Changes in industry interference in policy in the United Kingdom 2017-2020

Background

The Tobacco Industry Interference (TII) Index evaluates the implementation of FCTC Article 5.3. The first edition of the Global TII Index was published in 2019, included 33 countries, and covered the years 2017-2018. A second edition, covering 2018-2019, is scheduled to be published in October 2020. This paper reports on findings of the Index for the UK, the changes observed between 2017 and 2020, and the resulting policy recommendations.

Methods

The UK Index was based on a questionnaire covering different forms of tobacco industry interference. Lower scores indicate better compliance with Article 5.3. In order to complete the questionnaire, an expert consultation was conducted with UK's leading tobacco control specialists. This was supplemented by a scoping review of academic literature, media websites, government websites, and the Tobacco Tactics resource.

Results

In the 2019 Index the UK has achieved the lowest score among 33 countries surveyed. Strengths of the UK system included the exclusion of TI from government bodies that set public health policy and from FCTC COP delegations; the obligation of the government to publish information on all meetings with TI; and guidelines stipulating that its diplomats must not engage on behalf of TI. Nevertheless, weaknesses were also identified; including only partial implementation of the above obligations, the absence of an effective lobbying register, and the ongoing involvement of parliamentary consultative bodies, individual politicians and political parties with TI and affiliated organisations.

Discussion

The change of government in the UK in 2019, the shifting policy framework resulting from Brexit, and the increasing use by the tobacco industry of third parties to access policymakers, bring new challenges to the maintenance of robust Article 5.3 compliance. The presentation will analyse how this has affected the change in the UK's performance between the 2019 and the 2020 Tobacco Industry Interference Index.

Key messages

The need to strengthen transparency regulations for policymakers. A need for continued monitoring against an agreed framework in the light of very fluid political developments.

Interaction of a Plasmin A-Chain/t-PA B-Chain Hybrid Enzyme with Plasma Inhibitors In Vivo and In Vitro

A hybrid plasminogen activator consisting of the “A” chain of plasmin linked to the “B” chain of rt-PA was inhibited in vitro in human and guinea pig plasmas 4 to 5-fold more rapidly than its parent activator, two-chain t-PA. Using zymographic and autoradiographic techniques together with the use of immunodepleted plasma the major inhibitor was identified as aIpha-2-antiplasmin. The pharmacokinetic profile of the hybrid in guinea pigs was determined by two different methods: disappearance of fibrinolytic activity and removal of radiolabelled hybrid from the circulation. Fibrinolytic activity was cleared rapidly via inhibitory mechanisms, whilst radiolabelled material was cleared considerably more slowly due to the formation of hybrid-inhibitor complexes. When the active site of the hybrid was reversibly acylated inhibitory mechanisms were evaded and a prolonged pharmacokinetic profile of activity was observed.

A whole system approach to improving mortality associated with acute kidney injury

BACKGROUND

Acute kidney injury (AKI) is in the main managed by non-nephrologists, many who feel challenged by or lack awareness of the complexity that the renal element adds to their patients' care. National reports have raised major concerns about the quality of care and have predicted that mortality reductions of 30% are achievable with good medical practice.

AIM

This quality improvement project evaluated whether a whole system approach could improve outcomes for patients with AKI.

DESIGN AND METHODS

Quality improvement methodology was used to understand hospital patterns, processes and professional knowledge. Change concepts were developed which included management of patients at risk, staff education and awareness program, development of a patient specific electronic alert to prompt diagnosis, easy to remember care bundle (ABCDE-IT), dedicated outreach team and patient and family empowerment leaflet.

RESULTS

Statistical process control analysis was used to verify outcomes over time. A shift in the in-hospital mortality rate corresponded to a relative 23.2% reduction in mortality and was sustained over the next 33 months (P < 0.0001). The favourable shift in mortality was temporally distinct from the improved AKI detection rate. This timeframe corresponded to lying below the 99.8% lower confidence limit in comparison with all English acute trusts for comparative AKI specific SHMI/HSMR mortality rates. Length of stay also reduced shortly after onset of the project by 14.1% or 2.6 day reduction (P < 0.0001).

CONCLUSION

This project demonstrated that an integrated, whole-system approach is necessary to ensure sustained improvements in AKI mortality and length of stay.

The evolution of prenatal screening and diagnosis and its impact on an unselected population over an 18-year period

OBJECTIVE

To review changes in and impact of prenatal screening and diagnosis.

DESIGN

Population-based congenital anomaly register study.

SETTING

Oxfordshire.

POPULATION

Congenital anomalies confirmed and those suspected prenatally, delivered 1991-2008.

METHODS

Analysis of proportions of congenital anomalies confirmed and those suspected prenatally.

MAIN OUTCOME MEASURES

Birth prevalence, prenatal detection rates, pregnancy outcomes.

RESULTS

A total of 2651 (2.3%) infants/fetuses had a congenital anomaly diagnosed. There were 3839 suspected or confirmed cases, 2847 due to a prenatal suspicion, of which 1659 had an anomaly confirmed at delivery, and 1188 false-positive diagnoses, 91% due to reporting ultrasound normal variants. The percentage of prenatal notifications rose from 48% in 1991-93 to 83-88% from 1996 to 2003 and dropped to 61% in 2006-08, partly reflecting changes in the reporting of normal variants. Reporting these increased the prenatal diagnosis rate from 53 to 63% with an increase in false-positive rate from 0.09 to 1.04%. A total of 722 (44% of prenatally detected affected fetuses) resulted in termination; 48% of these had chromosome anomalies, 34% had isolated structural anomalies, 7% had multiple anomalies, 10% had familial disorders; 42% had lethal anomalies and 58% would probably have survived the neonatal period giving an estimated 20% reduction in birth prevalence of congenital anomalies compatible with survival because of terminations.

