Rattling the plate--reasons and rationales for early weaning.

To identify a range of attitudes and beliefs which influence the timing of introduction to solid food, five focus group discussions were undertaken within a maternity hospital setting. These sessions explored early feeding behaviour, stimuli to changing feeding habits and subsequent responses in 22 primiparous and seven multiparous mothers (mean age 27.0+/-4.8 years) with babies aged 8-18 weeks (mean age 13.0+/-4.2 weeks). One-third of the participants had introduced solid food to their infants (mean age of introduction 11.6 weeks, range 2-16 weeks). Mothers believed that the introduction of solids was baby led and initiated by some physical characteristic or behavioural action of the infant. All mothers were aware of current recommendations to avoid the introduction of solid food until 4 months. Few knew why this should be and concepts of long-term ill health were difficult to conceptualize. The conflict between rigid feeding guidelines and flexible advice from supportive health professionals created confusion over the importance of good weaning practices. The current findings highlight issues relevant to the introduction of solid food, and provide a foundation for further research which can identify the relative importance of these factors and provide a rationale for the design of contemporary intervention strategies.

Interval between fetal measurements in predicting growth restriction.

OBJECTIVE: To determine the influence of the interval between fetal measurements on performance of fetal growth velocity for predicting infants with anthropometric features of fetal growth restriction (FGR). METHODS: Two hundred seventy-four low-risk women had serial fetal biometry at scheduled intervals. Growth velocity of the fetal abdominal area for each was calculated with 2-, 4-, and 6-week scan intervals in which the second measurement was the last scan before delivery. Fetal abdominal area velocity over a 4-week interval in the early third trimester also was included. Fetal growth restriction was defined as skinfold thickness under the tenth percentile, ponderal index under the 25th percentile, midarm circumference-to-occipitofrontal circumference ratio of under -1 standard deviation (SD). Test performance was expressed as likelihood ratios with 95% confidence intervals (CI). RESULTS: Fetal abdominal area velocity calculated over a 4-week interval predicted FGR with a likelihood ratio of 10.4 (95% CI 3.9, 26) for skinfold thickness; 9.5 (95% CI 4.6, 19) for ponderal index; and 4.7 (2.3, 8.4) for midarm circumference-to-occipitofrontal circumference ratio. Intermeasurement intervals of 6 weeks had a likelihood ratio of 8.5 (95% CI 4, 17) for skinfold thickness; 7.5 (95% CI 3.4, 16.1) for ponderal index; and 14 (6.7, 28) for midarm circumference-to-occipitofrontal circumference ratio. The likelihood ratios for the 2-week interval and the early third trimester 4-week interval were all less than 5. CONCLUSION: Four- and 6-week measurement intervals were useful for predicting infants with FGR and were superior to a 2-week interval. Fetal growth velocity is influenced by proximity of the last fetal measurement to date of delivery, which adversely affects clinical use of growth velocity for predicting FGR.

AMEE Medical Education Guide No. 24: Portfolios as a method of student assessment.

This guide is intended to inform medical teachers about the use of portfolios for student assessment. It provides a background to the topic, reviews the range of assessment purposes for which portfolios have been used, identifies possible portfolio contents and outlines the advantages of portfolio assessment with particular focus on assessing professionalism. The experience of one medical school, the University of Dundee, is presented as a case study. The current state of understanding of the technical, psychometric issues relating to portfolio assessment is clarified. The final part of the paper provides a practical guide for those wishing to design and implement portfolio assessment in their own institutions. Five steps in the portfolio assessment process are identified: documentation, reflection, evaluation, defence and decision. It is concluded that portfolio assessment is an important addition to the assessor's toolkit. Reasons for using portfolios for assessment purposes include the impact that they have in driving student learning and their ability to measure outcomes such as professionalism that are difficult to assess using traditional methods.

Task-based learning: the answer to integration and problem-based learning in the clinical years.

