcomes at 3 years follow-up.

METHODS

The CORONIS trial was a pragmatic international 2 × 2 × 2 × 2× 2 non-regular fractional, factorial, unmasked, randomised controlled trial done at 19 sites in Argentina, Chile, Ghana, India, Kenya, Pakistan, and Sudan. Pregnant women were eligible if they were to undergo their first or second caesarean section through a planned transverse abdominal incision. Women were randomly assigned by a secure web-based allocation system to one intervention from each of the three assigned pairs. All investigators, surgeons, and participants were unmasked to treatment allocation. In this follow-up study, we compared outcomes at 3 years following blunt versus sharp abdominal entry, exteriorisation of the uterus for repair versus intra-abdominal repair, single versus double layer closure of the uterus, closure versus non-closure of the peritoneum, and chromic catgut versus polyglactin-910 for uterine repair. Outcomes included pelvic pain; deep dyspareunia; hysterectomy and outcomes of subsequent pregnancies. Outcomes were assessed masked to the original trial allocation. This trial is registered with the Current Controlled Trials registry, number ISRCTN31089967.

FINDINGS

Between Sept 1, 2011, and Sept 30, 2014, 13,153 (84%) women were followed-up for a mean duration of 3·8 years (SD 0·86). For blunt versus sharp abdominal entry there was no evidence of a difference in risk of abdominal hernias (adjusted RR 0·66; 95% CI 0·39-1·11). We also recorded no evidence of a difference in risk of death or serious morbidity of the children born at the time of trial entry (0·99, 0·83-1·17). For exteriorisation of the uterus versus intra-abdominal repair there was no evidence of a difference in risk of infertility (0·91, 0·71-1·18) or of ectopic pregnancy (0·50, 0·15-1·66). For single versus double layer closure of the uterus there was no evidence of a difference in maternal death (0·78, 0·46-1·32) or a composite of pregnancy complications (1·20, 0·75-1·90). For closure versus non-closure of the peritoneum there was no evidence of a difference in any outcomes relating to symptoms associated with pelvic adhesions such as infertility (0·80, 0·61-1·06). For chromic catgut versus polyglactin-910 sutures there was no evidence of a difference in the main comparisons for adverse pregnancy outcomes in a subsequent pregnancy, such as uterine rupture (3·05, 0·32-29·29). Overall, severe adverse outcomes were uncommon in these settings.

INTERPRETATION

Although our study was not powered to detect modest differences in rare but serious events, there was no evidence to favour one technique over another. Other considerations will probably affect clinical practice, such as the time and cost saving of different approaches.

FUNDING

UK Medical Research Council and the Department for International Development.

Caesarean section surgical techniques (CORONIS): a fractional, factorial, unmasked, randomised controlled trial

BACKGROUND

Variations exist in the surgical techniques used for caesarean section and many have not been rigorously assessed in randomised controlled trials. We aimed to assess whether any surgical techniques were associated with improved outcomes for women and babies.

METHODS

CORONIS was a pragmatic international 2×2×2×2×2 non-regular fractional, factorial, unmasked, randomised controlled trial that examined five elements of the caesarean section technique in intervention pairs. CORONIS was undertaken at 19 sites in Argentina, Chile, Ghana, India, Kenya, Pakistan, and Sudan. Each site was assigned to three of the five intervention pairs: blunt versus sharp abdominal entry; exteriorisation of the uterus for repair versus intra-abdominal repair; single-layer versus double-layer closure of the uterus; closure versus non-closure of the peritoneum (pelvic and parietal); and chromic catgut versus polyglactin-910 for uterine repair. Pregnant women were eligible if they were to undergo their first or second caesarean section through a planned transverse abdominal incision. Women were randomly assigned by a secure web-based number allocation system to one intervention from each of the three assigned pairs. All investigators, surgeons, and participants were unmasked to treatment allocation. The primary outcome was the composite of death, maternal infectious morbidity, further operative procedures, or blood transfusion (>1 unit) up to the 6-week follow-up visit. Women were analysed in the groups into which they were allocated. The CORONIS Trial is registered with Current Controlled Trials: ISRCTN31089967.

FINDINGS

Between May 20, 2007, and Dec 31, 2010, 15 935 women were recruited. There were no statistically significant differences within any of the intervention pairs for the primary outcome: blunt versus sharp entry risk ratio 1·03 (95% CI 0·91-1·17), exterior versus intra-abdominal repair 0·96 (0·84-1·08), single-layer versus double-layer closure 0·96 (0·85-1·08), closure versus non-closure 1·06 (0·94-1·20), and chromic catgut versus polyglactin-910 0·90 (0·78-1·04). 144 serious adverse events were reported, of which 26 were possibly related to the intervention. Most of the reported serious adverse events were known complications of surgery or complications of the reasons for the caesarean section.

