Giving birth in a good way when it must take place away from home: Participatory research into visions of Inuit families and their Montreal-based medical providers

BACKGROUND

Transferring pregnant women out of their communities for childbirth continues to affect Inuit women living in Nunavik-Inuit territory in Northern Quebec. With estimates of maternal evacuation rates in the region between 14% and 33%, we examine how to support culturally safe birth for Inuit families when birth must take place away from home.

METHODS

A participatory research approach explored perceptions of Inuit families and their perinatal healthcare providers in Montreal for culturally safe birth, or "birth in a good way" in the context of evacuation, using fuzzy cognitive mapping. We used thematic analysis, fuzzy transitive closure, and an application of Harris' discourse analysis to analyze the maps and synthesize the findings into policy and practice recommendations.

RESULTS

Eighteen maps authored by 8 Inuit and 24 service providers in Montreal generated 17 recommendations related to culturally safe birth in the context of evacuation. Family presence, financial assistance, patient and family engagement, and staff training featured prominently in participant visions. Participants also highlighted the need for culturally adapted services, with provision of traditional foods and the presence of Inuit perinatal care providers. Stakeholder engagement in the research resulted in dissemination of the findings to Inuit national organizations and implementation of several immediate improvements in the cultural safety of flyout births to Montreal.

CONCLUSIONS

The findings point toward the need for culturally adapted, family-centered, and Inuit-led services to support birth that is as culturally safe as possible when evacuation is indicated. Application of these recommendations has the potential to benefit Inuit maternal, infant, and family wellness.

Maternal health and Indigenous traditional midwives in southern Mexico: contextualisation of a scoping review

OBJECTIVES

Collate published evidence of factors that affect maternal health in Indigenous communities and contextualise the findings with stakeholder perspectives in the Mexican State of Guerrero.

DESIGN

Scoping review and stakeholder fuzzy cognitive mapping.

INCLUSION AND EXCLUSION

The scoping review included empirical studies (quantitative, qualitative or mixed methods) that addressed maternal health issues among Indigenous communities in the Americas and reported on the role or influence of traditional midwives before June 2020. The contextualisation drew on two previous studies of traditional midwife and researcher perspectives in southern Mexico.

RESULTS

The initial search identified 4461 references. Of 87 selected studies, 63 came from Guatemala and Mexico. Three small randomised trials involved traditional midwives. One addressed the practice of traditional midwifery. With diverse approaches to cultural differences, the studies used contrasting definitions of traditional midwives. A fuzzy cognitive map graphically summarised the influences identified in the scoping review. When we compared the literature's map with those from 29 traditional midwives in Guerrero and eight international researchers, the three sources coincided in the importance of self-care practices, rituals and traditional midwifery. The primary concern reflected in the scoping review was access to Western healthcare, followed by maternal health outcomes. For traditional midwives, the availability of hospital or health centre in the community was less relevant and had negative effects on other protective influences, while researchers conditioned its importance to its levels of cultural safety. Traditional midwives highlighted the role of violence against women, male involvement and traditional diseases.

CONCLUSIONS

The literature and stakeholder maps showed maternal health resulting from complex interacting factors in which promotion of cultural practices was compatible with a protective effect on Indigenous maternal health. Future research challenges include traditional concepts of diseases and the impact on maternal health of gender norms, self-care practices and authentic traditional midwifery.

Childbirth evacuation among rural and remote Indigenous communities in Canada: A scoping review

PROBLEM

Routine evacuation of pregnant Indigenous women from remote regions to urban centres for childbirth is a central strategy for addressing maternal health disparities in Canada. Maternal evacuation continues despite mounting evidence of its negative impacts on Indigenous women and families.

BACKGROUND

Since the 1960s, pregnant Indigenous women living in remote regions in Canada have been transferred to urban hospitals for childbirth. In the following decades, evidence emerged linking maternal evacuation with negative impacts on Indigenous women, their families, and communities. In some communities, resistance to evacuation and the creation of local birthing facilities has resulted in highly diverse experiences of childbirth and evacuation.

AIM

A scoping review mapped the evidence on maternal evacuation of Indigenous women in Canada and its associated factors and outcomes from 1978 to 2019.

METHODS

We searched MEDLINE, Embase, and CINAHL, and grey literature from governmental and Indigenous organizations. We collated the evidence on maternal evacuation into 12 themes.

