The impact of pre-eclampsia definitions on the identification of adverse outcome risk in hypertensive pregnancy - analyses from the CHIPS trial (Control of Hypertension in Pregnancy Study)

OBJECTIVE

To examine the association between pre-eclampsia definition and pregnancy outcome.

DESIGN

Secondary analysis of Control of Hypertension in Pregnancy Study (CHIPS) trial data.

SETTING

International multicentre randomised controlled trial (RCT).

POPULATION

In all, 987 women with non-severe non-proteinuric pregnancy hypertension.

METHODS

We evaluated the association between pre-eclampsia definitions and adverse pregnancy outcomes, stratified by hypertension type and blood pressure control.

MAIN OUTCOME MEASURES

Main CHIPS trial outcomes: primary (perinatal loss or high-level neonatal care for >48 hours), secondary (serious maternal complications), birthweight <10th centile, severe maternal hypertension, delivery at <34 or <37 weeks, and maternal hospitalisation before birth.

RESULTS

Of 979/987 women with informative data, 280 (28.6%) progressed to pre-eclampsia defined restrictively by new proteinuria, and 471 (48.1%) to pre-eclampsia defined broadly as proteinuria or one/more maternal symptoms, signs or abnormal laboratory tests. The broad (versus restrictive) definition had significantly higher sensitivities (range 62-79% versus 36-50%), lower specificities (range 53-65% versus 72-82%), and similar or higher diagnostic odds ratios and 'true-positive' to 'false-positive' ratios. Stratified analyses showed similar results. Addition of available fetoplacental manifestations (stillbirth or birthweight <10th centile) to the broad pre-eclampsia definition improved sensitivity (74-87%).

CONCLUSIONS

A broad (versus restrictive) pre-eclampsia definition better identifies women who develop adverse pregnancy outcomes. These findings should be replicated in a prospective study within routine healthcare to ensure that the anticipated increase in surveillance and intervention in a larger number of women with pre-eclampsia is associated with improved outcomes, reasonable costs and congruence with women's values.

TWEETABLE ABSTRACT

A broad (versus restrictive) pre-eclampsia definition better identifies the risk of adverse pregnancy outcomes.

A study into the effectiveness of a postural care training programme aimed at improving knowledge, understanding and confidence in parents and school staff

BACKGROUND

Parents and school staff lack knowledge and confidence when providing postural care to physically disabled children. This can act as a barrier to the successful implementation of therapy. To address this problem, we developed a novel training programme to improve knowledge and confidence in providing postural care and evaluate the impact of the training programme in parents and school staff.

METHODS

The postural care training programme included three elements: a 2-h interactive workshop facilitated by physiotherapists and occupational therapists, a follow-up home/school visit and a follow-up telephone call. The Understanding, Knowledge and Confidence in Providing Postural Care for Children with Disabilities questionnaire was utilized to evaluate the impact and includes subscales assessing knowledge and understanding, concerns and confidence in providing postural care. The Understanding, Knowledge and Confidence in Providing Postural Care for Children with Disabilities questionnaire was completed at baseline and 6 weeks later. The training programme was delivered to N = 75 parents and school staff. Of these, N = 65 completed both baseline and follow-up measures and were used in the data analysis. Participants and therapists were also invited to provide further feedback on the overall training programme via interviews and focus groups.

RESULTS

Paired samples t-tests were used to determine statistically significant differences between baseline and follow-up scores for each of the three subscales. Mean levels of understanding and knowledge and confidence improved (P < 0.001), while concerns decreased (P < 0.001). Qualitative data were collected via interviews and group discussions providing an in-depth perspective on how participants experienced change.

DISCUSSION

Results suggest improvement in knowledge, understanding and confidence in parents and school staff that care for children with significant physical postural care impairments.

Development and Validation of a Mental Practice Tool for Total Abdominal Hysterectomy

OBJECTIVE

Total abdominal hysterectomy (TAH) is a common operation performed by obstetrician-gynecologists. Training opportunities for this procedure are declining. Mental practice (MP), the use of mental imagery to rehearse a task symbolically before performance, has been used successfully in sports and music to enhance skill. This strategy demonstrates benefit in existing surgical education literature. We aimed to develop and validate a MP tool (MPT) for resident training in TAH.