INTERPRETATION

These findings suggest that any of these surgical techniques is acceptable. However, longer-term follow-up is needed to assess whether the absence of evidence of short-term effects will translate into an absence of long-term effects.

FUNDING

UK Medical Research Council and WHO.

The partial primary structure of bovine rhodopsin and its topography in the retinal rod cell disc membrane

The amino-terminal 39 amino acids of bovine rhodopsin have the sequence where both carbohydrate attachment sites (CHO) contain GlcNAc(3)Man(3). This region of rhodopsin's sequence is exposed at the internal membrane surface of the rod cell disc membrane. Rhodopsin's carboxyl-terminal 40 amino acids have the sequence where amino acid 1? is the carboxyl-terminal amino acid of rhodopsin. Serines and threonines in the sequence 6? ? 15? are phosphorylated by rhodopsin kinase in a light-dependent reaction. Trypsin can digest native rhodopsin, in the disc membrane at and thermolysin can hydrolyze bonds , and . Limited proteolysis by thermolysin at a site internal in the molecule has been exploited in order to prepare rhodopsin as two large fragments, F1 and F2. Cysteine(33)?, is highly reactive in the dark and is modified by N-ethylmaleimide and several alkylating agents. The carboxyl-terminal region 1?-39? reacts with the membrane-impermeable nitrene from N-(4-azido-2-nitrophenyl)-2-aminoethyl sulfonate and is therefore exposed at the external (cytoplasmic) surface of the disc membrane. 1-azldopyrene, a hydrophobic nitrene precursor, is being used to map those regions of the rhodopsin sequence which are located in a hydrophobic environment.

Treatment of asphyxiated newborns with moderate hypothermia in routine clinical practice: how cooling is managed in the UK outside a clinical trial

BACKGROUND

This is a phase 4 study of infants registered with the UK TOBY Cooling Register from December 2006 to February 2008. The registry was established on completion of enrolLment to the TOBY randomised trial of treatment with whole body hypothermia following perinatal asphyxia at the end of November 2006.

METHODS

We collected information about patient characteristics, condition at birth, resuscitation details, severity of encephalopathy, hourly temperature record, clinical complications and outcomes before hospital discharge.

RESULTS

120 infants born at a median of 40 (IQR 38-41) weeks' gestation and weighing a median of 3287 (IQR 2895-3710) g at birth were studied. Cooling was started at a median of 3 h 54 min (IQR 2 h-5 h 32 min) after birth. All but three infants underwent whole body cooling. The mean (SD) rectal temperature from 6 to 72 h of the cooling period was 33.57 degrees C (0.51 degrees C). The daily encephalopathy score fell: median (IQR) 11 (6-15), 9.7 (5-14), 8 (5-13) and 7 (2-12) on days 1-4 after birth, respectively. 51% of the infants established full oral feeding at a median (range) of 9 (4-24) days. 26% of the study infants died. MRI was consistent with hypoxia-ischaemia in most cases. Clinical complications were not considered to be due to hypothermia.

CONCLUSION

In the UK, therapeutic hypothermia following perinatal asphyxia is increasingly being provided. The target body temperature is successfully achieved and the clinical complications observed were not attributed to hypothermia. Treatment with hypothermia may have prevented the worsening of the encephalopathy that is commonly observed following asphyxia.

Parent satisfaction in a nurse led clinic compared with a paediatric gastroenterology clinic for the management of intractable, functional constipation

AIMS

To assess parent satisfaction with a nurse led clinic for children with intractable, functional constipation compared with a paediatric gastroenterology outpatient clinic.

METHODS

A validated questionnaire covering six separate domains in 48 statements (provision of information, empathy with the patient, technical quality and competence, attitude towards the patient, access to and continuity with the caregiver, and overall satisfaction) was employed. For all outcomes, the data were analysed on an intention-to-treat basis.

RESULTS

90/107 (84%) questionnaires were returned: 40/51 (78%) from the paediatric gastroenterology clinic and 50/56 (89%) from the nurse led clinic. Results indicated a high "total" satisfaction with the clinical care, but these were statistically significantly higher in the nurse led clinic compared with the paediatric gastroenterology clinic (median score 8.7 and 7.3 respectively, out of a maximum score of 10). This difference was consistent across all domains when the scores from those attending the nurse led clinic were compared with those attending the paediatric gastroenterology clinic (information median score 8.7 v 7.5; empathy 9.0 v 7.3; competence 9.1 v 8.0; attitude 8.7 v 7.3; access 8.2 v 6.7). All comparisons were highly statistically significant.

CONCLUSION

These results provide firm evidence that parents of children with intractable constipation are satisfied with the care they receive in both the paediatric and nursing clinic setting. Parent satisfaction, however, was significantly higher in those attending the nurse led clinic. This study adds further support to the development of a nurse led service to manage intractable, functional constipation in children.