RESULTS

Factors related to evacuation include (a) evacuation policies (b) institutional coercion (c) remoteness and (d) maternal-fetal health status. Evacuation-related outcomes include (e) maternal-child health impacts (f) women's experience of evacuation (g) financial hardships (h) family disruption (i) cultural continuity and community wellness (ij) engagement with health services (k) self-determination, and (l) quality of health services.

DISCUSSION

Numerous emotional, social and cultural harms are associated with evacuation of Indigenous women in Canada. Little is known about the long-term impacts of evacuation on Indigenous maternal-infant health. Evidence on evacuation from remote Métis communities remains a critical knowledge gap.

How beneficiaries see complex health interventions: a practice review of the Most Significant Change in ten countries

Background

The Most Significant Change is a story-based evaluation approach used in many international development programs. This practice review summarises practical experience with the approach in complex health interventions in ten countries, with the objective of making it more accessible in evaluation of other complex health interventions.

Results

Participatory research practitioners and trainees discussed five themes following brief presentations by each of the seven attendees who led the exercise: (i) sampling and recruitment; (ii) phrasing the questions to elicit stories; (iii) story collection strategies; (iv) quality assurance; and (v) analysis. Notes taken during the meeting provided the framework for this article.

Recruitment strategies in small studies included universal engagement and, in larger studies, a purposive, systematic or random sampling. Meeting attendees recommended careful phrasing and piloting of the question(s) as this affects the quality and focus of the stories generated. They stressed the importance of careful training and monitoring of fieldworkers collecting stories to ensure full stories are elicited and recorded. For recording, in most settings they preferred note taking with back-checking or self-writing of stories by story tellers, rather than audio-recording. Analysis can combine participatory selection of a small number of stories, deductive or inductive thematic analysis and discourse analysis. Meeting attendees noted that involvement in collection of the stories and their analysis and discussion had a positive impact for research team members.

Conclusions

Our review confirms the plasticity, feasibility and acceptability of the Most Significant Change technique across different sociopolitical, cultural and environmental contexts of complex interventions. Although the approach can surface unexpected impacts, it is not a 360-degree evaluation. Its strength lies in characterising the changes, where these happen, in the words of the beneficiaries. We hope this distillation of our practice makes the technique more readily available to health sector researchers.

Fuzzy cognitive mapping: An old tool with new uses in nursing research

AIMS

Describe the implementation and uses of fuzzy cognitive mapping (FCM) as a constructive method for meeting the unique and rapidly evolving needs of nursing inquiry and practice.

DESIGN

Discussion paper.

DATA SOURCES

Drawing on published scholarship of cognitive mapping from the fields of ecological management, information technology, economics, organizational behaviour and health development, we consider how FCM can contribute to contemporary challenges and aspirations of nursing research.

IMPLICATIONS FOR NURSING

Fuzzy cognitive mapping can generate theory, describe knowledge systems in comparable terms and inform questionnaire design and dialogue. It can help build participant-researcher partnerships, elevate marginalized voices and facilitate intercultural dialogue. As a relatively culturally safe and foundational approach in participatory research, we suggest that FCM should be used in settings of transcultural nursing, patient engagement, person- and family-centred care and research with marginalized populations. FCM is amenable to rigorous analysis and simultaneously allows for greater participation of stakeholders.

CONCLUSION

In highly complex healthcare contexts, FCM can act as a common language for defining challenges and articulating solutions identified within the nursing discipline.

IMPACT

There is a need to reconcile diverse sources of knowledge to meeting the needs of nursing inquiry. FCM can generate theory, describe knowledge systems, facilitate dialogue and support questionnaire design. In its capacity to engage multiple perspectives in defining problems and identifying solutions, FCM can contribute to advancing nursing research and practice.