DESIGN

A prospective survey study was performed in a large, urban, academic medical center in Philadelphia, Pennsylvania, USA. A MPT was developed by guiding expert surgeons through a cognitive walk-through of TAH to identify key procedural cues. For validation, a convenience sample of 22 residents and attendings (N = 11 per group) mentally rehearsed TAH. Motivation, confidence, quality of imagery, and utility of the activity were assessed with a previously validated Mental Imagery Questionnaire (MIQ) before and after exposure to the MPT.

RESULTS

Residents, but not attendings, found MP to be useful in preparation for surgery (residents, p = 0.01; attendings, p = 0.34) and had increased confidence following this exercise (residents, p = 0.01; attendings, p = 0.08). Significant improvement in global imagery score after use of the tool was shown by residents (p = 0.01) but not by the attendings (p = 0.08), with residents having lower imagery skills than attendings both pre-MP and post-MP. Reliability testing of the MIQ indicated internal consistency (pre-MPT, 0.91; post-MPT, 0.90).

CONCLUSIONS

MP may serve as a potentially effective, portable, and inexpensive resident surgical training tool in preparation for TAH. Attendings may benefit from certain aspects of MP. The MIQ may serve as a measure of imagery skills in future experiments of MP in preparation for surgery.

Development of a reliable, valid measure to assess parents' and teachers' understanding of postural care for children with physical disabilities: the (UKC PostCarD) questionnaire

BACKGROUND

Previous research has highlighted lack of knowledge, understanding and confidence among parents and teachers responsible for the postural care of children with physical disability. Interventions designed to improve these qualities require a reliable and validated tool to assess pre- and post-intervention levels. Currently, however, no validated measure of postural care confidence (i.e. self-efficacy) exists. Hence, the aim of this research was to develop a reliable and valid questionnaire to assess parents' and teachers' confidence, alongside knowledge and understanding of postural care - the Understanding Knowledge and Confidence in providing POSTural CARe for children with Disabilities (UKC PostCarD) questionnaire.

METHODS

Items were developed by a multidisciplinary team and designed to map onto the content of 'An A-to-Z of Postural Care'. Parents, teachers and therapists assessed items for face validity. Scale reliability was then assessed using Cronbach's alpha and known-group validity was assessed by comparing scores of an 'expert' group (physiotherapists and occupational therapists) with those of a 'non-expert' group (with no formal training in postural care).

RESULTS

The total scale and all three subscales (understanding and knowledge, confidence and concerns) demonstrated adequate reliability (α > 0.83) and subscale correlations formed a logical pattern (understanding and knowledge correlated positively with confidence and negatively with concerns). Experts' (n = 111) scores were higher than non-experts' (n = 79) for the total scale and all subscales (P < 0.001).

CONCLUSION

Findings support the reliability and validity of the UKC PostCarD questionnaire as a measure of understanding, knowledge and confidence in providing postural care for children with disabilities.

Do labetalol and methyldopa have different effects on pregnancy outcome? Analysis of data from the Control of Hypertension In Pregnancy Study (CHIPS) trial

OBJECTIVE

To compare pregnancy outcomes, accounting for allocated group, between methyldopa-treated and labetalol-treated women in the CHIPS Trial (ISRCTN 71416914) of 'less tight' versus 'tight' control of pregnancy hypertension.

DESIGN

Secondary analysis of CHIPS Trial cohort.

SETTING

International randomised controlled trial (94 sites, 15 countries).

POPULATION OR SAMPLE

Of 987 CHIPS recruits, 481/566 (85.0%) women treated with antihypertensive therapy at randomisation. Of 981 (99.4%) women followed to delivery, 656/745 (88.1%) treated postrandomisation.

METHODS

Logistic regression to compare outcomes among women who took methyldopa or labetalol, adjusted for the influence of baseline factors.

MAIN OUTCOME MEASURES

CHIPS primary (perinatal loss or high level neonatal care for >48 hours) and secondary (serious maternal complications) outcomes, birthweight <10th centile, severe maternal hypertension, pre-eclampsia and delivery at <34 or <37 weeks.