CONCLUSION

There has been an improvement in prenatal detection of congenital anomalies over the two decades studied. The recognition that reporting normal variants, although increasing prenatal detection rates, leads to an increase in false-positive diagnoses has had an impact on practice that has redressed the balance between these two effects.

Intra- and interobserver variability in fetal ultrasound measurements

OBJECTIVE

To assess intra- and interobserver variability of fetal biometry measurements throughout pregnancy.

METHODS

A total of 175 scans (of 140 fetuses) were prospectively performed at 14-41 weeks of gestation ensuring an even distribution throughout gestation. From among three experienced sonographers, a pair of observers independently acquired a duplicate set of seven standard measurements for each fetus. Differences between and within observers were expressed in measurement units (mm), as a percentage of fetal dimensions and as gestational age-specific Z-scores. For all comparisons, Bland-Altman plots were used to quantify limits of agreement.

RESULTS

When using measurement units (mm) to express differences, both intra- and interobserver variability increased with gestational age. However, when measurement of variability took into account the increasing fetal size and was expressed as a percentage or Z-score, it remained constant throughout gestation. When expressed as a percentage or Z-score, the 95% limits of agreement for intraobserver difference for head circumference (HC) were ± 3.0% or 0.67; they were ± 5.3% or 0.90 and ± 6.6% or 0.94 for abdominal circumference (AC) and femur length (FL), respectively. The corresponding values for interobserver differences were ± 4.9% or 0.99 for HC, ± 8.8% or 1.35 for AC and ± 11.1% or 1.43 for FL.

CONCLUSIONS

Although intra- and interobserver variability increases with advancing gestation when expressed in millimeters, both are constant as a percentage of the fetal dimensions or when reported as a Z-score. Thus, measurement variability should be considered when interpreting fetal growth rates.

An engineered solution to the maladministration of spinal injections

BACKGROUND

An overview is provided of the progress made in a Department of Health (DH) initiative to implement an engineered solution to the maladministration of spinal injections. In an effort to eliminate the possibility of misconnection errors at the spinal route, the DH is investigating the potential for dedicated spinal equipment that will be incompatible with standard Luer syringes, needles and associated devices.

METHOD

Background information on the problem of misconnection errors is provided and a systematic approach to their eradication is detailed. Research to date has entailed extensive bench-testing of prototype non-Luer connectors, a prospective hazard analysis of spinal procedures in haematology and anaesthesia and usability evaluation of prototype non-Luer devices in simulated environments.

RESULTS

The prospective hazard analysis identified two potential risks which will need to be managed as part of a successful implementation programme.

CONCLUSION

Usability testing of two prototype connection systems concluded that one design was inadequate, as the non-Luer element was provided as a separable adapter. The second connection system was modified following the first round of testing, and achieved improved satisfaction ratings from clinicians in round two. This system was selected to proceed to a pre-implementation evaluation and the research team are currently evaluating its acceptability in clinical use.

Congenital myotonic dystrophy: prenatal ultrasound findings and pregnancy outcome

OBJECTIVE

The objective of this study was to assess the maternal and prenatal ultrasound findings and outcome in pregnancies complicated by congenital myotonic dystrophy Type 1 (DM1).

METHODS

A retrospective chart review of all patients with a diagnosis of DM1 and pregnancy presenting to the Oxford Radcliffe Hospital between 1990 and 2004 was undertaken. Obstetric case notes were reviewed and details of all pregnancies obtained. This included data on prenatal diagnostic tests and obstetric ultrasound scans performed as well as pregnancy complications and pregnancy outcome. Maternal and fetal CTG expansion size was also recorded where available. Maternal genetic case notes were reviewed for details of maternal grip myotonia.

RESULTS

Sixty pregnancies among 26 couples in which one of the parents was a carrier of DM1 were identified during the study period. These resulted in 36 (60%) pregnancies affected by congenital DM1 and 19 (31.7%) unaffected pregnancies. There were four miscarriages and one termination of pregnancy for non-medical reasons. Nineteen of the 36 affected pregnancies ended in termination following the antenatal diagnosis of congenital DM1 by either chorionic villus sampling (CVS) or amniocentesis. In the remaining 17 affected pregnancies (16 singleton and one twin) there was one miscarriage of an affected fetus with co-existing Down syndrome and eight perinatal deaths. The principal cause of perinatal death was respiratory failure in the early neonatal period. Antenatally noted clinical/sonographic abnormalities in these pregnancies included polyhydramnios (100%), talipes (26.6%) and borderline ventriculomegaly (13.3%). Uni- or bilateral talipes was noted at delivery in 10 of 16 (62.5%) neonates. Maternal grip myotonia was present in all but one of these cases.

CONCLUSION

The antenatal findings of polyhydramnios and talipes should prompt a search for maternal grip myotonia. If present, definitive testing for congenital DM1 should be considered.