Weight loss in achalasia is determined by its phenotype

Patients with achalasia present with dysphagia, regurgitation, and varying degrees of weight loss. However, despite it being a disorder of the lower esophageal sphincter with functional obstruction in all patients, it is unclear why certain patients lose significantly more weight compared to others. The aims of this study are to assess demographic, clinical, and manometric characteristics of a large cohort of patients with achalasia to determine potential correlates of weight loss in this population. Patients with diagnosis of achalasia referred to our center between 2009 and 2016 were evaluated. Demographic and physiologic tests between those with and without weight loss were compared. The cohort of patients with initial self-reported weight loss were studied to determine change in weight after intervention (pneumatic dilation or myotomy). The Kruskal-Wallis test was used for comparison of continuous variables between groups and Pearson's χ2 test was used for comparison of categorical variables between groups. 138 patients with achalasia were evaluated. 35 patients were excluded due to lack of manometric data and 3 from lack of documented weight resulting in the study population of 100 patients with achalasia [51% male, median age: 56 years]. Weight loss was reported in 51/100 (51%) patients. BMI was lower in patients who reported weight loss (25 vs. 31, P < 0.001) with a median weight loss of 28 lbs (14-40 lbs). There were no significant differences in age at diagnosis, gender, or symptom presentation (dysphagia, regurgitation, or chest pain) between the groups. However, more patients with type II achalasia (63%) reported weight loss as compared to other sub-types (P = 0.013). 73% of type III achalasia denied having weight loss. Patients who denied weight loss had symptoms for longer duration (24 vs. 12 months, P < 0.001) and had lower mean residual LES pressure (20 vs. 30 mmHg, P = 0.006). Postintervention 42% of patients reported no weight regain despite appropriate therapy for achalasia with median follow-up of 22 months (range: 6-90 months). Type II achalasia patients are most likely and type III achalasia are least likely to have weight loss compared to type I achalasia. Given that no other demographic/physiologic parameters predicted weight loss, the role of underlying inflammatory cascade in achalasia phenotypes deserves special attention.

Clozapine plasma level monitoring for prediction of rehospitalization schizophrenic outpatients

INTRODUCTION

The aim of this naturalistic exploratory study was to examine whether blood antipsychotic drug concentrations can predict rehospitalizations in chronically medicated patients.

METHODS

The study included schizophrenic outpatients under clozapine (CLZ) maintenance treatment, supervised by therapeutic drug monitoring (TDM). Patients were observed for a period of 21 months. Their on average monthly measured plasma levels and the date of rehospitalizations were recorded. The variability of the first 3 CLZ plasma levels, measured in 3.6 months, was compared between patients with and without rehospitalization.

RESULTS

23 patients participated of which 6 patients were rehospitalized. Mean plasma concentrations of CLZ were similar in patients without (471 ± 180 ng/mL) and with rehospitalization (446 ± 266 ng/mL). However; coefficients of variation (CV) of plasma concentrations in the first 3 blood samples differed significantly between the rehospitalized and non-rehospitalized groups (37.1% vs. 13.0%, respectively, P = 0.012). A CV ≥ 19.8% was predictive for later rehospitalization with 100% sensitivity and 70.6% specificity.

DISCUSSION

Variability in CLZ plasma concentrations may be useful in identifying patients at risk of relapsing under maintenance therapy. Because of the small number of patients the findings need to be confirmed in a larger study.

Dopamine and serotonin metabolism in response to chronic administration of fluvoxamine and haloperidol combined treatment

Treating primary 'negative symptoms' of schizophrenia with a combination of a typical antipsychotic and a selective serotonin reuptake inhibitor, is more effective than with antipsychotic alone and is similar to the effect of the atypical antipsychotic, clozapine. The mechanism of this treatment combination is unknown and may involve changes in dopaminergic and serotonin systems. We studied dopamine and serotonin metabolism in different rat brain areas at 1.5 and 24 h after the last dosage of chronic treatment (30 days), with haloperidol plus fluvoxamine, each drug alone, and clozapine. Haloperidol-fluvoxamine combination, haloperidol, and clozapine treatments increased striatal and frontal cortex dopamine turnover and reduced striatal tyrosine hydroxylase activity at 1.5 h. At 24 h both dopamine turnover and tyrosine hydroxylase activity were reduced. Thus, in chronically treated animals, release of striatal dopamine increases following a drug pulse and returns to baseline by 24 h. Serotonin and 5-hydroxyindoleacetic acid concentrations were decreased at 1.5 h in haloperidol-fluvoxamine and clozapine groups and returned to normal levels by 24 h. A limited behavioral assessment showed that treatment with haloperidol plus fluvoxamine reduced motor activity compared to haloperidol, and increased sniffing compared to haloperidol, fluvoxamine and clozapine. These findings indicate that combining antipsychotic with SSRI results in specific changes in dopaminergic and serotonergic systems and in behavior. The possibility that these may be relevant to the mechanism underlying the clinical effectiveness of augmentation treatment warrant further study.