RESULTS

Methyldopa and labetalol were used commonly at randomisation (243/987, 24.6% and 238/987, 24.6%, respectively) and post-randomisation (224/981, 22.8% and 433/981, 44.1%, respectively). Following adjusted analyses, methyldopa (versus labetalol) at randomisation was associated with fewer babies with birthweight <10th centile [adjusted odds ratio (aOR) 0.48; 95% CI 0.20-0.87]. Methyldopa (versus labetalol) postrandomisation was associated with fewer CHIPS primary outcomes (aOR 0.64; 95% CI 0.40-1.00), birthweight <10th centile (aOR 0.54; 95% CI 0.32-0.92), severe hypertension (aOR 0.51; 95% CI 0.31-0.83), pre-eclampsia (aOR 0.55; 95% CI 0.36-0.85), and delivery at <34 weeks (aOR 0.53; 95% CI 0.29-0.96) or <37 weeks (aOR 0.55; 95% CI 0.35-0.85).

CONCLUSION

These nonrandomised comparisons are subject to residual confounding, but women treated with methyldopa (versus labetalol), particularly those with pre-existing hypertension, may have had better outcomes.

TWEETABLE ABSTRACT

There was no evidence that women treated with methyldopa versus labetalol had worse outcomes.

Effect of spontaneous pushing versus Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trials

OBJECTIVES

To critically evaluate any benefit or harm for the mother and her baby of Valsalva pushing versus spontaneous pushing in the second stage of labour.

SEARCH STRATEGY

Electronic databases from MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were systematically searched (last search May 2010). The reference lists of retrieved studies were searched by hand and an internet hand search of master theses and dissertations was performed. No date or language restriction was used.

SELECTION CRITERIA

Randomised controlled trials that compared instructed pushing with spontaneous pushing in the second stage of labour were considered. Studies were evaluated independently for methodological quality and appropriateness for inclusion by two authors (MP and JB).

DATA COLLECTION AND ANALYSIS

The primary outcome was instrumental/operative delivery. Other outcomes were length of labour, any perineal repair, bladder function, maternal satisfaction. Infant outcomes included low Apgar score < 7 after 5 minutes, umbilical arterial pH <7.2, admission to neonatal intensive care unit and serious neonatal morbidity or perinatal death.

MAIN RESULTS

Three randomised controlled studies covering 425 primiparous women met the inclusion criteria. Women who used epidural analgesia were excluded in all three studies. No statistical difference was identified in the number of instrumental/operative deliveries (three studies; 425 women; relative risk 0.70; 95% CI 0.34-1.43), perineal repair, postpartum haemorrhage. Length of labour was significantly shorter in women who used the Valsalva pushing technique (three studies; 425 women; mean difference 18.59 minutes; 95% CI 0.46-36.73 minutes). Neonatal outcomes did not differ significantly. Urodynamic factors measured 3 months postpartum were negatively affected by Valsalva pushing. Measures of first urge to void and bladder capacity were decreased (one study; 128 women; mean difference respectively 41.50 ml, 95% CI 8.40-74.60, and 54.60 ml, 95% CI 13.31-95.89).

AUTHORS' CONCLUSION

The evidence from our review does not support the routine use of Valsalva pushing in the second stage of labour. The Valsalva pushing method has a negative effect on urodynamic factors according to one study. The duration of the second stage of labour is shorter with Valsalva pushing but the clinical significance of this finding is uncertain. The primary studies are sparse, diverse and some flawed. Further research seems warranted. In the mean time supporting spontaneous pushing and encouraging women to choose their own method of pushing should be accepted as best clinical practice.

Measurement of regional cerebral blood flow associated with the M technique-light massage therapy: a case series and longitudinal study using SPECT

OBJECTIVES

The aim of this 2-study research project was to measure the physiologic effect of the M technique (see Appendix for description) on the brain using single photon emission computed tomography (SPECT) and compare it to conventional massage therapy.