Follow-up of children with isolated fetal echogenic bowel with particular reference to bowel-related symptoms

OBJECTIVES

To determine whether there was any evidence of long-term bowel pathology in children, apparently healthy at birth, who had a prenatal second-trimester diagnosis of isolated grade 2 fetal echogenic bowel.

METHODS

This was a retrospective study using data from the Oxford Congenital Anomaly Register. Fetuses with isolated grade 2 fetal echogenic bowel and date of delivery from 1994 to 2000 inclusive were identified. Information about the health of the children, particularly relating to bowel symptoms, was obtained from hospital records and from a questionnaire sent to the general practitioner.

RESULTS

A total of 109 cases were identified, with delivery details available for 108. There was one unexplained intrauterine death, and additional problems were subsequently diagnosed in four cases (cystic fibrosis (2), Down syndrome (1), and VACTERL (1)). Questionnaires were sent to the GPs of the 103 who had no problems identified at the time of discharge from the maternity hospital. Age at follow-up ranged from one to four years. Responses to the questionnaires were received from 83 (81%). Of these, 74 (89%) had not reported bowel symptoms to the GP, 9 (11%) reported symptoms relating to constipation (6), chronic abdominal pain (1), infantile colic with milk intolerance (1) and gastro-oesophageal reflux (1).

CONCLUSION

This small study provides some reassurance that there was no evidence of any serious long-term bowel pathology associated with isolated fetal echogenic bowel.

The usefulness of ultrasound assessment of amniotic fluid in predicting adverse outcome in prolonged pregnancy: a prospective blinded observational study

OBJECTIVE

To determine whether a single ultrasound scan at or beyond 40 weeks of gestation to detect a single deepest pool of amniotic fluid <2 cm and amniotic fluid index (AFI) <5 cm is clinically useful in the prediction of subsequent adverse pregnancy outcome.

DESIGN

A prospective double blind cohort study.

SETTING

A university teaching hospital delivering approximately 6000 women annually.

POPULATION

One thousand and five hundred and eighty-four pregnant women at or beyond 40 weeks of gestation.

METHODS

Ultrasound assessment of liquor to detect the single deepest pool of amniotic fluid and derive the AFI at or after 40 weeks of gestation.

MAIN OUTCOME MEASURES

Perinatal death, meconium aspiration, birth asphyxia, intervention in labour for fetal distress, a cord arterial pH <7 and admission to the neonatal unit.

RESULTS

An AFI <5 cm but not a single deepest pool <2 cm was significantly associated with birth asphyxia or meconium aspiration. An AFI <5 cm was also significantly associated with caesarean section for fetal distress in labour, a cord arterial pH <7 at delivery and low Apgar scores. Despite there being a statistically significant association with adverse outcomes the sensitivity of AFI was low at 28.6%, 12% and 11.5% for major adverse outcome, fetal distress in labour or admission to the neonatal unit, respectively.

CONCLUSIONS

The AFI is superior to a measure of the single deepest pool as an assessment of the fetus at or after 40 weeks but has a poor sensitivity for adverse pregnancy outcome. Routine use is likely to lead to increased obstetric intervention without improvement in perinatal outcomes.

An overview of scientific and regulatory issues for the immunogenicity of biological products

Immunogenicity of biological products can occur pre-clinically and clinically when products elicit immune responses in animals or humans receiving the products. This is a concern for manufacturers, regulatory agencies and clinicians as immune responses can result in effects on product effectiveness and safety. The clinical sequelae of immunogenicity range from no effects to serious, life-threatening syndromes. However, although many biological products are immunogenic to some extent, it is quite rare that immunogenicity leads to serious adverse events. Whilst there are methods to detect immunogenicity, they currently rely on detecting the humoral rather than the cellular response of the immune system. The design and validation of assays such as immuno-assays and bio-assays are critical for a meaningful assessment of immunogenicity. There are a growing number of computational and laboratory-based methods for the prediction of immunogenicity, as well as methods to reduce potential immunogenicity and these may lead to less immunogenic biological products in future.

Structural mechanisms of drug resistance for mutations at codons 181 and 188 in HIV-1 reverse transcriptase and the improved resilience of second generation non-nucleoside inhibitors

Mutations at either Tyr181 or Tyr188 within HIV-1 reverse transcriptase (RT) give high level resistance to many first generation non-nucleoside inhibitors (NNRTIs) such as the anti-AIDS drug nevirapine. By comparison second generation inhibitors, for instance the drug efavirenz, show much greater resilience to these mutations. In order to understand the structural basis for these differences we have determined a series of seven crystal structures of mutant RTs in complexes with first and second generation NNRTIs as well as one example of an unliganded mutant RT. These are Tyr181Cys RT (TNK-651) to 2.4 A, Tyr181Cys RT (efavirenz) to 2.6 A, Tyr181Cys RT (nevirapine) to 3.0 A, Tyr181Cys RT (PETT-2) to 3.0 A, Tyr188Cys RT (nevirapine) to 2.6 A, Tyr188Cys RT (UC-781) to 2.6 A and Tyr188Cys RT (unliganded) to 2.8 A resolution. In the two previously published structures of HIV-1 reverse transcriptase with mutations at 181 or 188 no side-chain electron density was observed within the p66 subunit (which contains the inhibitor binding pocket) for the mutated residues. In contrast the mutated side-chains can be seen in the NNRTI pocket for all seven structures reported here, eliminating the possibility that disordering contributes to the mechanism of resistance. In the case of the second generation compounds efavirenz with Tyr181Cys RT and UC-781 with Tyr188Cys RT there are only small rearrangements of either inhibitor within the binding site compared to wild-type RT and also for the first generation compounds TNK-651, PETT-2 and nevirapine with Tyr181Cys RT. For nevirapine with the Tyr188Cys RT there is however a more substantial movement of the drug molecule. We conclude that protein conformational changes and rearrangements of drug molecules within the mutated sites are not general features of these particular inhibitor/mutant combinations. The main contribution to drug resistance for Tyr181Cys and Tyr188Cys RT mutations is the loss of aromatic ring stacking interactions for first generation compounds, providing a simple explanation for the resilience of second generation NNRTIs, as such interactions make much less significant contribution to their binding.