Compression stockings for preventing deep vein thrombosis in airline passengers

BACKGROUND

Air travel might increase the risk of deep vein thrombosis (DVT). It has been suggested that wearing compression stockings might reduce this risk.

OBJECTIVES

To assess the effects of wearing compression stockings versus not wearing them among people travelling on flights lasting at least four hours.

SEARCH STRATEGY

We searched the Cochrane Peripheral Vascular Diseases Group's Specialized Register (January 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) (in The Cochrane Library, Issue 4, 2005), MEDLINE (January 1966 to November 2005), EMBASE (January 1980 to December 2005) and several other electronic or grey literature sources, detailed in full in the review. The most recent searches were done in January 2006.

SELECTION CRITERIA

Randomized trials of compression stockings versus no stockings in passengers on flights lasting at least four hours. Trials in which passengers wore a stocking on one leg but not the other, or those comparing stockings and another intervention were also eligible.

DATA COLLECTION AND ANALYSIS

At least two authors independently assessed the quality of each study and extracted data. We sought additional information from trialists.

MAIN RESULTS

Ten randomized trials (n = 2856) were included; nine (n = 2821) compared wearing stockings on both legs versus not wearing them, and one (n = 35) compared wearing a stocking on one leg for the outbound flight and on the other leg on the return flight. Of the nine trials, seven included people judged to be at low or medium risk (n = 1548) and two included high risk participants (n = 1273). All flights lasted at least seven hours. Fifty of 2637 participants with follow-up data available in the trials of wearing stockings on both legs had a symptomless DVT; three wore stockings, 47 did not (odds ratio 0.10, 95% confidence interval 0.04 to 0.25, P < 0.00001). There were no symptomless DVTs in three trials. No deaths, pulmonary emboli or symptomatic DVTs were reported. Wearing stockings had a significant impact in reducing oedema (based on six trials). No significant adverse effects were reported.

AUTHORS' CONCLUSIONS

Airline passengers similar to those in this review can expect a substantial reduction in the incidence of symptomless DVT and leg oedema if they wear compression stockings. We cannot assess the effect of wearing stockings on death, pulmonary embolus or symptomatic DVT because no such events occurred in these trials. Randomized trials to assess these outcomes would need to include a very large number of people.

Nurse management of intractable functional constipation: a randomised controlled trial

AIMS

To evaluate the effectiveness of a nurse led clinic (NLC) compared with a consultant led paediatric gastroenterology clinic (PGC) in the management of chronic constipation.

METHODS

Children (age 1-15 years) with functional constipation were randomised following a detailed medical assessment to follow up in either the NLC or PGC. An escalating algorithm of treatment was used as the basis of management in both the NLC and PGC. Main outcome measures were: time to cure at last visit or later confirmed by telephone; time to cure at last visit; and time to prematurely leaving the study.

RESULTS

A total of 102 children were recruited, of whom 52 were randomly assigned to NLC and 50 to PGC. Outcome assessment showed that 34 children in the NLC and 25 children in the PGC were confirmed cured at their last visit or later confirmed by telephone. The median time to cure was 18.0 months in the NLC and 23.2 months in the PGC. The probability of being cured was estimated as 33% higher in the NLC compared to PGC (hazard ratio 1.33). Attending the NLC hastened time to cure by an estimated 18.4%.

CONCLUSION

Children who attend an NLC are equally as, if not more likely to be cured of intractable constipation, than those attending a PGC and on average their cure will occur sooner. Results suggest that an NLC can significantly improve follow up for children with intractable constipation and highlight the important role for clinic nurse specialists in management of children with gastrointestinal disease.

An investigation of risk factors for symptomatic osteoarthritis of the knee in women using a life course approach

STUDY OBJECTIVE

To explore risk factors for symptomatic knee osteoarthritis (OAK) in women, which included wearing high heeled shoes.

DESIGN

Matched case-control study. Exposure information obtained by interview, included details about past footwear. Self reported weight and height data obtained representing when women left school, were aged 36-40 and were aged 51-55. Regular work activities (including periods when homemaker or carer), smoking, and hormone related data gathered using a life-grid.

SETTING

Interviews in participants' homes. Cases identified from orthopaedic hospital surgical waiting list, controls identified by general practitioners (GPs)

PARTICIPANTS

Women aged 50 to 70 years. Cases awaiting knee replacement surgery. Controls, who had no past knee surgery and no knee pain in the past three years, were matched for age and GP. Altogether 111 eligible women were interviewed (29 cases, 82 controls).

MAIN RESULTS

Univariate analyses identified several significant associations with OAK including past knee injury, arthritis of the feet, heavy smoking, being overweight (BMI 25 or above) and various occupational activities. Virtually all measures of high heeled shoes use were associated with reduced risk of OAK, although none of these findings were statistically significant. In multivariate analysis only BMI 25 or above at age 36-40 remained significantly associated with OAK (OR 36.4, 95% CI 3.07 to 432, p=0.004), although weak evidence suggested certain occupational activities might increase risk. Weight gain in early adult life was particularly pronounced among cases.