METHODS

In the first study, 4 participants received 1 M technique session. Each participant was injected through the intravenous cannula (IV) with 7 mCi (99m)Tc and scanned using SPECT before the M technique session, and then was injected with 25 mCi (99m)Tc through the IV and scanned using SPECT after the M technique session. In the second study, 1 participant received 10 conventional (Swedish) massages and one participant received 10 M technique sessions. Both participants were injected and scanned (using the identical scanning parameters as in Study 1) before, and immediately after, their 1st and 10th sessions. Baseline and 1st, and baseline and 10th sessions were compared using paired t tests.

RESULTS

Although the activation changes were positively correlated for the M technique and massage participants (r = 27, p < 0.05), when activation changes around the 1st and around the 10th sessions were compared (using paired t tests), significant differences emerged. There were significant activation changes for the M technique participant [t(64) = 2.32, p < 0.05): In particular, there was a 40% activation change and directional change in regional cerebral blood flow in the right caudate, which was not seen in the massage participant. The precuneus showed an approximate 15% reduction in activation changes around the M technique session for both the 1st and 10th treatment, but not for the massage participant.

CONCLUSIONS

These findings suggest that the M technique and conventional massage may both elicit blood flow brain activation changes; however, the participants' responses did differ. The M technique revealed greater changes (particular in the right caudate), and these responses increased when the M technique was repeated over time (unlike massage). These findings have implications for future research into the potential mechanism of the M technique in the treatment and care of patients.

Extra-amniotic prostaglandin for induction of labour

BACKGROUND

This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

OBJECTIVES

To determine the effects of extra-amniotic prostaglandin for third trimester cervical ripening or induction of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Date of last search: December 2000.

SELECTION CRITERIA

(1) clinical trials comparing extra-amniotic prostaglandin used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions.

DATA COLLECTION AND ANALYSIS

A strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This has involved a two-stage method of data extraction. The initial data were extracted centrally, and incorporated into a series of primary reviews arranged by methods of induction of labour, following a standardised methodology.

MAIN RESULTS

Oxytocin was used to initiate or augment labour significantly less frequently with extra-amniotic prostaglandins when compared to placebo (relative risk 0.50, 95% confidence interval 0.38-0.66). No other findings were significant in the comparisons that were made for this review including when extra-amniotic prostaglandins were compared with other methods of cervical ripening or induction of labour. Although this could suggest that extra-amniotic prostaglandins are as effective as other agents, the findings are difficult to interpret because they are based on very small numbers and may lack the power to show a real difference.

REVIEWER'S CONCLUSIONS

The studies in this review are limited by their small sample sizes which are in many cases further divided into multiple comparison groups. The analyses resulted in most comparisons showing no significant differences, with wide confidence intervals. Although extra-amniotic prostaglandins may be as effective as other modalities in initiating labour, there is little conclusive information from this review to guide clinical practice. An adequately powered randomised controlled trial would be useful to determine if the use of extra-amniotic prostaglandins would lower the rate of caesarean section. However, in the time since these studies were undertaken the use of extra-amniotic prostaglandins has largely been replaced by other modes of prostaglandin administration.

Functional differences between keratins of stratified and simple epithelia

Dividing populations of stratified and simple epithelial tissues express keratins 5 and 14, and keratins 8 and 18, respectively. It has been suggested that these keratins form a mechanical framework important to cellular integrity, since their absence gives rise to a blistering skin disorder in neonatal epidermis, and hemorrhaging within the embryonic liver. An unresolved fundamental issue is whether different keratins perform unique functions in epithelia. We now address this question using transgenic technology to express a K16-14 hybrid epidermal keratin transgene and a K18 simple epithelial keratin transgene in the epidermis of mice null for K14. Under conditions where the hybrid epidermal keratin restored a wild-type phenotype to newborn epidermis, K18 partially but not fully rescued. The explanation does not appear to reside in an inability of K18 to form 10-nm filaments with K5, which it does in vitro and in vivo. Rather, it appears that the keratin network formed between K5 and K18 is deficient in withstanding mechanical stress, leading to perturbations in the keratin network in regions of the skin that are subjected either to natural or to mechanically induced trauma. Taken together, these findings suggest that the loss of a type I epidermal keratin cannot be fully compensated by its counterpart of simple epithelial cells, and that in vivo, all keratins are not equivalent.