INTRODUCTION: Integrated teaching and problem-based learning (PBL) are powerful educational strategies. Difficulties arise, however, in their application in the later years of the undergraduate medical curriculum, particularly in clinical attachments. Two solutions have been proposed - the use of integrated clinical teaching teams and time allocated during the week for PBL separate from the clinical work. Both approaches have significant disadvantages. Task-based learning (TBL) is a preferred strategy. In TBL, a range of tasks undertaken by a doctor are identified, e.g. management of a patient with abdominal pain, and these are used as the focus for learning. Students have responsibility for integrating their learning round the tasks as they move through a range of clinical attachments in different disciplines. They are assisted in this process by study guides. METHOD: The implementation of TBL is described in one medical school. One hundred and thirteen tasks, arranged in 16 groups, serve to integrate the student learning as they rotate through 10 clinical attachments. RESULTS: This trans-disciplinary approach to integration, which incorporates the principles of PBL offers advantages to both teachers and students. It recognizes that clinical attachments in individual disciplines can offer rich learning opportunities and that such attachments can play a role in an integrated, as well as in a traditional, curriculum. In TBL, the contributions of the clinical attachments to the curriculum learning outcomes must be clearly defined and tasks selected which will serve as a focus for the integration of the students' learning over the range of attachments.

Using unconditional and conditional standard deviation scores of fetal abdominal area measurements in the prediction of intrauterine growth restriction.

OBJECTIVE: To compare the performance of unconditional and conditional standard deviation scores (Z scores) of fetal abdominal area (FAA) measurements in the antenatal identification of infants born with anthropometric features of intrauterine growth restriction. METHODS: A prospective observational study, involving 274 low-risk women participating in a longitudinal study of serial ultrasound in pregnancy. Conditional Z scores were established for the last FAA prior to delivery with reference to measurements made both 28 and 56 days previously. Unconditional Z scores (size) were calculated from the last FAA measurement prior to delivery. Receiver-operator characteristics curves were employed to determine an optimal cut-off point for Z scores to predict intrauterine malnourishment. The main outcome measures were: likelihood ratios (LR) for conditional and unconditional Z scores of FAA in the prediction of infants with skinfold thickness < 10th percentile; ponderal index < 25th percentile or mid-arm circumference to occipitofrontal circumference ratio (MAC/OFC) of < -1 SD. An LR of > 10 generates significant changes in the pretest probability of growth restriction, whereas an LR of 5-10 generates only moderate changes. RESULTS: Conditional Z scores with 28- and 56-day separations predicted growth restriction with LR 7.5 (95% confidence interval [CI], 3.7-14.7) and 4.8 (95% CI, 2.8-7.8) for ponderal index but did not usefully predict skinfold thickness or MAC/OFC. Unconditional Z scores did not usefully predict any of the parameters of growth restriction. CONCLUSIONS: Quantifying third trimester fetal growth by means of FAA conditional Z scores is moderately useful in predicting infants with a low ponderal index and is superior to unconditional FAA Z scores in late pregnancy.

Assessment of uterine arterial notching as a screening test for adverse pregnancy outcome.

OBJECTIVE: The objective of the study was to evaluate the screening potential of routine uterine arterial Doppler ultrasonography as a predictor of adverse pregnancy outcome. STUDY DESIGN: All women (n = 6579) with singleton pregnancies undergoing a fetal anomaly scan at 18 to 20 weeks' gestation between January 1, 1994, and December 31, 1995, at Ninewells Hospital and Medical School were screened for the presence of uterine arterial notching. Women who had evidence of bilateral notching were rescanned at 22 to 24 weeks' gestation. Outcome measures included proteinuric hypertension, premature separation of the placenta, and birth weight z score. RESULTS: The sensitivity and positive predictive value of uterine arterial notching as a predictor of adverse pregnancy outcomes was low. For all types of notching and disease, outcome sensitivity was never higher than 44% and positive predictive value was never higher than 27%. In contrast, the relative risk of adverse pregnancy outcome in the presence of uterine arterial notching was uniformly high for all disease outcomes (range of relative risk 3.5-30.7). Significant obstetric morbidity was seen in 57% of women with bilateral notches at 18 to 20 weeks' gestation and 72% of women with persistent bilateral notches. CONCLUSIONS: As a screening test for adverse pregnancy outcomes, detection of uterine arterial notching is poor. Nevertheless, the presence of bilateral uterine arterial notching is associated with a significantly increased risk of adverse pregnancy outcome. In units performing routine anomaly screening, the addition of maternal uterine arterial Doppler ultrasonography may help to discriminate this small group of women at high risk.

Relation of infant diet to childhood health: seven year follow up of cohort of children in Dundee infant feeding study.