CONCLUSIONS

Being overweight before the age of 40 considerably increased the risk of subsequent symptomatic OAK in women. Wearing high heeled shoes did not.

A mobile-bearing total knee prosthesis compared with a fixed-bearing prosthesis. A multicentre single-blind randomised controlled trial

Before proceeding to longer-term studies, we have studied the early clinical results of a new mobile-bearing total knee prosthesis in comparison with an established fixed-bearing device. Patients requiring bilateral knee replacement consented to have their operations under one anaesthetic using one of each prosthesis. They also agreed to accept the random choice of knee (right or left) and to remain ignorant as to which side had which implant. Outcomes were measured using the American Knee Society Score (AKSS), the Oxford Knee Score (OKS), and determination of the range of movement and pain scores before and at one year after operation. Preoperatively, there was no systematic difference between the right and left knees. One patient died in the perioperative period and one mobile-bearing prosthesis required early revision for dislocation of the meniscal component. At one year the mean AKSS, OKS and pain scores for the new device were slightly better (p < 0.025) than those for the fixed-bearing device. There was no difference in the range of movement. We believe that this is the first controlled, blinded trial to compare early function of a new knee prosthesis with that of a standard implant. It demonstrates a small but significant clinical advantage for the mobile-bearing design.

Impact of feeding problems on nutritional intake and growth: Oxford Feeding Study II

Poor nutritional status and growth failure are common in children with cerebral palsy (CP). The aim of this study was to assess, within a subgroup of a large and clearly defined population of children with disabilities, the impact of feeding difficulties on (1) the quality (micronutrient intake) and quantity (macronutrient intake) of their diet and (2) their growth. One hundred children with disabilities (40 females, 60 males; mean age 9 years, SD 2 years 5 months; range 4 years 6 months to 13 years 7 months) underwent a detailed dietetic analysis and a comprehensive anthropometric assessment. Diagnostic categories of disability were: CP (n=90); global developmental delay (n=3); Marfan syndrome (n=1); intractable epilepsy (n=2); agenesis of the corpus callosum (n=2); methyl malonic aciduria (n=1); and congenital rubella (n=1). Neurological impairment was classified according to difficulty with mobility which was graded as mild (little or no difficulty walking), moderate (difficulty walking but does not need aids or a helper), and severe (needs aids and/or a helper or cannot walk). Results confirmed the significant impact of neurological impairment in children on body growth and nutritional status becoming worse in those with a greater degree of motor impairment. The major nutritional deficit was in energy intake, with only one fifth reportedly regularly achieving over 100% estimated average requirement (EAR), whilst micronutrient intake was less markedly impaired and protein intake was normal in this group (96% above EAR). Many children with neurological impairment would benefit from individual nutritional assessment and management as part of their overall care.

Effect of death of Diana, princess of Wales on suicide and deliberate self-harm

BACKGROUND

The death of the Princess of Wales in 1997 was followed by widespread public mourning. Such major events may influence suicidal behaviour.

AIMS

To assess the impact of the Princess's death on suicide and deliberate self-harm (DSH).

METHOD

Analysis, using Poisson regression, of the number of suicides and open verdicts ('suicides') in England and Wales following the Princess's death compared to the 3 months beforehand, and the equivalent periods in 1992-1996. Similar analysis on DSH presentations to a general hospital.

RESULTS

Suicides increased during the month following the Princess's funeral (+17.4%). This was particularly marked in females (+33.7%), especially those aged 25-44 years (+45.1%). Suicides did not fall in the week between the death and the funeral. Presentations for DSH increased significantly during the week following the death (+44.3%), especially in females (+65.1%). Examination of case notes suggested that the influence of the death was largely through amplification of personal losses or exacerbation of existing distress.

CONCLUSIONS

The death of a major public figure can influence rates of suicidal behaviour. For DSH, the impact may be immediate, but for suicide it may be delayed.

Obstetric complications and affective psychoses. Two case-control studies based on structured obstetric records

BACKGROUND

Unlike schizophrenia, little interest has been taken in the incidence of obstetric complications in affective psychoses.

AIMS

To find out whether obstetric complications are more common in affective psychoses than matched controls.

METHOD

Two hundred and seventeen probands with an in-patient diagnosis of affective psychosis who had been born in Scotland in 1971-74, and a further 84 born in 1975-78, were closely matched with controls and the incidence of obstetric complications in the two compared using obstetric data recorded in a set format shortly after birth.

RESULTS

Abnormal presentation of the foetus was the only complication significantly more common in the affective probands in the 1971-74 birth cohort and artificial rupture of the membranes was the only event more common in the probands in the 1975-78 cohort. Both are probably chance findings.

