Guidelines for Using Simulation for Online Teaching and Learning of Clinical Social Work Practice in the Time of COVID

Due to COVID 19, Monash University's Social Work Department moved all clinical practice skills teaching in the Master of Social Work (graduate entry level) fully online using synchronous audio-visual conferencing platform Zoom for the first time from March to June 2020. The innovations associated with this move included the development of clinical practice laboratories (CPLs) to prepare 154 students for a modified version of an Objective Structured Clinical Examinations (OSCE) and their first field education practicum. The use of simulated clients to facilitate experiential learning of active listening skills, rapport-building and empathic communication in this mode of delivery is described in detail to encourage overcoming previous issues in teaching clinical practice skills to students located at a distance from campus.

Predicting delivery of a small-for-gestational-age infant and adverse perinatal outcome in women with suspected pre-eclampsia

OBJECTIVE

To evaluate the test performance of 47 biomarkers and ultrasound parameters for the prediction of delivery of a small-for-gestational-age (SGA) infant and adverse perinatal outcome in women presenting with suspected pre-eclampsia.

METHODS

This was a prospective, multicenter observational study in which 47 biomarkers and ultrasound parameters were measured in 397 women with a singleton pregnancy presenting with suspected preterm pre-eclampsia between 20 + 0 and 36 + 6 weeks' gestation, with the objective of evaluating them as predictors of subsequent delivery of a SGA infant and adverse perinatal outcome. Women with confirmed pre-eclampsia at enrollment were excluded. Factor analysis and stepwise logistic regression were performed in two prespecified groups stratified according to gestational age at enrollment. The primary outcome was delivery of a SGA infant with a birth weight < 3^rd customized centile (SGA-3), and secondary outcomes were a SGA infant with a birth weight < 10^th customized centile and adverse perinatal outcome.

RESULTS

In 274 women presenting at 20 + 0 to 34 + 6 weeks' gestation, 96 (35%) delivered a SGA-3 infant. For prediction of SGA-3, low maternal placental growth factor (PlGF) concentration had a sensitivity of 93% (95% CI, 84-98%) and negative predictive value (NPV) of 90% (95% CI, 76-97%) compared with a sensitivity of 71% (95% CI, 58-82%) and a NPV of 79% (95% CI, 68-87%) for ultrasound parameters (estimated fetal weight or abdominal circumference < 10^th centile). No individual biomarker evaluated had a better performance than did PlGF, and marker combinations made only small improvements to the test performance. Similar results were found in 123 women presenting between 35 + 0 and 36 + 6 weeks' gestation.

CONCLUSION

In women presenting with suspected preterm pre-eclampsia, measurement of PlGF offers a useful adjunct for identifying those at high risk of delivering a SGA infant, allowing appropriate surveillance and timely intervention. © 2017 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Standard- or high-dose oxytocin for nulliparous women with confirmed delay in labour: quantitative and qualitative results from a pilot randomised controlled trial

OBJECTIVE

Evidence suggests that a high dose of oxytocin for nulliparous women at 37-42 weeks of gestation with confirmed delay in labour increases spontaneous vaginal birth. We undertook a pilot study to test the feasibility of this treatment.

DESIGN

Pilot double-blind randomised controlled trial.

SETTING

Three teaching hospitals in the UK.

POPULATION

A total of 94 consenting nulliparous women at term with confirmed delay in labour were recruited, and 18 were interviewed.

METHODS

Women were assigned to either a standard (2 mU/min, increasing every 30 minutes to 32 mU/minute) or a high-dose regimen (4 mU/minute, increasing every 30 minutes to 64 mU/minutes) oxytocin by computer-generated randomisation. Simple descriptive statistics were used, as the sample size was insufficient to evaluate clinical outcomes. The constant comparative method was used to analyse the interviews.

MAIN OUTCOMES MEASURES

The main outcome measures: number of women eligible; maternal and neonatal birth; safety; maternal psychological outcomes and experiences; health-related quality of life outcomes using validated tools and data on health service resource use; incidence of suspected delay of labour (cervical dilatation of <2 cm after 4 hours, once labour is established); and incidence of confirmed delay of labour (progress of <1 cm on repeat vaginal examination after a period of 2 hours).