OBJECTIVE: To investigate the relation of infant feeding practice to childhood respiratory illness, growth, body composition, and blood pressure. DESIGN: Follow up study of a cohort of children (mean age 7.3 years) who had detailed infant feeding and demographic data collected prospectively during the first two years of life. SETTING: Dundee. SUBJECTS: 674 infants, of whom 545 (81%) were available for study. Data on respiratory illness were available for 545 children (mean age 7.3 (range 6.1-9.9) years); height for 410 children; weight and body mass index for 412 children; body composition for 405 children; blood pressure for 301 children (mean age 7.2 (range 6.9-10.0) years). MAIN OUTCOME MEASURES: Respiratory illness, weight, height, body mass index, percentage body fat, and blood pressure in relation to duration of breast feeding and timing of introduction of solids. RESULTS: After adjustment for the significant confounding variables the estimated probability of ever having respiratory illness in children who received breast milk exclusively for at least 15 weeks was consistently lower (17.0% (95% confidence interval 15.9% to 18.1%) for exclusive breast feeding, 31.0% (26.8% to 35.2%) for partial breast feeding, and 32.2% (30.7% to 33.7%) for bottle feeding. Solid feeding before 15 weeks was associated with an increased probability of wheeze during childhood (21.0% (19.9% to 22.1%) v 9.7% (8.6% to 10.8%)). It was also associated with increased percentage body fat and weight in childhood (mean body fat 18.5% (18.2% to 18.8%) v 16.5% (16.0% to 17.0%); weight standard deviation score 0.02 (-0.02 to 0.06) v -0.09 (-0.16 to 0.02). Systolic blood pressure was raised significantly in children who were exclusively bottle fed compared with children who received breast milk (mean 94.2 (93.5 to 94.9) mm Hg v 90.7 (89.9 to 91.7) mm Hg). CONCLUSIONS: The probability of respiratory illness occurring at any time during childhood is significantly reduced if the child is fed exclusively breast milk for 15 weeks and no solid foods are introduced during this time. Breast feeding and the late introduction of solids may have a beneficial effect on childhood health and subsequent adult disease.

UK study of intrapartum care for low risk primigravidas: a survey of interventions.

STUDY OBJECTIVE: To determine the extent of intrapartum intervention received by primigravidas. DESIGN: Cross sectional survey of NHS hospitals in the UK. SETTING: One hundred and one randomly selected hospital maternity units. PARTICIPANTS: Forty consecutive primigravid women, judged to be at low risk at the start of labour, in each hospital. MAIN OUTCOME MEASURES: Seven groups of interventions or monitoring procedures were identified from the first, second, and third stages of labour: fetal monitoring, vaginal examinations, artificial rupture of membranes, augmentation of labour, pain relief, type of delivery, and episiotomy. Data were collected during 1993. MAIN RESULTS: Ninety eight hospitals took part in the study and data were collected on 3160 low risk primigravidas. Seventy four per cent of these women had continuous cardiotocography. The proportion of women having restrictive or invasive fetal monitoring showed appreciable geographical variation for both the first and second stages of labour. Using the criterion of a vaginal examination every four hours and allowing for the length of each woman's labour, 72% had more vaginal examinations than expected; there was a significant geographical variation in the number of women receiving more than five examinations. Fifty three per cent had artificial rupture of membranes; the procedure was performed over a wide range of cervical dilatations (0 cm-10 cm). Thirty eight per cent of labours were augmented, most commonly by intravenous syntocinon; the procedure showed significant geographical variation. Twenty eight per cent had a spinal block or epidural analgesia for the relief of pain; this intervention varied by geographical region only for the second stage of labour. Over one quarter of the women required instrumental delivery. Forty six per cent had an episiotomy; the frequency of this intervention varied substantially by region. There were no infant deaths. Twelve babies were recorded at birth as having a congenital anomaly. CONCLUSIONS: The rates of several interventions seem high for this low risk group and there was substantial geographical variation in the use of six interventions. Clinical trials are needed to evaluate the optimum criteria for using these interventions from which guidelines should be drawn up by local groups and the Royal College.

A prospective evaluation of the value of intrapartum biophysical and Doppler parameters in identifying the potentially compromised fetus.