The genetic basis of epidermolysis bullosa simplex with mottled pigmentation

Epidermolysis bullosa simplex (EBS) is a group of autosomal dominant skin diseases characterized by blistering, due to mechanical stress-induced degeneration of basal epidermal cells. It is now well-established that the three major subtypes of EBS are genetic disorders of the basal epidermal keratins, keratin 5 (K5) and keratin 14 (K14). Here we show that a rare subtype, referred to as EBS with mottled pigmentation (MP), is also a disorder of these keratins. Affected members of two seemingly unrelated families with EBS-MP had a C to T point mutation in the second base position of codon 24 of one of two K5 alleles, leading to a Pro: Leu mutation. This mutation was not present in unaffected members nor in 100 alleles from normal individuals. Linkage analyses mapped the defect to this type II keratin gene (peak logarithm of odds score at phi = 0 of 3.9), which is located on chromosome 12q11-q13. This provides strong evidence that this mutation is responsible for the EBS-MP phenotype. Only conserved between K5 and K6, and not among any of the other type II keratins, Pro-24 is in the nonhelical head domain of K5, and only mildly perturbs the length of 10-nm keratin filaments assembled in vitro. However, this part of the K5 head domain is likely to protrude on the filament surface, perhaps leading to additional aberrations in intermediate filament architecture and/or in melanosome distribution that are seen ultrastructurally in patients with the mutation.

The basal keratin network of stratified squamous epithelia: defining K15 function in the absence of K14

Keratin 5 and keratin 14 have been touted as the hallmarks of the basal keratin networks of all stratified squamous epithelia. Absence of K14 gives rise to epidermolysis bullosa simplex, a human blistering skin disorder involving cytolysis in the basal layer of epidermis. To address the puzzling question of why this disease is primarily manifested in skin rather than other stratified squamous epithelia, we ablated the K14 gene in mice and examined various tissues expressing this gene. We show that a key factor is the presence of another keratin, K15, which was hitherto unappreciated as a basal cell component. We show that the levels of K15 relative to K14 vary dramatically among stratified squamous epithelial tissues, and with neonatal development. In the absence of K14, K15 makes a bona fide, but ultrastructurally distinct, keratin filament network with K5. In the epidermis of neonatal mutant mice, K15 levels are low and do not compensate for the loss of K14. In contrast, the esophagus is unaffected in the neonatal mutant mice, but does appear to be fragile in the adult. Parallel to this phenomenon is that esophageal K14 is expressed at extremely low levels in the neonate, but rises in postnatal development. Finally, despite previous conclusions that the formation of suprabasal keratin filaments might depend upon K5/K14, we find that a wide variety of suprabasal networks composed of different keratins can form in the absence of K14 in the basal layer.

Genetic and clinical mosaicism in a type of epidermal nevus

BACKGROUND

Many skin disorders are characterized by a mosaic pattern, often with alternating stripes of affected and unaffected skin that follow the lines of Blaschko. These nonrandom patterns may be caused by a postzygotic mutation during embryogenesis. We studied the genetic basis of one such disorder, epidermal nevus of the epidermolytic hyperkeratotic type. Epidermolytic hyperkeratosis is an autosomal dominant blistering skin disease arising from mutations in the genes for keratin (K) 1 and 10. The offspring of patients with epidermal nevi may have generalized epidermolytic hyperkeratosis.

METHODS

We studied the K1 and K10 genes in blood and in the keratinocytes and fibroblasts of lesional and nonlesional skin from three patients with epidermal nevi and four of their offspring with epidermolytic hyperkeratosis.

RESULTS

In the patients with epidermal nevi, point mutations in 50 percent of the K10 alleles of epidermal cells were found in keratinocytes from lesional skin; no mutations were detected in normal skin. This mutation was absent or underrepresented in blood and skin fibroblasts. In the offspring with epidermolytic hyperkeratosis, the same mutations as those in the parents were found in 50 percent of the K10 alleles from all cell types examined.