Perception of facial emotions in chronic schizophrenia does not correlate with negative symptoms but correlates with cognitive and motor dysfunction

BACKGROUND

Appropriate expression of emotions and correct perception of emotional expression in others are important social skills which may be impaired in schizophrenia and contribute to poor social adjustment. We examined the relationship between expression of emotions as measured by affective flattening and other negative symptoms and their perception. We compared performance on tests of perception of facial emotions with that in other cognitive areas.

METHODS

36 chronic schizophrenic patients on stable doses of atypical antipsychotics were assessed using tests of identification (FID) and discrimination (FDIS) of facial emotional expressions, visual retention (BVRT) and general cognitive function (Mini Mental State Examination, MMSE). Clinical symptoms were assessed with scales for the assessment of negative symptoms (SANS) and positive symptoms (SAPS). Motor symptoms were assessed with side effects (SA) and AIMS scales and Finger Tapping Test.

RESULTS

Negative symptoms showed no relation to FID or FDIS. FID showed significant correlation with Visual Retention and Finger Tapping but not MMSE.

CONCLUSION

The ability to identify facial emotional expressions is not related to negative symptoms in chronic schizophrenia and shares common mechanisms with visual reproduction and ability to make rapid motor movements. This suggests common defects in perceptual, timed processes consistent with postulated dysfunction of cortico-subcortical circuits.

Etiology and epidemiology of preterm premature rupture of the membranes

Preterm premature rupture of membranes continues to be a common complication of pregnancy with significant implications for perinatal outcome. Unfortunately, given the multiple risk factors that have been presented, which are reportedly associated with PPROM, attempts to reduce the incidence of this clinical event may seem daunting to the clinician. Despite this, one should attempt to address the potential risk factors that avail themselves to change. Unfortunately, although many risk factors have been identified, there are few randomized intervention trials for PPROM prevention. Examples of interventions documented to be beneficial include smoking cessation and screening for and treatment of chlamydial infections. These seem to be reasonable and logical interventions to consider in general, and may potentially have an effect on various causal agents of PPROM.

Fluvoxamine as an adjunctive agent in schizophrenia

Schizophrenia is a common mental disorder that has an early onset and rates high as a cause of medical disability. Antipsychotic agents are the mainstay of treatment but response is often inadequate. Negative symptoms (disturbances in volition, social interaction and affective functions) are particularly difficult to treat and form a major obstacle to rehabilitation. A promising approach to improve response of negative symptoms has been to add a selective serotonin reuptake inhibitor (SSRI) antidepressant to antipsychotic treatment. This review examines evidence pertaining to the efficacy, tolerability, and safety of the SSRI fluvoxamine, combined with antipsychotic agents, in the treatment of negative symptoms in schizophrenia. Important methodological issues, such as differentiating primary and secondary negative symptoms, are discussed. The balance of available evidence indicates that fluvoxamine can improve primary negative symptoms in chronic schizophrenia patients treated with typical antipsychotics and suggests that it may also do so in some patients treated with clozapine. This combination is generally safe and well tolerated although, as antipsychotic drug concentrations may be elevated, attention to dose and drug monitoring should be considered appropriately. Combination with clozapine may require particular caution because of potential toxicity if serum clozapine levels rise steeply. The fluvoxamine doses effective in augmentation are lower than those usually used to treat depression. Evidence regarding the use of fluvoxamine augmentation to treat phenomena, such as obsessions and aggression, which may be associated with schizophrenia, is also examined. An important goal of future studies will be to define which patient groups can benefit from combined treatment.

Fluvoxamine augmentation of antipsychotics improves negative symptoms in psychotic chronic schizophrenic patients: a placebo-controlled study

The efficacy and safety of adding fluvoxamine to antipsychotic treatment in schizophrenic patients with mixed positive and negative symptoms was examined. Fifty-three patients selected for persistent negative and positive symptoms who were receiving antipsychotic treatment were randomly allocated to additional fluvoxamine (50-100 mg/day) or placebo in a double-blind manner. Fluvoxamine was associated with significant improvement in negative symptoms (Scale for the Assessment of Negative Symptoms) compared to placebo. The combination was well tolerated. Fluvoxamine augmentation of antipsychotics is safe in chronic schizophrenic patients with mixed positive and negative symptoms and may ameliorate negative symptoms in such patients.