This study was designed to evaluate the use of the biophysical profile and umbilical arterial Doppler in early labour in identifying the potentially compromised fetus. Two hundred and forty-two women attending the labour suite in early labour were studied. One hundred and fifty-one were in spontaneous labour and the remaining 91 had labour induced. All women had intrapartum biophysical profile assessment and umbilical arterial Doppler performed. Umbilical arterial Doppler and fetal movements were variously identified as being independently and significantly associated with adverse perinatal outcomes. Positive predictive values for adverse outcomes were however poor. Umbilical arterial Doppler used individually or in combination with clinical risk, gave no advantage over the use of clinically assigned risk alone in identifying fetuses at risk of subsequent adverse outcome. The assignment of clinical risk on admission in labour remains the most predictive 'test' for identifying the fetus at risk of subsequent adverse outcome. The routine addition of intrapartum biophysical parameters and umbilical arterial Doppler as methods of assessment is not justified.

Should obstetricians see women with normal pregnancies? A multicentre randomised controlled trial of routine antenatal care by general practitioners and midwives compared with shared care led by obstetricians.

OBJECTIVE: To compare routine antenatal care provided by general practitioners and midwives with obstetrician led shared care. DESIGN: Multicentre randomised controlled trial. SETTING: 51 general practices linked to nine Scottish maternity hospitals. SUBJECTS: 1765 women at low risk of antenatal complications. INTERVENTION: Routine antenatal care by general practitioners and midwives according to a care plan and protocols for managing complications. MAIN OUTCOME MEASURES: Comparisons of health service use, indicators of quality of care, and women's satisfaction. RESULTS: Continuity of care was improved for the general practitioner and midwife group as the number of carers was less (median 5 carers v 7 for shared care group, P<0.0001) and the number of routine visits reduced (10.9 v 11.7, P<0.0001). Fewer women in the general practitioner and midwife group had antenatal admissions (27% (222/834) v 32% (266/840), P<0.05), non-attendances (7% (57) v 11% (89), P<0.01) and daycare (12% (102) v 7% (139), P<0.05) but more were referred (49% (406) v 36% (305), P<0.0001). Rates of antenatal diagnoses did not differ except that fewer women in the general practitioner and midwife group had hypertensive disorders (pregnancy induced hypertension, 5% (37) v 8% (70), P<0.01) and fewer had labour induced (18% (149) v 24% (201), P<0.01). Few failures to comply with the care protocol occurred, but more Rhesus negative women in the general practitioner and midwife group did not have an appropriate antibody check (2.5% (20) v 0.4% (3), P<0.0001). Both groups expressed high satisfaction with care (68% (453/663) v 65% (430/656), P=0.5) and acceptability of allocated style of care (93% (618) v 94% (624), P=0.6). Access to hospital support before labour was similar (45% (302) v 48% (312) visited labour rooms before giving birth, P=0.6). CONCLUSION: Routine specialist visits for women initially at low risk of pregnancy complications offer little or no clinical or consumer benefit.

Standards for ultrasound fetal growth velocity.

OBJECTIVES: An ultrasound study to establish the nature and limits of fetal growth in a low risk population from 22 weeks of gestation until term. DESIGN: Prospective, longitudinal ultrasound study of 274 low risk pregnancies involving organised scanning schedules with all measurements performed by one observer using the same equipment. RESULTS: Growth velocity charts have been created for a number of ultrasound parameters including estimated fetal weight, by applying appropriate statistical methods to the serial data. The rates of growth of the biparietal diameter, femur length, abdominal area and estimated weight each have characteristic patterns demonstrating maximal growth rates at different gestations. CONCLUSIONS: Appropriately derived and calculated ultrasound fetal growth velocity standards have been established. These data are suitable for the evaluation of ultrasonically estimated fetal growth rates in the prediction of adverse perinatal outcome and the further investigation of the role of the intrauterine environment in the origin of adult disease.

Neonatal cerebral arterial flow velocity waveforms in term infants with and without metabolic acidosis at delivery.