RESULTS

We successfully developed systems to recruit eligible women in labour and to collect data. Rates of spontaneous vaginal birth (10/47 versus 12/47, RR 1.2, 95% CI 0.6-2.5) and caesarean section (15/47 versus 17/47, RR 1.1, 95% CI 0.6-2.0) were increased, and rates of instrumental birth were reduced (21/47 versus 17/47, RR 0.8, 95% CI 0.5-1.3). No evidence of increased harm for either mother or baby was found. The incidences of suspected delay (14%) and confirmed delay (11%) in labour were less than anticipated. Of those who did not go on to have delayed labour confirmed, all except one woman gave birth vaginally.

CONCLUSIONS

A pilot trial assessing the efficacy of high-dose oxytocin was feasible, but uncertainty remains, highlighting the need for a large definitive trial. The implementation of national guidance of suspected and confirmed delay in labour is likely to reduce intervention.

Women's perception of future risk following pregnancies complicated by preeclampsia

OBJECTIVE

To elicit women's personal understanding of future cardiovascular risk, following a pregnancy complicated by preeclampsia, and to identify the postnatal needs of these women.

METHODS

Semi-structured interviews with 12 women with a recent history of preeclampsia who had attended a postnatal follow-up clinic.

RESULTS

The interviews were held at a median of 47 weeks postpartum (range 24-62 weeks). Family history of cardiovascular disease was associated with a greater awareness of future cardiovascular risk. Women without traditional risk factors found it hard to envisage themselves as being at risk and may not see the relevance of such information. It may take several months after delivery for a woman to be able to fully consider her own health as well as the baby's; a reminder of risk and health information is needed.

CONCLUSIONS

Although receptive to follow-up, the situational factors of being a new mother need to be taken into account to engage successfully with this patient group. Further research is needed to help clarify the extent to which a history of preeclampsia is an independent factor for future cardiovascular disease to provide a solid foundation for effective risk communication.

Thromboelastography and peripartum coagulation profiles associated with caesarean section delivery

Thromboembolic (TE) disease remains the leading direct cause of maternal death in the UK and caesarean section increases TE risk. Women are assessed for their TE risk and may receive thromboprophylaxis. From a single blood sample thromboelastography(®) (TEG(®)) allows a test of coagulation. Blood samples from women undergoing elective caesarean sections were collected at specific stages: antenatally, following overnight 'nil-by-mouth', immediately after surgery, four hours post-delivery and 24 hours post-delivery. Analyses of the R time (time taken for blood to clot) and maximum amplitude (MA) (overall clot strength) were performed. Analyses of the high and moderate risks cohorts were performed and compared to the low risk group. Fifty-four women were recruited. A reduction in the R time was demonstrated following pre-operative fluid restriction and a further reduction in R time occurred after surgery. The R time increased 24 hours after surgery and became comparable to pre-operative levels. The MA changed similarly due to pre-operative fluid restriction. Analysis also showed that pre-operatively, the combined high and moderate risk groups' R time was shorter than the low risk group. The high and moderate risk group, having received thromboprophylaxis, had similar R times 24 hours postoperatively compared to the low risk group. TEG(®) demonstrates that following pre-operative fluid restriction and surgery women become hypercoagulable but by 24 hours coagulation has returned to third trimester levels. Sub-group analysis suggests the relative pre-operative hypercoagulability of high and moderate risk women compared to low risk women, becoming comparable after 24 hours following thromboprophylaxis.

Pre-eclampsia is associated with airway hyperresponsiveness

Several large retrospective cohort studies demonstrate that pre-eclampsia is common in asthmatics. Whether airway hyperresponsiveness (AHR), a hallmark of asthma, is associated with pre-eclampsia is unknown. We measured AHR, using a methacholine challenge, and atopy in 19 women 3-60 months postpartum following pre-eclamptic or normotensive pregnancies. The geometric mean (95% CI) concentration of methacholine required to produce a >20% fall in the forced expiratory volume in 1 second (PC20 FEV1) was 8.9 (2.2-36) mg/ml in pre-eclamptics versus 72 (32-131) mg/ml in controls (P = 0.01) and 9 (1.9-40) mg/ml in atopic pre-eclamptics without asthma versus 54 (17-174) mg/ml (P = 0.038) in matched controls. Therefore, AHR was increased in women who have had pre-eclampsia. This association and its possible mechanisms warrant further investigation.