Prenatal diagnosis of an epignathus: a case report and review of the literature

An epignathus is an extremely rare form of teratoma that arises from the oral cavity, most commonly from the palate. We describe a case identified sonographically at 17 weeks' gestation after a raised maternal serum alpha-fetoprotein was recorded. This pregnancy was terminated but we review the literature over the last 10 years and describe the management options available in such cases.

Preventive intervention for maltreated preschool children: impact on children's behavior, neuroendocrine activity, and foster parent functioning

OBJECTIVE

This article describes the results of a pilot study that evaluated the effectiveness of the Early Intervention Foster Care (EIFC) program in the period immediately following a child's placement in a new foster home.

METHOD

Data were collected from an EIFC group, a regular foster care group, and a community comparison group-each with 10 participants-via questionnaires for children and their caretakers and salivary cortisol sampling.

RESULTS

EIFC foster parents adopted and maintained positive parenting strategies, EIFC children's behavioral adjustment improved, and changes occurred in several salivary cortisol measures. Moreover, regular foster care children exhibited decrements in functioning in several areas over the same time period.

CONCLUSIONS

Results are discussed with regard to how such research fits into a larger program of prevention research for high-risk preschool children.

Megacystis-microcolon-intestinal hypoperistalsis syndrome: the difficulties with antenatal diagnosis. Case report and review of the literature

Megacystis on antenatal scan in female fetuses is rare and has serious diagnostic implications. We report two cases of megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) in female infants in whom antenatal scan abnormalities were identified, but the diagnosis not made until after delivery. MMIHS is a rare autosomal recessive condition which is usually lethal in the first year of life. Prenatal diagnosis is hampered by the lack of specific diagnostic findings on ultrasound and the absence of an identified genetic locus. The prenatal findings in MMIHS are reviewed and contrasted with those of other causes of lower abdominal masses on antenatal ultrasound.

Five cases of brain injury following amniocentesis in mid-term pregnancy

This paper describes the neuroimaging and neuropathological findings in five cases of severe brain damage after traumatic mid-trimester amniocentesis, all performed between 1986 and 1994. Although fetal injury after amniocentesis has been reported, reports of brain injury are infrequent. Continuous ultrasound monitoring may reduce the risk of fetal injury but follow-up ultrasound scans can be falsely reassuring. Withdrawal of blood-stained fluid, particularly if it contains tissue fragments, should alert the operator to the possibility of fetal damage. Histological examination of such tissue fragments may confirm the nature of the fetal damage. The consequences of fetal brain injury are severe, all five of our cases showed evidence of disruption of brain development compatible with mid-term injury. Obstetricians and their patients should be aware of the small but significant risk of brain damage after mid-term amniocentesis.

Lipoprotein-associated phospholipase A(2), platelet-activating factor acetylhydrolase: a potential new risk factor for coronary artery disease

A specific and robust immunoassay for the lipoprotein-associated phospholipase A(2) (Lp-PLA(2)), platelet-activating factor acetylhydrolase, is described for the first time. The immunoassay was used to evaluate possible links between plasma Lp-PLA(2) levels and atherosclerosis risk amongst susceptible individuals. Such an investigation was important because Lp-PLA(2) participates in the oxidative modification of low density lipoprotein by cleaving oxidised phosphatidylcholines, generating lysophosphatidylcholine and oxidised free fatty acids. The majority of Lp-PLA(2) was found associated with LDL (approximately 80%) and, as expected, enzyme levels were significantly positively correlated to LDL cholesterol. Plasma Lp-PLA(2) levels were significantly elevated in patients with angiographically proven coronary artery disease (CAD) when compared with age-matched controls, even though LDL cholesterol levels did not differ significantly. Indeed, when included in a general linear model with LDL cholesterol and other risk factors, Lp-PLA(2) appeared to be an independent predictor of disease status. We propose, therefore, that plasma Lp-PLA(2) mass should be viewed as a potential novel risk factor for CAD that provides information related to but additional to traditional lipoprotein measurements.

Congenital diaphragmatic hernia: prenatal diagnosis, outcome and continuing morbidity in survivors

OBJECTIVE

To improve counselling by investigating the prenatal diagnosis, outcome and morbidity in survivors of congenital diaphragmatic hernia.

SETTING

Prenatal Diagnosis Unit, Oxford Radcliffe Women's Centre, Oxford.

DESIGN

Cohort study.

SAMPLE

Babies with congenital diaphragmatic hernia diagnosed postnatally and born to women scanned prenatally identified between January 1991 and December 1996.