Vitamin B12 levels are low in hospitalized psychiatric patients

BACKGROUND

Deficiency of vitamin B12, a key component in the catabolism of monoamines, is associated with various neuropsychiatric disorders and may be more frequent in hospitalized patients.

METHOD

We reviewed vitamin B12 assays performed in a laboratory of a large Israeli psychiatric hospital over a 23-month period to examine prevalence of low values and compared vitamin B12 deficient patients to those with normal levels on various parameters. In addition, vitamin levels in a random sample of in-patients whose nutritional intake was determined, were examined.

RESULTS

20% of 644 vitamin B12 assays were in the low (200 pg/ml) and 10% in the deficient (< 160 pg/ml) range. 24 selected vitamin B12 deficient patients (70.8% with diagnosis of schizophrenia) did not differ from controls (N = 35) in age, sex ratio, hemoglobin concentration, MCV, diagnostic distribution or number and length of hospitalizations, but had slightly lower (but normal) mean folate levels. Rates of vitamin B12 deficiency in the patient sample, whose nutritional intake was adequate, did not differ significantly from those in the laboratory survey.

CONCLUSION

Vitamin B12 deficiency is common in chronically ill psychotic patients with adequate nutrition and is not readily detected by routine hematology tests.

Lymphocytes, autoantibodies and psychosis--coincidence versus etiological factor: an update

Several factors have been suggested in the etiopathology of schizophrenia, including autoimmune factors. Subgroup of schizophrenics have been found to have immunologic abnormalities. Evidence is presented of the role of lymphocytes and cytokine production in psychiatric disorders. Hypersecretion of IL-2 and IL-6 in acute exacerbation or in relapse-prone patients, decreased ratio of CD4+/CD8+, detection of antinuclear, anticytoplasmatic, antiphospholipid antibodies and others in chronic schizophrenic patients and lately the presence of antiphospholipid antibodies in unmedicated psychotic patients are examples of the immunologic abnormalities findings. These results suggest that schizophrenia may result from an immunologic disorder, which is mediated mainly (but probably not only) by lymphocyte dysfunction.

MAO-A and MAO-B activities in rat striatum, frontal cortex and liver are unaltered after long-term treatment with fluvoxamine and desipramine

In the course of investigating the mechanisms underlying the beneficial effect of fluvoxamine augmentation on negative symptoms of schizophrenia, the authors found a reduction in human platelet monoamine oxidase-B activity after 5 weeks of treatment. This unexpected finding raised the possibility that MAO activity may be one of the factors altered by chronic tricyclic or SSRI antidepressant treatment. The current study examined the effect of long-term administration, up to 6 weeks, of fluvoxamine, desipramine or saline on MAO-A and MAO-B activities in rat striatum, frontal cortex and liver. No differences were noted between drug-treated groups and their saline-treated controls. The hypothesis that long-term treatment with tricyclic and SSRI antidepressants alters MAO activity was not supported. MAO is not among proteins whose activity may be altered by chronic tricyclic or SSRI antidepressant treatment.

Applications of forensic identity testing in the clinical laboratory

DNA analysis is becoming routine in the clinical laboratory for the diagnosis of human diseases using various tissue sources. Most clinical specimens are followed by tracking forms that include patient demographic data, accession number, and date and time of collection. As part of a thorough quality assurance program, proper documentation of test requisitions and tracking forms is mandatory. Despite these efforts, specimen mislabeling or other mix-ups can, and do, occur. We demonstrate the utility of the PM + DQA1 typing kit and STR analysis using the Visible Genetics automated DNA sequencing system in the proper identification of such clinical specimens as urine, blood, and paraffin-embedded tissues. In each case, sufficient DNA was extracted from these specimen types using a nonorganic extraction protocol for typing purposes. We conclude that DNA typing methods are feasible for distinguishing clinical laboratory specimens of questionable identity and compliment existing quality assurance techniques.

The effect of augmentation with moclobemide on symptoms of schizophrenia

The effectiveness of adding moclobemide to antipsychotic treatment in schizophrenic patients with prominent negative symptoms was examined. Eleven chronic schizophrenic patients had their regular antipsychotic treatment augmented by the addition of moclobemide 450 mg/day for 8 weeks. A significant improvement was seen on the Positive and Negative Syndrome Scale (PANSS) negative factor and for the Scale for the Assessment of Negative Symptoms (SANS) scores, PANSS total score, PANSS general factor score and Hamilton Depression Scale scores. Positive symptoms were not altered. Moclobemide augmentation may ameliorate negative, depressive and general symptoms in schizophrenia.