Effect of laser intensity on fast-electron-beam divergence in solid-density plasmas

Metal foil targets were irradiated with 1 mum wavelength (lambda) laser pulses of 5 ps duration and focused intensities (I) of up to 4x10;{19} W cm;{-2}, giving values of both Ilambda;{2} and pulse duration comparable to those required for fast ignition inertial fusion. The divergence of the electrons accelerated into the target was determined from spatially resolved measurements of x-ray K_{alpha} emission and from transverse probing of the plasma formed on the back of the foils. Comparison of the divergence with other published data shows that it increases with Ilambda;{2} and is independent of pulse duration. Two-dimensional particle-in-cell simulations reproduce these results, indicating that it is a fundamental property of the laser-plasma interaction.

Referral and attendance at a specialist antenatal clinic: qualitative study of women's views

OBJECTIVE

To explore women's views on being referred to and attending a specialist antenatal hypertension clinic.

DESIGN

Qualitative interview study.

SETTING

A pregnancy hypertension clinic in a large teaching hospital in the East Midlands.

POPULATION

Twenty-one women (aged 18 years and above) attending the pregnancy hypertension clinic for the first time during their current pregnancy.

METHODS

Women who had been referred to and attended a specialist antenatal clinic participated in semi-structured interviews. Data analysis was based on the constant comparative method.

MAIN OUTCOME MEASURES

Women's experiences and perceptions of being referred to and attending a specialist antenatal clinic.

RESULTS

Being referred to the clinic conferred an 'at risk' status on women. Some women welcomed the referral but others experienced it as unsettling. Many were unclear about why they had been identified as being at risk or had difficulties in accepting the legitimacy of the reason for referral. Women were often inadequately informed about why they were referred to the clinic, what they could expect and the benefits of attending the clinic over management in the community. Although attendance at the clinic was cited as a source of reassurance, the reassurance was often made necessary by concern raised by the initial referral.

CONCLUSIONS

Women's accounts suggest that the interface between community and secondary antenatal services needs improvement to minimise possible adverse effects from identifying women as being 'at risk' during pregnancy.

Practices and views on fetal heart monitoring: a structured observation and interview study

OBJECTIVE

To assess and explain deviations from recommended practice in National Institute for Clinical Excellence (NICE) guidelines in relation to fetal heart monitoring.

DESIGN

Qualitative study.

SETTING

Large teaching hospital in the UK.

SAMPLE

Sixty-six hours of observation of 25 labours and interviews with 20 midwives of varying grades.

METHODS

Structured observations of labour and semistructured interviews with midwives. Interviews were undertaken using a prompt guide, audiotaped, and transcribed verbatim. Analysis was based on the constant comparative method, assisted by QSR N5 software.

MAIN OUTCOME MEASURES

Deviations from recommended practice in relation to fetal monitoring and insights into why these occur.

RESULTS

All babies involved in the study were safely delivered, but 243 deviations from recommended practice in relation to NICE guidelines on fetal monitoring were identified, with the majority (80%) of these occurring in relation to documentation. Other deviations from recommended practice included indications for use of electronic fetal heart monitoring and conduct of fetal heart monitoring. There is evidence of difficulties with availability and maintenance of equipment, and some deficits in staff knowledge and skill. Differing orientations towards fetal monitoring were reported by midwives, which were likely to have impacts on practice. The initiation, management, and interpretation of fetal heart monitoring is complex and distributed across time, space, and professional boundaries, and practices in relation to fetal heart monitoring need to be understood within an organisational and social context.

CONCLUSION

Some deviations from best practice guidelines may be rectified through straightforward interventions including improved systems for managing equipment and training. Other deviations from recommended practice need to be understood as the outcomes of complex processes that are likely to defy easy resolution.

Effects of pre-eclampsia on maternal plasma, cerebrospinal fluid, and umbilical cord urotensin II concentrations: a pilot study † †This work was presented at the Liverpool meeting of the Anaesthetic Research Society, July 8–9, 2004 (E. Cowley, J. Waugh, N. Ali, P. Sharpe, J. P. Thompson and D. G. Lambert. Urotensin II concentrations are not elevated in pre-eclampsia. Br J Anaesth 2004; 612P)

BACKGROUND

Urotensin II (UII) is the most potent endogenous vasoconstrictor identified to date. Pre-eclampsia is associated with arteriolar vasospasm but the precise underlying mechanism is uncertain and we hypothesized that UII concentrations might also be elevated. In this study we measured UII concentrations in maternal plasma and cerebrospinal fluid (CSF), and umbilical vein plasma from pre-eclamptic (PET) and normotensive patients undergoing elective Caesarean section under spinal or combined spinal-epidural anaesthesia.