METHODS

Associated anomalies, outcome of pregnancy and final diagnoses were determined from hospital records. A report from the general practitioner and paediatrician recorded health and development information.

MAIN OUTCOME MEASURES

Accuracy of prenatal diagnosis, survival of cases of congenital diaphragmatic hernia and presence of ongoing morbidity in survivors.

RESULTS

There were 35 pregnancies with congenital diaphragmatic hernia, nine of which were not diagnosed prenatally. In 22 pregnancies with isolated congenital diaphragmatic hernia, four were terminated, there were six perinatal deaths and two later deaths. Thirteen of 35 cases (37%) with congenital diaphragmatic hernia were associated with other abnormalities: four with abnormal karyotype and nine with other structural anomalies. Five of these women continued with their pregnancy; there were two neonatal deaths and three survivors. Thirteen of 35 infants (37%) survived, eight with chronic disorders requiring specialist intervention including respiratory problems (n = 6); developmental delay (n = 4); poor growth (n = 5); artificial feeding (n = 3); gastro-oesophageal reflux (n = 3); recurrent hospital admissions (n = 6); and further surgery (n = 4).

CONCLUSIONS

The survival for infants born alive with congenital diaphragmatic hernia was 56% (13/23), 61% of whom have persistent disorders. Despite advances in neonatology there is a high mortality and morbidity with congenital diaphragmatic hernia. Prenatal counselling should reflect this.

Amniotic fluid concentrations of dimeric inhibins, activin A and follistatin in pregnancy

OBJECTIVE

The feto-placental unit is the major source of circulating concentrations of inhibin A and activin A in human pregnancy. The aim of this study was to measure the amniotic fluid concentrations of inhibin A, inhibin B, activin A and follistatin in pregnancies bearing male and female fetuses.

DESIGN AND METHOD

Amniotic fluid samples collected by amniocentesis were stored at -20 degrees C. Dimeric inhibins, 'total' activin A and 'total' follistatin were measured using specific two-site enzyme immunoassays. Samples were assayed blindly and the information on fetal sex was obtained from the cytogenetics laboratory.

RESULTS

Data show that amniotic fluid concentrations of inhibin A, inhibin B and activin A gradually increase with gestation whilst concentrations of follistatin are similar between weeks 15 and 20 of pregnancy. Mean amniotic fluid levels of inhibin A and inhibin B at 16 and 17 weeks gestation and mean activin A levels at 15 and 16 weeks gestation are considerably lower in pregnancies with male (n=24) compared with female (n=28) fetuses. Levels of follistatin are not different in the male and female fetal pregnancies at any studied gestation.

CONCLUSIONS

The results indicate that amniotic fluid contains high concentrations of inhibins (A and B), activin A and follistatin in early pregnancy suggesting that these hormones are produced by the fetal membranes and may be involved in the development of the fetus.

6-year experience of prenatal diagnosis in an unselected population in Oxford, UK

BACKGROUND

The benefits and harm associated with prenatal diagnosis are open to debate. We give a 6-year overview of the experience of one prenatal-diagnosis unit using a defined, unselected population.

METHODS

All congenital malformations suspected prenatally and all congenital malformations, including chromosome anomalies, confirmed at birth were identified from the local Congenital Malformation Register. All fetuses or infants of women booked for delivery at the Oxford Women's Centre who had an OX postcode and date of delivery between 1991 and 1996 were eligible for the study.

FINDINGS

725 (2%) of 33,376 babies, were judged abnormal at delivery. 396 (55%) malformed fetuses and infants had been correctly identified prenatally. 174 fetuses had a suspected abnormality identified on scan and subsequently proved to be normal. 160 (92%) of these false-positive results were attributable to the reporting of so called ultrasound soft markers. Accuracy of ultrasound diagnosis was good for structural malformations. Ultrasound soft markers were responsible for a 4% increase in detection of malformations (from 51% to 55%) and a 12-fold increase in false-positive rate (one in 2332 to one in 188). 171 pregnancies (43% of prenatally diagnosed malformed babies) were terminated because of suspected abnormality. Suspicion of abnormality in these cases was first aroused after ultrasound scan in 136 (79%); chromosome analysis because of advanced maternal age, family history, or higher risk in biochemical screening test in 25 (15%); and molecular analysis of single gene defect because of family history in ten (6%). There was a 20% reduction in prevalence of conditions compatible with survival beyond the neonatal period because of termination of such pregnancies.

INTERPRETATION

More than half of all malformed fetuses can be identified prenatally in routine practice, mostly following initial suspicion from ultrasound examination. Ultrasound soft markers lead to a small increase in detection of malformations but a large increase in false positives. Further research on the impact, including psychological, and value of markers is required to determine whether the benefits of reporting them exceeds the harm. Because methods and techniques continually change, ongoing surveillance of prenatal diagnostic services is vital.

Comparison of two community alternatives to incarceration for chronic juvenile offenders

The relative effectiveness of group care (GC) and multidimensional treatment foster care (MTFC) was compared in terms of their impact on criminal offending, incarceration rates, and program completion outcomes for 79 male adolescents who had histories of chronic and serious juvenile delinquency. Results show that boys who participated in MTFC had significantly fewer criminal referrals and returned to live with relatives more often. Multiple regression analyses showed that assignment to a treatment condition (i.e., GC or MTFC) predicted official and self-reported criminality in follow-up beyond other well-known predictors of chronic juvenile offending (i.e., age at 1st offense, number of previous offenses, age at referral).