Augmentation with fluvoxamine but not maprotiline improves negative symptoms in treated schizophrenia: evidence for a specific serotonergic effect from a double-blind study

There is considerable evidence that adding selective serotonin reuptake inhibitor (SSRI) antidepressants to antipsychotic treatment improves negative symptoms of schizophrenia. This augmentation effect may be due to "nonspecific" antidepressant action or be specifically related to action on the serotonergic system. This study examined the serotonergic specificity of SSRI augmentation by comparing an SSRI antidepressant with a comparably effective antidepressant acting via the noradrenergic system. Consenting patients having chronic schizophrenia with prominent negative symptoms were studied. Either fluvoxamine or maprotiline was added to their regular antipsychotic treatment in a double-blind manner for 6 weeks. Patients were assessed using the Brief Psychiatric Rating Scale, the Scale for the Assessment of Negative Symptoms, the Scale for the Assessment of Positive Symptoms, the Montgomery-Asberg Depression Rating Scale (MADRS), and the Neurological Rating Scale for Extrapyramidal Side Effects. Twenty-five patients completed the study. Negative symptoms improved significantly in the fluvoxamine group, but not in the maprotiline group. MADRS scores, which were low, did not change significantly in either group. Positive symptoms were not affected by either treatment. It is concluded that the mechanism by which fluvoxamine augmentation improves negative symptoms involves the serotonergic system and is distinct from its antidepressant action.

Kidney 11 beta-HSD2 is inhibited by glycyrrhetinic acid-like factors in human urine

We have previously shown that human urine contains substances that, like glycyrrhetinic acid, inhibit 11 beta-HSD1. We have named these substances "glycyrrhetinic acid-like factors" or GALFs. We now have found that human urine contains measurable quantities of both 11 beta(HSD1)- and 11 beta(HSD2)-GALF inhibitory substances. Both are markedly elevated in pregnancy. Their chemical and high-performance liquid chromatography (HPLC) characteristics suggest that several of the GALFs are steroidal. Large quantities of neutral 11 beta(HSD1)- and 11 beta(HSD2)-GALFs can be extracted directly from urine into ethyl acetate, yielding fraction EA1. Hydrolysis of the GALFs remaining in the aqueous phase by beta-glucuronidase markedly increases the total amounts of GALFs, with the majority now being ethyl acetate extractable (fraction EA2). These EA2 post-hydrolysis GALFs can be separated by HPLC resulting in at least six components with inhibitory activity against each isoenzyme. Only two GALF peaks are active against both 11 beta-HSD1 and 11 beta-HSD2. The others are peaks with specific 11 beta(HSD1)- and 11 beta(HSD2)-GALF inhibitory activity. The GALFs in the same posthydrolysis EA2 extract are also inhibitory toward the 11 beta-HSD1 that is present in vascular smooth muscle where they may play a role in the mechanisms controlling blood pressure. We have also found that 11 beta-HSD2 is selectively inhibited by 5 alpha- (but not by 5 beta-) reduced steroids. GC-MS analysis of the 11 beta(HSD2)-GALFs in EA2 is now being performed to determine whether this group includes 3 alpha,5 alpha-ring A-tetrahydro-reduced derivatives of steroids.

Dose ranging study of the oxytocin antagonist atosiban in the treatment of preterm labor. Atosiban Study Group

OBJECTIVE

To evaluate the minimal effective dose regimen of the oxytocin antagonist atosiban in the treatment of acute preterm labor and the effect of a bolus on uterine activity within the first 2 hours compared with no bolus and the same infusion rate.

METHODS

A randomized, double-blind (except the ritodrine group), parallel group, multicenter study compared four different intravenous atosiban regimens (6.5 mg bolus plus 300 micrograms/minute, placebo bolus plus 300 micrograms/minute, 2mg bolus plus 100 micrograms/minute, and 0.6 mg plus 30 micrograms/minute) and intravenous ritodrine with respect to the cessation of uterine contractions for 1 hour or more during infusion, four or fewer contractions per hour in the last hour of therapy, and discontinuation because of adverse experiences. Three hundred two patients were enrolled.