METHODS

With LREC approval and informed consent we recruited two groups of 10 patients; control [mean (range) age, 29 (22-43) yr; BMI, 25 (20-32); gestation, 273 (267-281) days; mean arterial pressure (MAP) on day of delivery, 81 (75-96) mm Hg] and PET [age, 34 (22-40) yr; BMI, 25 (21-46); gestation, 253 (203-289) days; MAP on day of delivery, 106 (88-128) mm Hg]. Maternal blood and CSF samples and umbilical vein blood samples were taken. UII was extracted and concentrations measured using a radioimmunoassay.

RESULTS

Two plasma and two CSF samples in the control and two CSF samples in the PET group were below the assay detection limits. There were no differences in maternal plasma or CSF or umbilical vein UII concentrations between the groups. However, there was a small ( approximately 40%) but significant increase in cord UII concentrations when compared with paired plasma in the PET group. There was a weak but significant negative correlation (r=-0.4, P=0.049) between cord UII concentrations and gestation in the PET group. In addition, we observed a significant positive correlation between plasma and CSF (r(2)=+0.57, P=0.0009, n=16), plasma and cord (r(2)=+0.43, P=0.0031, n=18) and CSF and cord (r(2)=+0.32, P=0.022, n=16) UII concentrations for the whole data set.

CONCLUSIONS

Collectively the data indicate that UII concentrations do not increase in PET compared with controls but, in PET patients, cord UII concentrations are elevated relative to paired plasma samples. Elevated umbilical vein UII concentrations may simply indicate reduced placental viability and possibly UII metabolism as a result of reduced blood flow or possibly that the placenta is producing UII.

Adrenal metastases of malignant melanoma: Characteristic computed tomography appearances

Malignant melanoma is an extremely aggressive form of cancer. Adrenal metastases are found in 50% of cases of malignant melanoma, and are most often clinically and biochemically silent. Clinical presentation varies, and the diagnosis of adrenal metastases is often made incidentally, and frequently years after treatment of the primary lesion. An adrenal mass lesion seen on a CT scan, greater than 5 cm in diameter, with central or irregular areas of necrosis/haemorrhage (and no lipomatous component) is characteristic of a metastasis from malignant melanoma, in the setting of normal gland function. If these features are bilateral, they are pathognomonic. Oval, low-attenuation (on CT) adrenal masses less than 3 cm in diameter should not be considered benign in a patient with any prior history of melanoma. Careful imaging review of the adrenal glands should be undertaken in all patients with malignant melanoma. Early diagnosis of these distant metastases has important prognostic and therapeutic implications. The four cases presented illustrate the spectrum of presentations and clinical course of adrenal metastases from malignant melanoma. The accompanying CT images show the characteristic appearances of adrenal metastases.

Embolization for major lower gastrointestinal haemorrhage: five-year experience

The management of major lower gastrointestinal haemorrhage has changed dramatically in the last 15 years. Innovations in coaxial catheter technology have allowed the interventional radiologist to reach the small peripheral mesenteric arteries and perform superselective embolization with a variety of agents. The present large series represents the 5-year experience of this technique at the Alfred Hospital, Melbourne, in a patient cohort with a high number of comorbidities. Technical success was achieved in 96% of cases. The clinical symptoms of mesenteric ischaemia developed in four patients after embolization and were managed conservatively in two. The procedure-related mortality was low when compared with the published complication rates for emergency surgery, in this clinical setting.

Cerebellar metastases from prostatic carcinoma

A 67-year-old man presented with worsening headaches and gait disturbance, and with minimal clinical signs. A brain MRI showed multiple solid cerebellar metastases. The pathological diagnosis of metastatic carcinoma of the prostate was further suggested by an elevation in prostate specific antigen, and was pathologically confirmed following the neurosurgical removal of the tumours. The rarity of this presentation, as documented in the clinical literature, is reviewed.