Comparison of two community alternatives to incarceration for chronic juvenile offenders

The relative effectiveness of group care (GC) and multidimensional treatment foster care (MTFC) was compared in terms of their impact on criminal offending, incarceration rates, and program completion outcomes for 79 male adolescents who had histories of chronic and serious juvenile delinquency. Results show that boys who participated in MTFC had significantly fewer criminal referrals and returned to live with relatives more often. Multiple regression analyses showed that assignment to a treatment condition (i.e., GC or MTFC) predicted official and self-reported criminality in follow-up beyond other well-known predictors of chronic juvenile offending (i.e., age at 1st offense, number of previous offenses, age at referral).

Outcome of prenatally diagnosed anterior abdominal wall defects

One hundred consecutive cases of confirmed anterior abdominal wall defect, identified prenatally in the Oxford Prenatal Diagnosis Unit over 11 years, were studied. Fifty nine per cent of cases were suspected omphaloceles and 41% suspected gastroschisis. Fifty four per cent of omphaloceles were accompanied by other defects compared with 5% of those with gastroschisis. Overall, 29% of fetuses with omphalocele had an abnormal karyotype, and of those with another abnormality identified on scan (excluding four cases with no karyotype performed), 54% had an abnormal karyotype. Of the 27 cases with suspected isolated omphalocele, 14 were live born, all of whom have survived. If the 11 whose parents opted for termination of pregnancy are excluded, survival to birth was 88%. Six of the suspected isolated omphaloceles have Beckwith Wiedemann syndrome (BWS). Eight (57%) of the live born babies with omphaloceles had major problems up to the age of 2, but only one (7%) has long term major problems. This child has BWS and is deaf. Of the 39 cases of suspected isolated gastroschisis, 33 (85%) pregnancies resulted in live birth and one in neonatal death after surgery. Survival rate (excluding terminated pregnancies) was 97%. Gastroschisis was associated with a younger maternal age than omphalocele (p < 0.001) and lower birthweight centile (p < 0.01). Fifteen per cent of the gastroschisis babies had major problems up to the age of 2 years and 12% long term developmental problems. Ninety three per cent of the omphalocele babies and 88% of those who had gastroschisis have no long term problems. Over the study period there have been major changes in scanning equipment and expertise. Since 1991 no woman with a suspected isolated lesion has opted for termination of pregnancy.

Prenatal sonographic diagnosis of skeletal dysplasias--a report of the diagnostic and prognostic accuracy in 35 cases

Sonographic assessment of the skeleton is a routine part of fetal anomaly scanning. We report a series of 35 cases seen during a 7-year interval in which a skeletal dysplasia was suspected prenatally. In seven (20 per cent) of the 35 cases, a specific diagnosis could not be made either pre- or postnatally. Follow-up was incomplete in one case. In 32 (91 per cent) of the 35 cases, prenatal sonographic examination correctly predicted the prognosis, although in only 11 (31 per cent) of the 35 cases was the suggested prenatal diagnosis proven to be correct. The difficulty of making an accurate prenatal sonographic diagnosis in fetuses with suspected skeletal dysplasias throughout gestation, especially in the third trimester, and the importance of comprehensive multidisciplinary postnatal assessment in these cases are emphasized.

Conducting ecologically valid prevention research: recruiting and retaining a "whole village" in multimethod, multiagent studies

Many prevention studies are now designed with complementary interventions in different settings. Evaluations of these interventions require assessing the child's behavior in each of these settings. Conducting these studies, therefore, may involve recruiting school districts, principals, classroom teachers, peers, parents, siblings, and in later years, employers and intimate partners. These participants may be considered natural raters or satellite subjects, depending on their degree of involvement. Issues of recruitment and retention thus are magnified in multimethod, multiagent studies. To illustrate these issues, findings are presented for three studies conducted with risk populations in the past decade at the Oregon Social Learning Center: a passive longitudinal study, a selected prevention study, and an indicated prevention study. Findings indicate that achieving high recruitment and retention rates for at-risk and high-risk subjects in multisetting studies is possible, and that a developmental approach should be taken to recruiting risk populations.

Uterine cavity assessment prior to in vitro fertilization: comparison of transvaginal scanning, saline contrast hysterosonography and hysteroscopy

A total of 44 patients undergoing in vitro fertilization (IVF) and requiring uterine cavity assessment agreed to have both saline contrast hysterosonography (SCHS) and hysteroscopy. SCHS was performed following a baseline transvaginal scan by injection of saline into the uterine cavity during continuous scanning. Hysteroscopy was performed with a flexible fiberscope with a 3.6-mm outer diameter; 38 of 44 women (86%) underwent both procedures. Hysteroscopy diagnosed intrauterine abnormalities in 16 women. SCHS was in complete agreement in 13 of 16 cases. As a screening test for any cavity abnormality, SCHS had a 87.5% sensitivity, 100% specificity, 100% positive predictive value and 91.6% negative predictive value. In 14 women, an abnormal uterine cavity was apparent on transvaginal scanning (TVS). However, TVS, unlike SCHS, could not (1) confidently diagnose submucosal fibroids in the presence of a uterus with multiple fibroids; (2) distinguish between a hyperplastic endometrium and a large polyp; or (3) differentiate between an arcuate and a septate uterus. In addition, ovarian pathology was diagnosed on TVS in five women: endometrioma (n = 1), complex cysts (n = 2) and polycystic ovaries (n = 2). SCHS is a simple, accurate, well-tolerated procedure that can be performed within a fertility unit, avoiding invasive and expensive diagnostic hysteroscopy. Significant findings can be treated by operative hysteroscopy prior to commencing an IVF treatment cycle.