CONCLUSION

It is unlikely that the incidence of obstetric complications is raised in people with affective psychoses of early onset.

Obstetric complications and schizophrenia. Two case-control studies based on structured obstetric records

BACKGROUND

Most previous case-control studies of obstetric complications in schizophrenia have been small scale and many have relied on retrospective information.

AIMS

To determine which obstetric complications are more common in probands with schizophrenia than matched controls.

METHOD

Two hundred and ninety-six probands with an in-patient diagnosis of schizophrenia who had been born in Scotland in 1971-74, and a further 156 born in 1975-78, were closely matched with controls and the incidence of obstetric complications in the two compared using obstetric data recorded in a set format shortly after birth.

RESULTS

Not a single complication of pregnancy or delivery was significantly more common in the probands with schizophrenia than the controls in the 1971-74 birth cohort and only emergency Caesarean section and labour lasting over 12 hours were significantly more common in the schizophrenia probands in the 1975-78 cohort.

CONCLUSION

The evidence that schizophrenia is associated with a raised incidence of obstetric complications is weaker than has recently been assumed.

Pre- and perinatal risk factors for childhood leukaemia and other malignancies: a Scottish case control study

A case control study of Scottish children aimed to identify risk factors for leukaemia and other cancers operating in the prenatal environment, during delivery and neonatally. Cases (0-14 years) were age-and sex- matched to two population-based controls and details abstracted from the mother's hospital obstetric notes. Analyses of 144 leukaemias (124 acute lymphoblastic leukaemias (ALL)), 45 lymphomas, 75 central nervous system (CNS) tumours and 126 'other solid tumours' were conducted using conditional logistic regression. The presence of a neonatal infection significantly reduced the risk of ALL (odds ratio (OR) 0.49, 95% confidence interval (CI) 0.26-0.95), particularly in 0- to 4-year-olds. Positive swab tests confirmed 47% of ALL cases with any infection and 46% of controls. This is consistent with the hypothesis that early exposure to infections may reduce the risk of childhood ALL. Asphyxia at birth significantly increased the risk of leukaemia, which was accounted for by ALL. For the 'other solid tumours' higher levels of maternal education were inversely associated with risk (OR 0.59, 95% CI 0.37-0.94) but positively associated with antibiotics (OR 2.16 95% CI 1.10-4.25) and respiratory tract infections (OR 14.1, 95% CI 1.76-113.7) in pregnancy. No obvious plausible patterns of risk were detected either within or across disease subgroups.

Neonatal mortality amongst Scottish preterm singleton births (1985-1994)

OBJECTIVE

To provide a valid estimate of singleton neonatal mortality based on birthweight and gestational age at delivery.

DESIGN

Record linkage of maternity data and neonatal mortality data.

SETTING

Scotland, UK.

POPULATION

All singleton preterm deliveries from 24 to 36 weeks inclusive between 1985 and 1994.

MAIN OUTCOME MEASURE

Neonatal death.

RESULTS

There were 625,646 liveborn singleton deliveries over the study period, of which 33,912 were preterm (5.4%). The overall neonatal mortality in the preterm group was 41/1000 and the data have been presented by both gestational age and birthweight. The neonatal mortality rate fell with advancing gestation from 795/1000 live births at 24 weeks to 9/1000 live births at 36 weeks and was higher at the extremes of birthweight for a given gestational age. There was a significant increase in the proportion of babies delivered iatrogenically over the study period (chi test for trend P < 0.001).

CONCLUSION

This is the largest recent series to consider neonatal mortality using both birthweight and gestational age. These figures will be of use in obstetric management when elective preterm delivery is considered, and for providing prognostic guidance following preterm delivery.

Case-control study of childhood leukaemia and cancer in Scotland: findings for neonatal intramuscular vitamin K

OBJECTIVE

To test the hypothesis of an association between neonatal intramuscular vitamin K and childhood leukaemia and other cancers.

DESIGN

Population based case-control study with data abstracted from hospital records.

SETTING

Scotland.

SUBJECTS

Children aged 0-14 years resident in Scotland from 1991-4 and diagnosed with leukaemia (150), lymphomas (46), central nervous system tumours (79), a range of other solid tumours (142), and a subset of acute lymphoblastic leukaemia (129). Controls were 777 children matched for age and sex, providing 417 matched sets (360 triplets and 57 pairs) for analysis.

MAIN OUTCOME MEASURE

Odds ratios for the risk of childhood leukaemia and cancer and intramuscular vitamin K versus a combined group of oral doses, none, and no record. Results are given for information recorded in medical notes and data supplemented by hospital policy.