CONCLUSIONS

Epidermal nevus of the epidermolytic hyperkeratotic type is a mosaic genetic disorder of suprabasal keratin. The correlation of mutations in the K10 gene with lesional skin and the correlation of the normal gene with normal skin provide evidence that genetic mosaicism can cause clinical mosaicism.

Making a connection: direct binding between keratin intermediate filaments and desmosomal proteins

In epidermal cells, keratin intermediate filaments connect with desmosomes to form extensive cadherin-mediated cytoskeletal architectures. Desmoplakin (DPI), a desmosomal component lacking a transmembrane domain, has been implicated in this interaction, although most studies have been conducted with cells that contain few or no desmosomes, and efforts to demonstrate direct interactions between desmoplakin and intermediate filaments have not been successful. In this report, we explore the biochemical nature of the connections between keratin filaments and desmosomes in epidermal keratinocytes. We show that the carboxy terminal "tail" of DPI associates directly with the amino terminal "head" of type II epidermal keratins, including K1, K2, K5, and K6. We have engineered and purified recombinant K5 head and DPI tail, and we demonstrate direct interaction in vitro by solution-binding assays and by ligand blot assays. This marked association is not seen with simple epithelial type II keratins, vimentin, or with type I keratins, providing a possible explanation for the greater stability of the epidermal keratin filament architecture over that of other cell types. We have identified an 18-amino acid residue stretch in the K5 head that is conserved only among type II epidermal keratins and that appears to play some role in DPI tail binding. This finding might have important implications for understanding a recent point mutation found within this binding site in a family with a blistering skin disorder.

Genetic bases of epidermolysis bullosa simplex and epidermolytic hyperkeratosis

Keratins are the major structural proteins of the epidermis. Analyzing keratin gene sequences, appreciating the switch in keratin gene expression that takes place as epidermal cells commit to terminally differentiate, and elucidating how keratins assemble into 10-nm filaments have provided the foundation that has led to the discoveries of the genetic bases of two major classes of human skin diseases. In this report, we review the cell biology and human genetics of these diseases, epidermolysis bullosa simplex and epidermolytic hyperkeratosis. Both of these diseases are epidermal disorders of keratin, typified by cell fragility as a consequence of defects in the mechanical strength of basal epidermolysis bullosa simplex or suprabasal epidermolytic hyperkeratosis cells.

Disease severity correlates with position of keratin point mutations in patients with epidermolysis bullosa simplex

Keratins are the major structural proteins of the epidermis. Recently, it was discovered that point mutations in the epidermal keratins can lead to the blistering skin diseases epidermolysis bullosa simplex (EBS) and epidermolytic hyperkeratosis (EH), involving epidermal cell fragility and rupture upon mechanical stress. In this study, we demonstrate a correlation between disease severity, location of point mutations within the keratin polypeptides, and degree to which these mutations perturb keratin filament structure. Interestingly, of the 11 EBS or EH mutations thus far identified, 6 affect a single highly evolutionarily conserved arginine residue, which, when mutated, markedly perturbs keratin filament structure and keratin network formation. This site also appears to be a hot spot for mutation by CpG methylation and deamination. In the four epidermal keratins, there are several other CpG dinucleotides that exist at codons within the highly conserved ends of the keratin rod. To elucidate why mutations at these sites have not been detected in severe cases of EBS, we engineered 7 of these C-->T transitions in K14 and tested their ability to perturb keratin network formation and keratin filament assembly in vitro. The effects of these mutants on keratin filament network formation were significantly less severe than the EBS/EH arginine mutation, suggesting that the high incidence of mutations of the residue in EBS and EH patients is a result of both a special sensitivity of filament structure to perturbations in this residue and its susceptibility to mutagenesis.

Applying the new concepts of the Neuman Systems Model

The latest version of the Neuman Systems Model contains new terminology--"spiritual variable" and "created environment"--and an emphasis on the concepts of primary prevention and wellness. A case study of a client who has tested positive for HIV explores the new terms and demonstrates the expanded concepts of primary prevention and wellness. Nurses can utilize this framework and the concept of wellness with terminally ill or healthy individuals. Nursing frameworks can be practical and useful to nurses and not just words in a theory book.