Is routine diagnostic laparoscopy for infertility still justified? A pilot study assessing the use of hysterosalpingo-contrast sonography and magnetic resonance imaging

We assessed the value of hysterosalpingo-contrast sonography (HyCoSy) and magnetic resonance imaging (MRI) as alternatives to laparoscopy and dye insufflation with or without hysteroscopy in the investigation of infertility. A total of 19 women had all three procedures, in addition, one became pregnant after HyCoSy alone. The findings were: uterine fibroids (n = 5), minimal-mild endometriosis (n = 4) and moderate-severe endometriosis (n = 3) including one case of bilateral endometriomas, endometrial polyp (n = 1), polycystic ovaries (n = 2), bilateral dermoid cysts (n = 1), haemorrhagic corpus luteal cyst (n = 1) and minimal adhesions (n = 3). At laparoscopy, 31/37 tubes were patent and there was 84% concordance with the tubal patency findings at HyCoSy. The uterine fibroids and ovarian cysts were detected using transvaginal scanning; the endometrial polyp and a congenital uterine anomaly were identified using HyCoSy. These findings were detected using MRI, but in addition the technique distinguished the dermoid cysts from the endometriomas, identified the two other cases of moderate-severe endometriosis, fibroids <2 cm (n = 2) and adenomyosis (n = 5), and interpreted the haemorrhagic corpus luteum as an endometrioma. Our data suggest that women with normal HyCoSy and MRI findings have a normal pelvis and may not need routine surgical investigation.

Contrast sonography for uterine cavity assessment: a comparison of conventional two-dimensional with three-dimensional transvaginal ultrasound; a pilot study

OBJECTIVE

To compare conventional two- (2-D) and three-dimensional (3-D) scanning of the uterine cavity with and without saline contrast medium.

DESIGN

Observational pilot study.

SETTING

University-based fertility service.

PATIENT(S)

Ten IVF patients requiring uterine cavity assessment.

INTERVENTION(S)

Two-dimensional and 3-D transvaginal scans before and after injection of saline into the uterine cavity.

MAIN OUTCOME MEASURE(S)

Number and type of uterine cavity abnormalities detected by each technique.

RESULT(S)

The 2-D scanning suggested cavity abnormalities in 4 of 10 women (fibroids, 3; hyperechoeic thick endometrium, 1). The 3-D scanning confirmed these and revealed one additional abnormality suggestive of a uterine septum. The 2-D scanning with saline injection diagnosed abnormalities in 5 of 10 (uterine septum, 1; fibroids, 3; endometrial polyp, 1). The 3-D contrast scanning with saline did not add any further information to 2-D contrast scanning with saline.

CONCLUSION(S)

In this pilot study, 3-D scanning to assess the uterine cavity appeared to offer no advantages over conventional 2-D contrast sonography.

Hysterosalpingo-contrast sonography (HyCoSy) using Echovist-200 in the outpatient investigation of infertility patients

This study describes the introduction of hysterosalpingo-contrast sonography (HyCoSy) as a first line outpatient investigation of uterine and tubal factors in two fertility units. 136 infertile women had transvaginal scanning before and during the intrauterine injection of contrast medium (Echovist-200). HyCoSy was successfully completed in 132 cases (97%) within a mean time of 12.6 +/- 8.4 (4-50) min. The uterus and its cavity appeared normal in 108 (82%) women. Uterine abnormalities in the remaining 24 women (18%) included structural abnormality (n = 7), fibroids (n = 12) and endometrial polyps (n = 5). A total of 261 fallopian tubes in 132 women were assessed: 186 (71%) appeared patent and 55 (21%) blocked. The remaining 20 (8%) could not be assessed for technical reasons. Polycystic ovaries and ovarian cysts were diagnosed in eight women. The most common adverse effect was mild/moderate pain, similar to period pain, with 24 (18%) women requiring simple analgesia. HyCoSy is a simple and well tolerated outpatient procedure. The technique provides clinically valuable information about tubal patency, ovarian and uterine abnormalities.

Omphalocele and pericardial effusion: possible sonographic markers for the pentalogy of Cantrell or its variants

BACKGROUND

The pentalogy of Cantrell consists of defects involving the diaphragm, abdominal wall, pericardium heart, and lower sternum.

CASES

We report three cases of the pentalogy of Cantrell (variant form), involving an omphalocele complicated by an anterior diaphragmatic hernia. In two cases, a pericardial effusion was noted at antenatal scanning; the case without a pericardial effusion had an intact diaphragmatic pericardium at surgical repair.

CONCLUSION

The presence of a pericardial effusion in association with an omphalocele should prompt a detailed search for other features of the pentalogy of Cantrell or its variants.

Antenatal diagnosis of a late abdominal pregnancy using ultrasound and magnetic resonance imaging: a case report of successful outcome

A case of an advanced abdominal pregnancy diagnosed by ultrasound and magnetic resonance imaging (MRI) at 21 weeks' gestation is presented. The complementary roles of ultrasound and MRI in achieving accurate diagnosis and the role of ultrasound in ongoing pregnancy assessment are emphasized.