RESULTS

Odds ratios based on medical record abstractions showed no significant positive association for leukaemias (odds ratio 1.30; 95% confidence interval 0.83 to 2.03), acute lymphoblastic leukaemia (1.21; 0.74 to 1.97), lymphomas (1.06; 0.46 to 2.42), central nervous system tumours (0.74; 0.40 to 1.34), and other solid tumours (0.59; 0.37 to 0.96). There was no association with acute lymphoblastic leukaemia in children aged 1 to 6 years. Imputation of exposure from hospital policy gave similar results. Adjustment for deprivation and type of delivery moved risk estimates closer to unity for all major diagnostic groups.

CONCLUSIONS

The observation of an increased risk of childhood leukaemia and cancer associated with intramuscular vitamin K is not confirmed by this independent population based study.

Suicide in the 12 months after discharge from psychiatric inpatient care, Scotland 1968-92

STUDY OBJECTIVE

To investigate the rate of suicide in the 12 months after discharge from psychiatric hospital and to determine its relationship to age, diagnosis, and period.

DESIGN

Cohort study of patients discharged from psychiatric hospital.

SETTING

Scotland.

PARTICIPANTS

Altogether 159,742 men and 178,271 women, aged 15-84, who were discharged from Scottish psychiatric hospitals during 1968-92.

MAIN RESULTS

During the 25 year period, 1212 male patients committed suicide in 198,059 person years at risk (612 per 100,000; 95% confidence interval (CI) 578,647) and 1099 female patients committed suicide in 228,993 person years at risk (480 per 100,000; 95% CI 452, 509). The overall standardised mortality ratio (general population rate = 1) was 27 (95% CI 26, 29) in men and 40 (95% CI 38, 43) in women. There were variations in the suicide rates in relation to age, diagnosis, and period. The ratio of the 1-28 day rate to the rate between days 29 and 365 over the whole study period was 1.7 (95% CI 1.4, 1.9) in men and 1.6 (95% CI 1.3, 1.8) in women.

CONCLUSIONS

The variations in the post discharge suicide rate by age, sex, diagnosis, geographical location, and period suggest that there are several risk factors which vary in their distribution. Further study of these may lead to the development of effective interventions.

Long-term survival in patients with advanced immunodeficiency

OBJECTIVE

To identity prognostic factors associated with survival time in HIV-infected patients with advanced immunodeficiency.

DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 1284 HIV-infected patients with serial CD4 count measurements and at least one CD4 cell count < or = 50 x 10(6)/I (CD4 < or = 50).

MAIN OUTCOME MEASURE

Survival from initial CD4 cell count < or = 50 x 10(6)/l.

RESULTS

The median survival from initial CD4 < or = 50 x 10(6)/l was 17.1 months. The risk of death increased by 2% 195% confidence interval (Cl), 1-31 for each year of age, by 10% (95% Cl, 3-16) for each 10 x 10(6)/l decrease in CD4 count, and by 14% (95% Cl, 9-18) for each 1 g/dl decrease in haemoglobin level. Compared to AIDS-free patients with CD4 < or = 50 x 10(6) cells/l, the risk of dying was 1.5-fold (95% Cl, 1.2-1.9) that of patients who had an AIDS diagnosis for fewer than 3 months prior to CD4 < or = 50, 1.8-fold for patients with an AIDS diagnosis for 4-11 months prior to CD4 < or = 50, and twice that of patients with AIDS for > or = 12 months prior to CD4 < or = 50. The risk of dying for patients whose rate of CD4 cell decline was > 40 x 10(6)/l per 6 months was 1.7-fold (95% Cl, 1.3-2.3) that of patients with an average CD4 cell loss < 40 x 10(6)/l per 6 months, after adjusting for age, haemoglobin and duration of AIDS prior to CD4 < or = 50 x 10(6) cells/l. A prognostic score was developed from the final multivariate model, based on age at CD4 < or = 50, haemoglobin at CD4 < or = 50, duration of AIDS and rate of CD4 decline prior to CD4 < or = 50.

CONCLUSIONS

Routinely available clinical and laboratory data including haemoglobin level, rate of CD4 decline and duration of AIDS can be readily translated into a prognostic score and then used to predict the survival experience of an HIV-infected patient with advanced immunodeficiency.

Development of hematopoietic cancers after implantation of total joint replacement

The evidence from the 4 epidemiologic studies published before mid 1995, which have investigated the incidence of cancers in patients who have undergone joint implants, is conflicting. The results of the 2 earlier studies suggested a sustained increase in the risk of lymphoma and leukemia after total hip arthroplasty. The results of the 2 more recent studies have not confirmed this, although in 1 study an increased risk was observed in the first year after implantation. The heterogeneity may be statistical in origin, but could also have a biologic explanation in the greater proportion of metal on metal prostheses used before 1973. All 4 studies used national data as the comparison. Here, are presented the results of 2 matched cohort studies and a case control study set in North America and Scotland, and an overview of the 4 previous studies. Neither the results of the matched studies of patients operated on after 1973 nor the results of the latter 2 published studies suggest an increased risk of lymphoma or leukemia. If metal on metal articulations are reintroduced, careful surveillance is essential.