Intravenous administration of an AAV-2 vector for the expression of factor IX in mice and a dog model of hemophilia B

Previous experiments have demonstrated the stable expression of factor IX (FIX) protein in mice and canine models of hemophilia B following portal vein gene transfer with a recombinant adeno-associated virus (rAAV) vector encoding FIX. Here, we present the results of studies that further optimized the rAAV vector transgene cassette used to express FIX and explored the use of the less-invasive intravenous (i.v.) route of vector administration for the treatment of hemophilia B. First, a liver-specific promoter was evaluated in conjunction with cis-acting regulatory elements in mice. Constructs that included both the beta-globin intron and the woodchuck hepatitis virus post-transcriptional regulatory element resulted in the highest level of FIX expression in vivo. Using this optimized vector, we demonstrate that i.v. injection was feasible for hepatic gene transfer in mice, achieving 70-80% of portal vein expression levels of FIX. In further studies using the Chapel Hill strain of hemophilia B dogs, we demonstrate for the first time FIX expression and partial correction of the bleeding disorder following i.v. administration of an AAV vector.

Management of pregnancy in women with pulmonary hypertension secondary to SLE and anti-phospholipid syndrome

Pulmonary hypertension is found in about 10% of patients with systemic lupus erythematosis (SLE). Pulmonary hypertension may be present at the time of diagnosis or may develop after the diagnosis of SLE or anti-phospholipid syndrome (APS). It often presents in the reproductive years and has a significant impact on pregnancy outcome, being a significant cause of indirect maternal deaths. In our observational case series of three patients there were two deaths (66%). In cases 1 and 2 the pulmonary hypertension developed during pregnancy and deteriorated rapidly with markedly abnormal mean pulmonary artery pressures of 80 and 70 mmHg respectively prior to death. Both patients died within 48 hours of delivery. In case 3 the pulmonary hypertension was milder and was diagnosed very early in pregnancy. The patient received multidisciplinary care from the first trimester and the management of the pregnancy, delivery and the early puerperium was planned. Careful epidural anaesthesia was used and the patient had invasive monitoring on the intensive therapy unit (ITU) for 72 hours. Women with pulmonary hypertension need to be aware of the high risk of maternal mortality associated with pregnancy but we believe that an improvement in outcome can be achieved by careful assessment and the use of a multidisciplinary approach from early in pregnancy.

Effect of concentration and biochemical assay on the accuracy of urine dipsticks in hypertensive pregnancies

OBJECTIVE

To assess how urine concentration and biochemical assay influence the assessment of proteinuria.

METHODS

This was a prospective study to assess the accuracy of detection and quantification of proteinuria within the day assessment unit and antenatal ward of a teaching hospital in Leicester, United Kingdom. We studied hypertensive pregnancies (of mixed parity) referred to day care assessment or attending the antenatal hypertension clinic after 20 completed weeks of gestation (n = 197). Aliquots of a well-mixed 24-h urine collection were tested by routine dipstick urinalysis and then assayed for protein using the Benzethonium Chloride and the Bradford assays (n = 197).

MAIN OUTCOME MEASURES

Total protein excretion in 24 h and protein concentration per liter of urine for both biochemical assays were compared to semiquantitative dipstick protein measurement.

RESULTS

The prevalence of proteinuria in the study group varied according to the method used for testing. Dipstick urinalysis recorded the lowest prevalence (16.2%) and the Benzethonium Chloride assay measuring total protein excretion in 24 h recorded the highest (70.1%). When the positive and negative predictive values for dipstick urinalysis were calculated, performance was found to be dependent on both the units of measurement compared and the type of assay used as the "gold standard." Positive predictive values ranged from 87.5% to 96.9% and negative predictive values ranged from 35.2% to 92.1%.

CONCLUSIONS

The prevalence of proteinuria in hypertensive pregnancies is dependent on the method used to detect it. The amount of protein assessed quantitatively is further dependent on the biochemical assay employed. However, regardless of the quantitative assessment, dipstick urinalysis has a significant false-negative rate. This first reporting of a variation in performance between dipstick urinalysis and two different biochemical assays in pregnancy may be explained in relation to protein assay specificity and the observed protein compositions of the samples on electrophoretic analysis. The significance of proteinuria should be considered in light of the method used to detect it, but, ultimately, it must be related to clinical outcome.