A comparison of patient tolerance of hysterosalpingo-contrast sonography (HyCoSy) with Echovist-200 and X-ray hysterosalpingography for outpatient investigation of infertile women

The aim of this study was to assess patient tolerance of two outpatient tests. Sixty-six infertile women were prospectively randomized to hysterosalpingo-contrast sonography (HyCoSy) (n = 34) or X-ray hysterosalpingography (HSG) (n = 32). The procedures were performed by the same operator. The uterine cavity outline and tubal patency were determined by both procedures. The mean times taken and the volume of contrast medium required for HyCoSy and HSG were similar: 12.1 +/- 5.2 and 9.5 +/- 4.8 min and 9.4 +/- 5.2 and 11.5 +/- 8.4 ml, respectively. Side-effects were assessed during the procedure, at 2 h, 24 h and 28 days. The most common side-effect was pelvic pain, in 56/66 (84%) women, occurring during the procedures (HyCoSy 19/34 (56%); HSG 23/32 (72/%)) and/or in the following 24 h (HyCoSy 14/34 (41%); HSG 15/32 (47%)). This was described as less severe or equal to their usual period pains (HyCoSy 100%; HSG 85%). Only 12/66 (18%) women required simple non-steroidal analgesia (HyCoSy 8/34 (24%); HSG 4/32 (13%)). There were no significant differences between the two methods concerning the frequency or severity of pains at different stages during and after the procedure or analgesia requirements. HyCoSy and HSG are equally well tolerated outpatient procedures for assessing tubal patency and uterine abnormalities. In addition, HyCoSy avoids the risks of ovarian irradiation and allows scanning of the uterine corpus and ovaries at the same time.

Antenatal diagnosis of cystic hygroma or nuchal pad--report of 92 cases with follow up of survivors

Information on the outcome of pregnancy was collected on 92 fetuses with cystic hygroma or nuchal pad, identified prenatally. Forty three (47% of the total) were associated with abnormal karyotype. Twenty five (27%) had normal karyotype but an additional abnormality was identified on ultrasound scan. There were 10 liveborn babies in this group of whom seven had significant problems postnatally. In twenty four (26%) cases the cystic hygroma or nuchal pad was an isolated finding. Seventeen (89% of those in which the pregnancy was electively continued) were liveborn and reported to be normal. Those with a normal karyotype, no other anomaly identified on antenatal scan, and smaller non-septate lesions have a good prognosis.

Generation and characterization of monoclonal antibodies to human type-5 tartrate-resistant acid phosphatase: development of a specific immunoassay of the isoenzyme in serum

We have characterized four monoclonal antibodies (mAbs) to the purple ("tartrate-resistant," band 5) acid phosphatase of the human osteoclast (TRAP) and used these to develop a specific serum immunoassay. All four mAbs are of high affinity (Ka = 1-5 x 10(8) L/mol) with a very fast Kassoc (0.2-2.0 x 10(5) L mol-1 s-1) and a moderate Kdissoc (1-3 x 10(-3) s). Two of the mAbs were selected to develop a time-resolved fluorescence immunoassay to measure serum concentrations of TRAP. The mean serum immunoreactive TRAP in a group of healthy premenopausal women and men was 3.7 +/- 1.8 micrograms/L (mean +/- SD) and 3.5 +/- 1.6 micrograms/L, respectively. Significantly higher concentrations of TRAP were found in postmenopausal women (6.3 +/- 2.3 micrograms/L) and in eight patients with Gaucher disease (19.3 +/- 4.7 micrograms/L). Further studies are required to investigate the value of serum TRAP as a marker of bone resorption.

Generation and characterization of monoclonal antibodies to human type-5 tartrate-resistant acid phosphatase: development of a specific immunoassay of the isoenzyme in serum

We have characterized four monoclonal antibodies (mAbs) to the purple ("tartrate-resistant," band 5) acid phosphatase of the human osteoclast (TRAP) and used these to develop a specific serum immunoassay. All four mAbs are of high affinity (Ka = 1-5 x 10(8) L/mol) with a very fast Kassoc (0.2-2.0 x 10(5) L mol-1 s-1) and a moderate Kdissoc (1-3 x 10(-3) s). Two of the mAbs were selected to develop a time-resolved fluorescence immunoassay to measure serum concentrations of TRAP. The mean serum immunoreactive TRAP in a group of healthy premenopausal women and men was 3.7 +/- 1.8 micrograms/L (mean +/- SD) and 3.5 +/- 1.6 micrograms/L, respectively. Significantly higher concentrations of TRAP were found in postmenopausal women (6.3 +/- 2.3 micrograms/L) and in eight patients with Gaucher disease (19.3 +/- 4.7 micrograms/L). Further studies are required to investigate the value of serum TRAP as a marker of bone resorption.

Innovative culture shock prescribed for health care

Finally, organizations must accept that inefficiencies are often present in creative cultures. Resources that were devoted to operating and revenue-generating functions must be shifted to finance the capacity to be creative. The short-term focus of today's organizations blinds them from envisioning the long-term benefits of fostering creative changes and improvements. When creativity is properly managed, meaningful risks may be taken with reasonable costs occasionally yielding monumental results.