RESULTS

The lowest dose of atosiban (0.6 mg plus 30 micrograms/minute) was significantly less effective than ritodrine with respect to cessation of contractions and four or fewer contractions per hour in the last hour of therapy. Other atosiban regimens were comparable to ritodrine, except for the drug discontinuation rate for adverse experiences. Bolus therapy with high-dose atosiban resulted in a significantly greater proportion of patients who stopped contracting within the first 2 hours of treatment (17 of 63) compared with those not receiving a bolus (six of 58, P = .017). Because of adverse experiences, the study drug was discontinued in one of 244 atosiban patients and 15 of 58 ritodrine patients.

CONCLUSION

Atosiban's effect on uterine activity in preterm labor was enhanced by bolus infusion and was similar to the effect of ritodrine, but with fewer side effects.

Effects of fetal number and multifetal reduction on length of in vitro fertilization pregnancies

OBJECTIVE

To determine the effects of multifetal reduction and other variables on the duration of gestation of in vitro fertilization (IVF) pregnancies.

METHODS

All 274 IVF pregnancies from the inception of the Women and Infants' Hospital IVF Program on May 26, 1988, until December 31, 1993, were evaluated.

RESULTS

Spontaneous reduction occurred in ten pregnancies, and multifetal reduction was elected in 28 multiple gestations. Among 260 pregnancies that remained viable beyond 20 weeks, 162 singletons (37.9 +/- 0.29 weeks; mean +/- standard error) had a longer mean gestation than did 64 twins (34.6 +/- 0.61 weeks), 25 pregnancies reduced to twins (33.4 +/- 1.0 weeks), or nine triplets (29.7 +/- 1.9 weeks). Triplets delivered 4.9 weeks earlier than nonreduced twins (P < .05) and 3.7 weeks before twins resulting from multifetal pregnancy reduction (P < .05). Regression analysis showed that at the 8-week ultrasound, each viable fetus could be expected to reduce the duration of the gestation by about 3.6 weeks, and each fetus reduced medically or as a result of natural causes could be expected to prolong the gestation by approximately 3.0 weeks. Only 14% of triplet pregnancies underwent spontaneous multifetal reduction.

CONCLUSION

Multifetal reduction of pregnancies with three or more fetuses was beneficial and increased the duration of gestation.

Treatment of preterm labor with the oxytocin antagonist atosiban

The purpose of this study was to describe the course of preterm labor in patients receiving a standard intravenous infusion of the oxytocin antagonist atosiban. An open-labeled, non-randomized study was conducted at 4 sites. Successful tocolysis was defined as delay of delivery larger than 48 hours from starting atosiban and no need for an alternate tocolytic. Atosiban was administered by continuous intravenous infusion at a rate of 300 micrograms per minute until uterine contractions were absent for 6 hours, or up to a maximum infusion time of 12 hours. Sixty-two patients of between 20 and 36 weeks' gestation were enrolled over 6 months. One had rupture of membranes and was excluded. Successful tocolysis was noted in 43 of 61 (70.5%). Four delivered spontaneously within 48 hours and 14 (23.0%) required an alternate tocolytic agent. The chance of successful tocolysis was related to the degree of cervical dilation at the start of therapy. Cessation of uterine contractions was noted in 38 patients (62.3%). A decrease in uterine contraction frequency of 50% or more was noted in 50 of 61 patients (82.0%). Four patients reported side effects (nausea, vomiting, headache, dysguesia, chest pain), but in no case did side effects require discontinuation of the medication. Intravenous administration of atosiban is associated with a delay in delivery comparable to that seen with other tocolytics. If this effect is confirmed in planned placebo-controlled trials, its favorable side effect profile may give it a place in the armamentarium.

No difference in the effect of biperiden and amantadine on parkinsonian- and tardive dyskinesia-type involuntary movements: a double-blind crossover, placebo-controlled study in medicated chronic schizophrenic patients

BACKGROUND

There are few objective guidelines for the clinician in the choice of antiparkinsonian drugs, even though these drugs are a heterogeneous group. We compared the effect of biperiden (M1 selective anticholinergic) and amantadine (dopaminergic) on neuroleptic-induced parkinsonian extrapyramidal symptoms (EPS) and tardive dyskinesia (TD)-type involuntary movements.