To define the effects of acid base status at delivery on neonatal cerebral artery flow velocity waveform patterns obtained using Doppler ultrasound during the first week of life, a longitudinal comparative study of neonates born at term with and without evidence of metabolic acidosis in the umbilical artery was undertaken. Eighty-two appropriate for gestational age infants delivered after uncomplicated pregnancies with non-acidotic umbilical artery blood gases and in whom no neonatal complications were noted were studied to establish reference values of neonatal cerebral arterial vascular resistance index (RI) in normal term infants during the first week of life. A further 189 infants were grouped according to the presence and severity of metabolic acidosis at delivery, and also the presence of high risk features in the antenatal period. In the normal non-acidotic infants, over the first 24 h of life, there was a significant fall in the cerebral arterial resistance index (RI) in all the vessels examined, after which a steady state value was attained with no significant changes in vascular resistance index being noted during the remainder of the study period. The fall in RI between 12 and 24 h of age was consistent in all study groups. Infants with metabolic acidosis at delivery had blood flow patterns compatible with decreased resistance to flow in both anterior and middle cerebral arteries which persisted throughout the first week of life. This reduction in cerebral vascular resistance was most marked in those infants with severe metabolic acidosis. The majority of severely acidotic infants had a benign clinical outcome in the first week of life and all infants had normal cerebral ultrasound scans during the neonatal period. These findings suggest that metabolic acidosis at birth is associated with changes in neonatal cerebral arterial vascular resistance during the first week of life, and in the presence of benign clinical course the significance of this observation with regard to neurodevelopmental outcome requires evaluation.

Are 'notched' uterine arterial waveforms of prognostic value for hypertensive and growth disorders of pregnancy?

In a case-control controlled study of 86 women identified as having bilaterally 'notched' uterine arterial waveform patterns at 18 weeks, the presence of bilateral 'notched' uterine arterial waveforms at that time was associated with the subsequent development of hypertension and small-for-gestational-age infants, but the predictive value was poor. For those women in whom the bilateral uterine 'notches' were observed to persist to 24 weeks, the relative risk of developing proteinuric hypertension increased 14 times, and in these women the positive predictive value for the subsequent development of hypertension increased to 58.6% when compared with their matched controls. The identification of women with persistent bilateral uterine 'notches' provides a means of identifying women at significant risk of hypertensive and growth disorders at a stage when therapeutic intervention aimed at limiting the severity of the disease and its associated complications could be commenced.

Decrease in human plasma gravidin levels after medical abortion.

The aim of this study was to determine if loss of pregnancy is associated with a decrease in plasma levels of gravidin, a phospholipase inhibitor thought to maintain pregnancy. Blood was taken from 28 women in the first trimester of pregnancy who had requested an abortion. The progesterone receptor antagonist, RU-486 was given on Day 0 for termination of pregnancy. Plasma gravidin levels were measured on day 0 and on day 2 just before the patients were given misoprostol, a prostaglandin E1 analogue (600 micrograms). In a small group of patients, plasma measurements were continued up to 42 days. By day 2, plasma gravidin levels had fallen significantly (100% to 94%, p = 0.010 in a paired t-test). Following treatment with prostaglandins and pregnancy loss, plasma gravidin levels continued to fall until day 14 when the non pregnant level was reached at 80% of the pregnant level. We conclude that a decrease in plasma gravidin levels is associated with loss of pregnancy. This may occur because progesterone action is blocked.

PIP: In Scotland, obstetrician-gynecologists at the Simpson Memorial Maternity Pavilion in Edinburgh took a 10 ml blood sample from 28 healthy women asking for an early medical abortion on day 0 just before administration of 200 mg RU-486 and day 2 just before administration of 600 mcg misoprostol. The researchers wanted to determine whether decreased plasma gravidin levels are associated with pregnancy loss. Gravidin, a phospholipase inhibitor, is believed to maintain pregnancy. All the women were at less than 57 days amenorrhea. The physicians continued to collect blood samples from 10 patients for 6 weeks after RU-486 administration. All 28 women had a complete abortion. Between day 0 and day 2, plasma gravidin levels had decreased from 100% to 94%% (p = 0.01 in a paired t-test). After misoprostol treatment, they fell consistently until day 14 (p 0.01), at which time the nonpregnant level was 80% of the pregnant level. These findings suggest that a reduction in plasma gravidin levels is indeed linked to pregnancy loss, perhaps due to a block of progesterone action.

Neonatal cerebral Doppler flow velocity waveforms in the pre-term infant with cerebral pathology.