Home monitoring of blood pressure in pregnancy at high risk of pre-eclampsia

The early detection of pre-eclampsia is a major challenge in obstetric care. We report a case where pre-eclampsia was detected by home blood pressure monitoring between routine antenatal visits. This novel management approach allows early diagnosis and optimises antenatal care in fulminating disease.

Noninvasive techniques to detect fetal anemia due to red blood cell alloimmunization: a systematic review

OBJECTIVE

To estimate, in maternal red blood cell alloimmunization, the diagnostic value of fetal ultrasonography and Doppler blood flow velocity in the evaluation and prediction of fetal anemia.

METHODS

Literature from 1970 to 2000 was identified using general bibliographic databases (MEDLINE and EMBASE), the Cochrane Library and relevant specialist register of the Cochrane Collaboration, and by checking reference lists of known primary and review articles. Studies were selected if the accuracy of the fetal ultrasound parameters or Doppler studies of blood flow in the fetal vessels was estimated compared with a reference standard (fetal hemoglobin). The diagnostic tests evaluated were ultrasound measurement of the fetal spleen perimeter and Doppler studies of blood velocity estimates in the umbilical vein, ductus venosus, middle cerebral artery, thoracic aorta, and umbilical vessel combined with the thoracic aorta. Study selection, quality assessment, and data abstraction were performed independently and in duplicate. Data from the selected studies were abstracted as 2 x 2 tables comparing the diagnostic test result with the reference standard. Diagnostic accuracy was expressed as likelihood ratios.

RESULTS

The review included eight primary studies with 362 pregnancies affected by red cell alloimmunization. Prospective patient recruitment and complete population details were reported in half of the selected studies (four of eight). Only one study reported masking the diagnostic test results to clinicians. The diagnostic test performance varied widely according to the type of the test evaluated and the cutoff level used to define fetal anemia, which varied from study to study. The diagnostic test study of highest methodological quality reported a positive likelihood ratio of 8.45 (95% confidence interval 4.69, 15.56) and negative likelihood ratio of 0.02 (95% confidence interval 0.001, 0.25) for maximum middle cerebral artery Doppler velocity.

CONCLUSION

The literature reporting noninvasive techniques to predict fetal anemia is methodologically poor and a standard approach to the evaluation of these techniques is lacking. A recommendation for practice cannot be generated without further rigorous research.

Intrauterine growth restriction: diagnosis and management

The diagnosis of intrauterine growth restruction often results in preterm delivery with its associated morbidity and mortality. This review aims to outline the main diagnostic and management tools available to obstetricians for the management of such pregnancies as well as the aetiological factors that might be associated with this condition.

Inpatient monitoring on an outpatient basis: managing hypertensive pregnancies in the community using automated technologies

Automated measurement of blood pressure and urinalysis is reviewed, and the strengths and weaknesses of these devices are compared with conventional techniques. The few early reports of such management strategies are reviewed with emphasis on the advantages of automated monitoring. The article concludes with a review of published pilot data in this field and places those findings in the context of recent recommendations for the development of obstetric care in the United Kingdom.

Birth weight and 24-hour ambulatory blood pressure in nonproteinuric hypertensive pregnancy

OBJECTIVE

The aim of this study was to examine the relationship between maternal ambulatory blood pressure monitor measurements during pregnancy and birth weight in a population of women considered to have hypertension according to conventional antenatal clinic measurement.

STUDY DESIGN

A prospective observational study was carried out within the obstetric departments of Leicester Royal Infirmary and Queen Charlotte's Hospital. A total of 237 women were found to have hypertension (blood pressure >/=140/90 mm Hg) without significant proteinuria during examination in the antenatal assessment area. Sequential-day unit blood pressure recordings and a 24-hour automated ambulatory blood pressure recording were performed, and the results were compared with the principal outcome measure of birth weight.

RESULTS

A significant inverse association (gradient, -13.5; 95% confidence interval -23.4 to -3.6) was found between daytime ambulatory diastolic blood pressure measurement and birth weight. An increase of 5 mm Hg in daytime mean diastolic blood pressure was associated with a fall in birth weight of 68.5 g. This association remained after adjustment for potential confounders that included maternal age, maternal weight, smoking status, ethnicity, and gestational age at delivery. No such association was found between obstetric day unit assessment of blood pressure and birth weight.