Measuring outcomes: one month survival after acute myocardial infarction in Scotland

OBJECTIVE

To examine 30 day survival after acute myocardial infarction as an outcome indicator, and explore the effects of adjusting for available prognostic factors such as age, sex, co-morbidity, deprivation, and deaths outside hospital.

DESIGN

Cohort study.

SETTING

The Scottish Record Linkage System was analysed. This national data-base links inpatient data to death certificate information for a population of 5.1 million.

SUBJECTS

All 40,371 admissions to hospital with a principal diagnosis of acute myocardial infarction, plus all 18,452 deaths outside hospital with a principal cause of death registered as acute myocardial infarction (ICD9 code 410) during 1988-1991.

MAIN OUTCOME MEASURES

The outcome event was death from any cause, within hospital or elsewhere, within 30 days of admission.

RESULTS

During 1988-1991, 30 day survival after acute myocardial infarction was 77% in 40,371 hospital admissions, but only 53% when 18,452 acute myocardial infarction deaths in the community were included (a population-based outcome indicator with many advantages). Using logistic regression at an individual patient level, the odds of dying within 30 days effectively doubled for each decade of age (odds ratio compared with patients aged under 55: 2.3 aged 55-64, 4.4 aged 65-74, 8.2 aged 75-84, 12.0 aged 85 plus); were marginally higher in females than in males (odds ratio 1.07); were almost doubled in patients with a history of previous infarction, coronary heart disease, or other heart disease, and were also significantly increased in patients with circulatory disease, respiratory disease, neoplasm, or diabetes. Socioeconomic deprivation had no significant effect. Marked variations in survival between different hospitals and health board areas persisted, even after adjusting for the above prognostic factors.

CONCLUSION

One month survival after acute myocardial infarction could be a useful means of measuring outcome of hospital care. There was important geographical variation in one month survival. These differences could be accounted for by variations in referral, admission, diagnosis, definition, and coding. These variables merit further research and local clinical audit before one month survival after acute myocardial infarction can be reliably used for detecting differences in quality of care. In addition, it would be essential to take account of infarct severity.

Obstetric complications and schizophrenia: a case control study based on standardised obstetric records

BACKGROUND

There have been many reports of a higher incidence of 'obstetric complications' in the histories of schizophrenics than of controls, but because of the methodological shortcomings of most of these comparisons the relationship remains controversial.

METHOD

Comprehensive records covering all psychiatric hospital admissions and all hospital deliveries in Scotland since 1971 made it possible to identify the obstetric records of people born in 1971-74 who were subsequently admitted to hospital with a diagnosis of schizophrenia, and then to compare their standardised obstetric records with those of closely matched controls.

RESULTS

One hundred and fifteen schizophrenic/control pairs were compared. The former showed a highly significant (P < 0.001) excess of complications of both pregnancy and delivery. In particular, there was a significant excess of pre-eclampsia (10 v. 2) and of infants detained in hospital for neonatal care (18 v. 6).

CONCLUSION

The raised incidence of obstetric complications often reported in people with schizophrenia is genuine and probably contributes to the aetiology of the condition.

Period trends in rate of suicide in first 28 days after discharge from psychiatric hospital in Scotland, 1968-92

OBJECTIVE

To examine period trends in the rate of suicide in the first 28 days after discharge from psychiatric hospital.

DESIGN

Cohort study of patients discharged from psychiatric hospital.

SETTING

Scotland.

SUBJECTS

All patients aged 15-84 who were discharged from Scottish psychiatric hospitals during 1968 to 1992.

OUTCOME MEASURE

The rate of suicide (classified as codes E950-9 and E980-9 according to the International Classification of Diseases, Ninth Revision) within 28 days of discharge per 100,000 person years at risk for five year periods during 1968 to 1992. Crude, within cohort rates and externally standardised rates were calculated.

RESULTS

Overall, 196 male patients committed suicide in 20,520 person years at risk, and 171 female patients committed suicide in 24,114 person years at risk. A significant linear trend was seen in period effect on externally standardised mortality ratios in both sexes: a decrease in male patients (P = 0.008) and an increase in female patients (P = 0.0001). The adjusted standardised mortality ratio in 1988-92 compared with 1968-72 was 0.62 (95% confidence interval 0.39 to 0.98) in male patients and 2.73 (1.64 to 4.56) in female patients.

CONCLUSION

The increase in the rate of suicide in the 28 days after discharge in female psychiatric patients makes this an increasingly important period to target. The rise has occurred against the background of a reduction of 60% in the number of psychiatric beds for adults.