METHOD

Thirty-two schizophrenic (DSM-III-R) inpatients on long-term stable antipsychotic and trihexyphenidyl treatment entered the study. Antipsychotics were kept constant, but trihexyphenidyl was replaced by placebo under single-blind conditions for 1 week, and the the patients were randomly assigned to either amantadine 100 mg b.i.d. or biperiden 2 mg b.i.d. treatment under double-blind conditions for 2 weeks. After a second 1-week placebo period, the test drugs were crossed over under double-blind conditions. Assessments of tardive dyskinesia (Abnormal Involuntary Movement Scale [AIMS]) and of parkinsonian extrapyramidal side effects (Simpson-Angus Neurologic Rating Scale) were made pretreatment and posttreatment.

RESULTS

Twenty-six patients completed all study procedures. Amantadine and biperiden were equally effective in relieving neuroleptic-induced EPS and did not exacerbate TD-type movements. AIMS scores during treatment were significantly lower than during placebo period. The findings were similar in patients with diagnosable TD.

CONCLUSION

Amantadine and biperiden have similar effects on neuroleptic-induced EPS and TD and may ameliorate mild TD.

Effects of biperiden and amantadine on memory in medicated chronic schizophrenic patients. A Double-blind cross-over study

BACKGROUND

The effects on memory of an anticholinergic (biperiden) and a dopaminergic (amantadine) anti-Parkinsonian agent were compared.

METHOD

Twenty-six chronically medicated schizophrenic (DSM-III-R) in-patients received amantadine (200 mg/day) or biperiden (4 mg/day) for two weeks in a double-blind cross-over design.

RESULTS

Biperiden treatment was associated with significantly lower scores on Benton Visual Retention Test (P < 0.003) and the visual subscale of Wechsler Memory Scale (WMS) (P < or = 0.02), with a trend to poorer scores on WMS total (P = 0.086) and the digit span (P = 0.07) and logical memory (P = 0.06) subscales.

CONCLUSIONS

In usual clinical doses, biperiden interferes with memory, particularly visual, more than amantadine.

Pretreatment with sedative-hypnotics, but not with nondepolarizing muscle relaxants, attenuates alfentanil-induced muscle rigidity

STUDY OBJECTIVE

To evaluate and compare the efficacy of various pretreatment agents to attenuate or prevent opioid-induced muscle rigidity using a well-established, previously described clinical protocol.

DESIGN

Prospective, controlled, single-blind, partially randomized study.

SETTING

Large medical center.

PATIENTS

ASA physical status I-III patients undergoing elective surgical procedures of at least 3 hours' duration.

INTERVENTIONS

The effect of pretreatment with nondepolarizing muscle relaxants (atracurium 40 micrograms/kg or metocurine 50 micrograms/kg), benzodiazepine agonists (diazepam 5 mg or midazolam 2.5 mg), or thiopental sodium 1 mg/kg on the increased muscle tone produced by alfentanil 175 micrograms/kg was compared with a control group (given no pretreatment).

MEASUREMENTS AND MAIN RESULTS

Rigidity was assessed quantitatively by measuring the electromyographic activity of five muscle groups (biceps, intercostals, abdominals, quadriceps, and gastrocnemius). Rigidity also was rated qualitatively by attempts to initiate and maintain mask ventilation, attempts to flex an extremity, and the occurrence of myoclonic movements. Pretreatment with the two nondepolarizing muscle relaxants had no effect on the severe muscle rigidity produced by high-dose alfentanil. Whereas thiopental was only mildly effective, the benzodiazepines midazolam and diazepam significantly attenuated alfentanil rigidity (p < 0.05).

CONCLUSION

This study suggests that benzodiazepine pretreatment is frequently, but not always, effective in preventing opioid-induced muscle rigidity.

Drug abuse in schizophrenia: comparison of patients who began drug abuse before their first admission with those who began abusing drugs after their first admission

The relationship between the onset of drug abuse and onset of illness (first hospitalisation) and its correlates were examined in 42 hospitalised schizophrenics identified as drug abusers. 60% of the patients began drug use before their first hospitalisation. No differences on sociodemographic or clinical parameters between patients who began drug use before their first hospitalisation and those who began after it were detected when drug abuse was treated as a unitary phenomenon. Use of specific drugs was associated with significant differences in age, age at first hospitalisation, premorbid functioning and type of schizophrenia between patients who began drug pre-morbidly and those who began to use drugs post-morbidly. The differences were not uniform for the different drugs used. The findings are discussed in relation to vulnerability and self medication models of comorbidity of drug abuse and schizophrenia.