CONCLUSION

There is a significant association between blood pressure and birth weight in nonproteinuric hypertensive pregnancies. The best predictor of this association is the daytime mean ambulatory diastolic blood pressure measurement. This is further evidence that maternal blood pressure may be an important confounding and potentially genetic variable in the association between birth weight and subsequent adult hypertension.

Cloning and characterization of TRAIL-R3, a novel member of the emerging TRAIL receptor family

TRAIL-R3, a new member of the TRAIL receptor family, has been cloned and characterized. TRAIL-R3 encodes a 299 amino acid protein with 58 and 54% overall identity to TRAIL-R1 and -R2, respectively. Transient expression and quantitative binding studies show TRAIL-R3 to be a plasma membrane-bound protein capable of high affinity interaction with the TRAIL ligand. The TRAIL-R3 gene maps to human chromosome 8p22-21, clustered with the genes encoding two other TRAIL receptors. In contrast to TRAIL-R1 and -R2, this receptor shows restricted expression, with transcripts detectable only in peripheral blood lymphocytes and spleen. The structure of TRAIL-R3 is unique when compared to the other TRAIL receptors in that it lacks a cytoplasmic domain and appears to be glycosyl-phosphatidylinositol-linked. Moreover, unlike TRAIL-R1 and -R2, in a transient overexpression system TRAIL-R3 does not induce apoptosis.

Prevalence and aetiology of neurological impairment in extremely low birthweight infants

OBJECTIVE

To determine the prevalence and perinatal predictors of cerebral palsy, intellectual impairment, visual impairment and deafness in a cohort of extremely low birthweight (ELBW) infants at two years of age.

METHODOLOGY

The study population comprised 199 of the 224 (89%) ELBW infants managed at the Mater's Mothers Hospital, Brisbane, between July 1977 and February 1990 and who survived to two years. The prevalence of cerebral palsy, intellectual impairment, blindness and deafness was measured by clinical,psychometric and audiological assessment and the association with 24 risk factors examined.

RESULTS

Cerebral palsy occurred in 20 children (10%). Risk of cerebral palsy was associated with ventricular dilatation, intraventricular haemorrhage, necrotizing enterocolitis and multiple birth, though only ventricular dilatation (OR 4.41; 95% CI 1.32-14.8) remained significant in the adjusted analysis. Intellectual impairment occurred in 20 children (10%) and was independently associated with ventricular dilatation (OR 15.0; 95% CI 2.2-102.8), ventilation F(i)(2) > 80% (OR 3.4; 95% CI 1.01-11.5), vaginal delivery (OR 3.5; 95% Cl 1.09-11.4) and male sex (OR 6.1; 95% Cl 1.67-22.3). No perinatal predictor was statistically associated with risk of deafness. Retinopathy of prematurity (OR 36.9; 95% Cl 2.8-495.5) was associated with risk of later visual impairment.

CONCLUSIONS

Intellectual impairment was associated with a broad range of perinatal variables. Cerebral palsy was associated with fewer variables, all of which were also associated with intellectual impairment. Neurologic injury was associated with male sex and multiple birth, which are not biological insults themselves, but may be markers of susceptibility to injury.

Diagnosis of renal allograft rejection by analysis of fine-needle aspiration biopsy specimens with immunostains and simple cytology

Fine-needle aspiration biopsy specimens of renal transplants were analysed by means of commercially available monoclonal antibodies and an immunoperoxidase stain. Three cellular features associated with acute cellular rejection were identified--heavy infiltrates of activated T cells or large mononuclear cells strongly expressing HLA-DR antigens, and HLA-DR expression by renal tubular cells. A combination of semiquantitative scores for these features correctly identified rejection in 32 of 34 cases, with no false positives in cases of cyclosporin nephrotoxicity or stable graft function.

