Migraine and preterm birth.

OBJECTIVE: To investigate whether maternal migraine was associated with preterm birth. STUDY DESIGN: Case-control sample within a population-based study of risk factors for cerebral palsy (CP). Infants without CP were matched for gestational age with those with CP. Maternal migraine was self-identified at first prenatal visit, most in the first trimester. RESULT: Infants without CP born to women with migraine had a higher rate of preterm birth (odds ratio (OR)=3.5, 95% confidence interval (CI) 1.5, 8.5), as did infants who died in the perinatal period (OR=7.3, 95% CI 0.98, 54), the difference marginal for nominal statistical significance. In all outcome groups, infants of women with migraine had a higher observed rate of suboptimal intrauterine growth. In term infants, the rate of maternal migraine was higher in those with CP than in controls (OR=2.18, 95% CI 0.92, 5.25). Pre-eclampsia was reported more frequently in women with migraine who gave birth to a child with CP or a perinatal death, particularly in those born preterm; OR=5.1 (1.3, 20) and OR=2.9 (1.1, 7.6), respectively, but not in women giving birth to a control whether term or preterm. CONCLUSION: Maternal migraine, as self-reported early in pregnancy, was associated with preterm birth in survivors without CP and in infants who died in the perinatal period. The combination of maternal migraine and pre-eclampsia was associated with CP and perinatal death. The association of maternal migraine with outcomes of pregnancy warrants further study.

Perinatal and postneonatal mortality among Indigenous and non-Indigenous infants born in Western Australia, 1980-1998.

OBJECTIVE: To describe cause-specific perinatal and postneonatal mortality for Indigenous and non-Indigenous infants using a new classification system. DESIGN: Total population retrospective cohort study. PARTICIPANTS AND SETTING: All registered births in Western Australia of birthweight greater than 399 g from 1980 to 1998, inclusive. MAIN OUTCOME MEASURES: Rates and time trends for all births 1980-1998, and cause-specific rates for births 1980-1993 of fetal, neonatal and postneonatal mortality among Indigenous and non-indigenous infants, using a classification system designed for use in perinatal, postneonatal and childhood deaths. RESULTS: For Indigenous infants born 1980-1998, the mortality rate before the first birthday was 2.7 times (95% CI, 2.5-2.9 times) that for non-Indigenous infants. Indigenous infants born 1980-1993 had a higher mortality rate in all cause-of-death categories. The highest relative risk was for deaths attributable to infection (8.1; 95% CI, 6.5-10.0) which occurred primarily in the postneonatal period; the source of the infection was less likely to be identified in Indigenous deaths. From 1980-1998, the rate of neonatal deaths decreased at a greater rate for Indigenous than for non-Indigenous infants. However, while stillbirth and sudden infant death syndrome rates for non-Indigenous births fell, they remained static for Indigenous births. CONCLUSIONS: The new classification system, which considers the underlying rather than immediate cause of death, enables investigation of the causes of all deaths, from stillbirths to childhood. This system has highlighted the comparative importance of infection as a cause of death for Indigenous infants, particularly in the postneonatal period.

The effect of botulinum toxin type A on the functional ability of the child with spastic hemiplegia a randomized controlled trial.

It has been demonstrated that botulinum toxin type A (BTX-A) injections reduce spasticity and improve muscle growth in children with spasticity. It has been postulated that BTX-A allows the learning of more normal movement patterns. The aim of this study was to measure the effect of this treatment on functional ability, as measured by the Gross Motor Function Measure (GMFM), in children with spastic hemiplegic cerebral palsy. Children of 3--13 years and meeting the selection criteria were randomly allocated to the control or injection group using a matched pair design. A match constituted a child within 6 months of age with the same Modified Ashworth Score (MAS) for the gastroc-soleus and within 10% of the same goal scores on the Gross Motor Function Measure. Twelve matched pairs were enrolled. Outcomes were measured on enrolment and at 1, 3 and 6 months post injection. The time course of the response to BTX-A was assessed with measurements of the MAS, dynamic range of motion (R1) and static muscle length (R2). Motor function was assessed using the 88-item GMFM and parental satisfaction with a 10-point visual analogue scale. Within pair comparisons of the GMFM using the Wilcoxon signed rank test indicated that the treatment group made significantly greater gains than controls at 3 months (P=0.02) with even greater differences seen at 6 months (P=0.004). Using parametric statistics, the intrapair difference in proportional change of GMFM increased from 35% (4 to 65) at 3 months to 52% (17--87) at 6 months. Response to injection was confirmed by a decrease in MAS in the treatment group and very little change in controls. This difference was significant (P=0.002) at 3 months and was attenuated but still significant (P=0.016) at 6 months; the difference in proportional change decreased from 44% at 3 months to 22% at 6 months. Changes in R1 reflected those of MAS in the treatment group and deteriorated significantly over the study period in controls. Parents of children in the treatment group were more satisfied than controls, but satisfaction scores did not correlate with changes in function or technical outcomes suggesting that this may be a placebo effect. The changes in GMFM correlated with changes in technical outcomes at 3 months, suggesting a causal relationship. The intrapair differences in GMFM continued to increase even after the local response to injection had started to wane.

Proportional change: an additional method of reporting technical and functional outcomes following clinical interventions.