[Further research into the formation of the "vitality and adequacy of emotion-emotional blunting" relationship in paranoid schizophrenia]

A sample of 100 paranoidal schizophrenic patients were assessed. Scales of "vitality and the adequacy of emotion" and "emotional blunting" which are described in a separate paper were used. At the beginning attention was focused on the fact that several synonimous terms are used to describe the blunting of emotion (flatness of affect, blunted or inappropriate affect, presence of affect as opposed to flatness). The results indicate that in only a very few cases the intensity of both studied qualities was negligible, however in the majority of the cases it appeared that the quality of "vitality" and its opposite is present. In 62 patients the emotional blunting was moderate. Emotional vitality in these cases remained in the wide range from moderate to significant. Both factors may be considered to be additional factors on the basis of the size and type of correlation. The coefficient of both Scales is expressed by r = -0.77. The correlation between the studied proportion and the syntonic-autistic proportion is expressed by r = 0.69. The cases of emotional blunting which occurred at different levels of intensity were generally accompanied by relative vitality and adequate emotional reaction. The formation of the studied proportion and in particular the high correlation coefficient between this proportion and the syntonic-autistic proportion suggests that autistic schizophrenia and syntonic schizophrenia form two basic subgroups of paranoidal schizophrenia.

Complete heavy and light chain variable region sequence of anti-arsonate monoclonal antibodies from BALB/c and A/J mice sharing the 36-60 idiotype are highly homologous

Structural and serologic studies on murine A/J monoclonal anti-arsonate antibodies resulted in the identification of a second idiotype family (Id36-60) in addition to the predominant idiotype family (IdCR). Id36-60, unlike IdCR, is a dominant idiotype in the BALB/c strain but is a "minor" idiotype in the A/J strain. The complete heavy and light chain variable region (VH and VL) amino acid sequences of a representative Id36-60 hybridoma protein from both the A/J and BALB/c strains have been determined. There are only four amino acid sequence differences between the VH of antibody 36-60 (A/J) and antibody 1210.7 (BALB/c). Two of these differences arise from single nucleotide changes in which the A/J and BALB/c Id36-60 VH germline gene sequences differ. The two other differences are the result of somatic mutation in hybridoma protein 36-60. In addition, Id36-60 heavy chains employ the same D and JH3 segments in both strains. The entire Vk2 VL of 36-60 and 1210.7 differ by only two amino acids, suggesting that like the heavy chains, they are derived from highly homologous VL genes. The same Jk segment is used in both antibodies. A comparison of the amino acid sequence data from Id36-60-bearing hybridomas suggests that a heavy chain amino acid difference accounts for the diminished arsonate binding by the 1210.7 hybridoma protein. Because the 1210.7 heavy chain is the unmutated product of the BALB/c VH gene, somatic mutation in VH may be required to enhance Ars affinity in this system.

Complete heavy and light chain variable region sequence of anti-arsonate monoclonal antibodies from BALB/c and A/J mice sharing the 36-60 idiotype are highly homologous

Structural and serologic studies on murine A/J monoclonal anti-arsonate antibodies resulted in the identification of a second idiotype family (Id36-60) in addition to the predominant idiotype family (IdCR). Id36-60, unlike IdCR, is a dominant idiotype in the BALB/c strain but is a "minor" idiotype in the A/J strain. The complete heavy and light chain variable region (VH and VL) amino acid sequences of a representative Id36-60 hybridoma protein from both the A/J and BALB/c strains have been determined. There are only four amino acid sequence differences between the VH of antibody 36-60 (A/J) and antibody 1210.7 (BALB/c). Two of these differences arise from single nucleotide changes in which the A/J and BALB/c Id36-60 VH germline gene sequences differ. The two other differences are the result of somatic mutation in hybridoma protein 36-60. In addition, Id36-60 heavy chains employ the same D and JH3 segments in both strains. The entire Vk2 VL of 36-60 and 1210.7 differ by only two amino acids, suggesting that like the heavy chains, they are derived from highly homologous VL genes. The same Jk segment is used in both antibodies. A comparison of the amino acid sequence data from Id36-60-bearing hybridomas suggests that a heavy chain amino acid difference accounts for the diminished arsonate binding by the 1210.7 hybridoma protein. Because the 1210.7 heavy chain is the unmutated product of the BALB/c VH gene, somatic mutation in VH may be required to enhance Ars affinity in this system.

The structure of bovine rhodopsin

We have isolated 16 peptides from a cyanogen bromide digest of rhodopsin. These cyanogen bromide peptides account for the complete composition of the protein. Methionine-containing peptides from other chemical and enzymatic digests of rhodopsin have allowed us to place the cyanogen bromide peptides in order, yielding the sequence of the protein. We have completed the sequence of most of the cyanogen bromide peptides. This information, in conjunction with that from other laboratories, forms the basis for our prediction of the secondary structure of the protein and how it may be arranged in the disk membrane.