Differential cytotoxicity of cis-platinum and blenoxane against human carcinoma KBE cells in multicellular spheroids of different ages: response at different temperatures

Human KBE epidermoid carcinoma cells were reproducibly grown in suspension as multicellular spheroids (MCS). Initial aggregation at 48 hours is followed by a rapid diameter increase until day 10. The size increase then continues with daily refeedings, under the growth conditions used, but at a slower rate. When cells are treated in MCS with either blenoxane (bleomycin) or cis-diamminedichloroplatinum (II) (cis-platinum), the survival of cells (by cloning efficiency (CE) essay) varied from that of surface attached (SA) cells. The survival was dependent on the age of the MCS as well as their size; the age response was significantly different for cis-platinum and blenoxane. Hyperthermic incubation of KBE cells in MCS at different ages for 1 hour (40-43 degrees C) resulted in cell killing similar to that observed after hyperthermic incubation of surface attached cells. In combined hyperthermia/chemotherapy experiments, simultaneous treatment with blenoxane resulted in little or no increase in MCS cell toxicity at 40 degrees C; at 42.5 degrees C, there was increased toxicity. The increase in toxicity was similar for MCS of different ages. Upon simultaneous cis-platinum treatment, an increase in toxicity was observed at 40 degrees C, but only in older MCS. At 42.5 degrees C, an increased toxicity (relative to treatment at 37 degrees C) was observed in MCS of all ages. These results are, in general, similar to those described for other in vitro and in vivo systems, but emphasize the differences in the survival response which can result for treatment of human cancer cells in MCS of different ages over even a small size range (up to 1 mm diameter). This is much smaller than clinically detectable tumors. This reproducible human cancer cell multicellular spheroid model has great potential for representing the variability likely to be present in micrometastases of different sizes, and in small regions of solid tumors, and therefore for assisting in preliminary evaluation of combined modality protocols.

Pancreatic polypeptide. Release following surgery for duodenal ulcer disease

The pancreatic polypeptide (PP) response to food has been measured by radioimmunoassay in patients with duodenal ulcer and 3 months following proximal gastric vagotomy (PGV), 18 and 49 months following truncal vagotomy and pyloroplasty (TV), 35 months following Billroth II gastrectomy (BII), and 35 months following truncal vagotomy and antrectomy (TV&A). Basal PP levels and those in response to food were similar in DU and PGV, but these values were significantly higher than those 18 months or 49 months after TV, or after BII and TV&A. The responses in the latter four groups were similar and in particular, the levels 18 and 49 months after TV were the same. These results indicate that the release of PP by food in unoperated patients consists of two phases, a primary phase which requires both intact vagi and an intact stomach and a secondary phase which also depends on vagal innervation and normal gastric anatomy. Disturbances in vagal innervation or gastric integrity lead to profound changes in PP release which may be due to interruption of neural arcs or loss of gastric hormones. Unlike others, we have been unable to document a return of PP secretion towards normality with time after TV.

Serum gastrin after 12 months' continuous cimetidine therapy for duodenal ulcer

Serum immunoreactive gastrin was measured in 14 patients with duodenal ulcer before and during a 12-month course of cimetidine 400 mg bd. All patients were symptomatically well during the cimetidine therapy and both basal gastrin and that in response to a protein rich meal were assessed before, at six months and at 12 months during therapy. The basal and post-prandial gastrin were significantly higher at six and 12 months on cimetidine than before cimetidine but the six and 12 month levels were similar. This study thus shows that the progressive increase in serum gastrin during six months of continuous cimetidine therapy does not occur beyond this time period.

The effect of cimetidine on gastrin release in ulcer disease

The effect of a single dose of 400 mg of the H2-receptor antagonist cimetidine on protein meal stimulated immunoreactive gastrin was assessed in ten patients with gastric ulcer and ten patients with duodenal ulcer. In gastric ulcer patients, serum gastrin (mean +/- SE) rose from 34 +/- 2.2 pmol.l-1 to a peak of 80 +/- 5.0 pmol.l-1 at 45 minutes without and from 36 +/- 2.2 to 107 +/- 8.0 pmol.l-1 at 60 minutes with cimetidine; in duodenal ulcer it rose from 26 +/- 3.0 to 47 +/- 5.1 pmol.l-1 at 45 minutes without and 26 +/- 3.2 to 52 +/- 5.1 pmol.l-1 at 60 minutes with cimetidine. Integrated gastrin responses in gastric ulcer were 4900 +/- 800 pmol.l-1 120 minutes without and 7000 +/- 900 pmol.l-1 120 minutes with cimetidine and 1560 +/- 300 pmol.l-1 120 minutes without and 2620 +/- 400 pmol.l-1 120 minutes with cimetidine in duodenal ulcer patients. These gastrin increases after cimetidine are comparable to those achieved with continuous intragastric neutralisation with alkali.