One of the major challenges in disability management research is to express results in a manner that can be generalized to subjects with varying degrees of disability. Absolute measurements of change are often dependent on initial characteristics, in which case they can only be generalized to subjects with the same characteristics. We define proportional change as the ratio of change to the maximum possible or targeted change. It can be assessed in any situation where a maximum possible or targeted change is definable. Its estimated value will be sensitive to the choice of denominator. Subjective assessments, such as those measured with Likert scales, are naturally expressed as proportional change with the denominator being set by the subject. Denominators may also be determined objectively by physical limitations or, less desirably, by the measurement tool. Where there is no readily or objectively determinable denominator, they should be chosen for each subject in advance of the intervention according to carefully specified criteria. Proportional change is proposed, as an adjunct to the reporting of absolute measures of change following therapeutic interventions, as a means of expressing change in a manner that is both individualized and generalizable.

Newly recognised craniosynostosis syndrome that does not map to known disease loci.

We describe a consanguineous family of Pakistani origin with five sibs, three of whom were affected by craniosynostosis of variable presentation. In addition, they had other congenital abnormalities principally affecting neurological, ocular, and limb development. We provide linkage evidence using intragenic and flanking microsatellite markers suggesting that the disease in this family was not caused by a mutation in one of the known craniosynostosis loci (FGFR1, FGFR2, FGFR3, MSX2, TWIST). Given the clinical novelty and parental consanguinity, we hypothesise that the affected individuals were autozygous for a recessively inherited mutation, at a novel locus, predisposing to craniosynostosis.

Trends in childhood disability.

Technology enhances human survival, but at a cost of increased prevalence of disability. This, together with the trend to later child-bearing, increases society's financial responsibility for disabled people. For rational planning for future requirements, we need registers based on geographically defined areas, enumerating, by year of birth, all individuals with each type of disability, defined by criteria which remain constant over time.

Nursing and administration: a synthesis model.

The position taken in this article is that nursing administrative practice is a synthesis of knowledge and skills from the two major fields of study, nursing and administration. This synthesis is unique, needs further explication, and differs from a simple combination of content from two separate fields. Expanded study of nursing is an essential component of graduate programs in nursing administration and embraces both discipline and practice considerations. It proceeds from the perspective of clients as pluralities and organizations and systems as appropriate units of analysis. Nurses in executive positions, operating from an expanded knowledge base, have an opportunity to empower nursing and exert substantial influence on the nature and direction of health care. Concurrently they can empower other members of the executive team through development of creative patterns of interdependence as the organization pursues the goal of high-quality, evenly distributed, cost-effective patient care.

Studies on the mechanism and characteristics of action of a uricosuric diuretic, indacrinone (MK-196).

1 The renal action of indacrinone (MK-196), a phenoxyacetic acid derivative with diuretic and uricosuric properties, has been studied in fifteen male subjects. 2 Increasing single doses of up to 60 mg of oral indacrinone produced a linear increase in urinary volume and excretion of Na+ and Cl-, whilst the responses of urinary K+, Ca2+, Mg2+ and uric acid excretion, rose to a plateau at the 40 mg dose. 3 Indacrinone evoked a rapid diuretic response which reached a maximum of 2-4 h and was largely complete at 8-12 h after administration. 4 During maximal hydration, indacrinone produced a substantial fall in fractional free water clearance (CH2O), from 8.89% to 5.83% of the filtered load of water, associated with an increase in osmolal clearance, from 1.38% to 5.78% of the filtered load of solute. The reduction in CH2O was of the same order as that produced by a dose of ethacrynic acid with comparable saluretic activity and significantly greater than that produced by an equi-saluretic dose of hydrochlorothiazide. These findings imply an action of indacrinone upon solute transport in the diluting segments of the distal tubule. 5 At the time of maximal indacrinone-induced saluresis, which amounted to an increase from 0.48% to 4.61% of the filtered load of NaCl, fractional urate clearance increased from 5.16% to 12.24% of the filtered load of uric acid. 6 Indacrinone is a long acting diuretic, sharing some properties in common with both loop diuretics and benzothiadiazines. The results are discussed in relation to structure-activity amongst derivatives of phenoxyacetic acid.

Values and value changes of graduate nursing students: their relationship to faculty values and to selected educational factors.

Values of 75 graduate nursing students in one university school of nursing were compared at times of entry into the program and at the completion of one academic year of study. Gordon's Survey of Interpersonal Values and Survey of Personal Values and a questionnaire were used to collect data. The students' perceived impact of certain educational factors was explored for possible relationship of these factors to changes that occurred. Values of the graduate nursing faculty and their perception of the importance of the same factors were obtained and compared with those of the students. Students showed signficant increases in values of support, recognition, and independence and significant decreases in benevolence, conformity, and practical mindedness. These changes bore similarity to those reported in previous studies of undergraduate nursing students and medical students. Differences between the students and faculty on two values, practical mindedness and independence, had disappeared by the end of one year; difference on one value, recognition, had appeared; and difference on one value, achievement, remained the same. The influence of specific educational factors was not clear. Faculty judged almost all factors as having a greater impact on students than students judged their impact to have been. Students' preestimate of probable influence of the same factors was significantly higher than their postestimate. Some uniform processes of socialization occurred even though students and faculty were not always in agreement about the importance of educational activities and outcomes.