In a longitudinal study of 217 infants delivering at < 37 completed weeks gestation, Doppler flow velocity waveforms were obtained, and resistance index (RI) values calculated from the middle (MCA) and anterior (ACA) cerebral arteries during the first 10 days of life. Sixty infants demonstrated ultrasound evidence of cerebral pathology, of which five cases were congenital, and an additional 13 cases were complicated by patent ductus arteriosus during the study period. The Doppler data obtained during the first week of life from the remaining 42 infants who developed cerebral pathology, and 15 infants who had evidence of metabolic acidosis at delivery without ultrasound evidence of cerebral pathology were compared with local reference data obtained from non-acidotic infants with normal cranial ultrasound from 24 h of age. In those infants who had evidence of minor periventricular haemorrhage alone (Grade I/II PVH), there was no significant difference between the ACA or MCA RI during the study period compared with the reference data. In those groups of infants who demonstrated major PVH (Grade III/IV) or persistent periventricular flares, the ACA and MCA RI was found to be consistently significantly higher than the reference group throughout the study period. In those infants who developed ultrasound evidence of periventricular cystic leukomalacia (PVCL), the MCA RI was significantly lower than the reference data between 48 and 72 h of age, there being no significant difference in the ACA RI. The Doppler findings in those infants with evidence of metabolic acidosis at delivery (umbilical arterial pH < 7.20; BD > 8 mmol/l) but with normal ultrasound findings were similar to those infants who developed PVCL, namely a significant fall in MCA RI between 48 and 72 h of life, with no significant difference in the ACA RI during the study period. These findings suggest that variable changes in cerebral vascular resistance occur with the evolution of, or as a consequence of the development of cerebral pathology in the pre-term infant, and these changes of increased and decreased vascular resistance are discussed. Further investigation of the changes occurring in the cerebral circulation in the early neonatal period of infants who develop PVCL is required to clarify the vascular changes taking place, but if the findings of this study are confirmed, this technique may provide a means of identifying infants at risk of developing ischaemic cerebral pathology at an early stage when it may be possible to initiate therapeutic intervention to limit the cerebral damage.

Neonatal cerebral Doppler flow velocity waveforms in the uncomplicated pre-term infant: reference values.

In a longitudinal study of 217 infants delivering at < 37 completed weeks gestation, Doppler flow velocity waveforms were obtained and resistance index (RI) values calculated from the middle (MCA) and anterior (ACA) cerebral arteries during the first 10 days of life. One hundred thirty-seven of these infants were non-acidotic at delivery and during the early neonatal period, and had normal cerebral ultrasound scans throughout the study period. These infants formed the reference group. In three gestational subgroups considered (< or = 32 weeks, 33-34 weeks, > or = 35 weeks) from the reference group, the median RI for both the ACA and MCA was noted to fall significantly during the first 12 h of life (P < 0.01 for all groups). For infants delivering at > or = 33 weeks gestation, both MCA and ACA RI values reached a steady state with no significant change in the median value for the remainder of the study period. For infants delivering at < or = 32 weeks, there was a further significant fall in both the MCA and ACA RI between 12 and 24 h of life (P < 0.05), after which a steady state value was reached. During the first 12 h of life the RI for both vessels was significantly higher in infants delivering at < or = 32 weeks compared to the more mature infants (P < 0.01), but for the remainder of the study period, there were no significant differences in RI values between the gestational subgroups.(ABSTRACT TRUNCATED AT 250 WORDS)

Early detection of metabolic abnormalities in preterm infants impaired by disorders of blood glucose concentrations.

We recently reported (Acta Paediatr Scand 1992;8: 580-4) three preterm infants with severe respiratory distress syndrome and abnormal glucose profiles for the first 5 days of life who subsequently died in infancy; only at autopsy were they shown to have abnormal glucose-6-phosphatase activity. We have therefore studied retrospectively in a matched cohort of 109 infants the blood glucose profiles correlated with the severity of respiratory distress syndrome (expressed as the fraction of inspired oxygen, FiO2): group A, mild, FiO2 < 0.25; group B, moderate, FiO2 0.26-0.50; group C, severe, FiO2 > 0.51. All groups had a similar frequency of low blood glucose values (15% < or = 2.2 mmol/L; 29% < or = 2.6 mmol/L), but high blood glucose values and greater variability in glucose values were more common in groups B and C despite lower caloric intakes (A, 4.3%; B, 9.3%; C, 9.6% > or = 7 mmol/L). We conclude that the early blood glucose patterns in those three previously described preterm infants with abnormal hepatic glucose-6-phosphatase activity at autopsy cannot be viewed as abnormal when considered against a matched cohort of infants. Preterm infants at risk of genetic or developmental delays in blood glucose homeostasis should be reassessed after recovery from their acute illnesses.

Risk of preterm delivery in pregnant women with group B streptococcal urinary infections or urinary antibodies to group B streptococcal and E. coli antigens.

OBJECTIVE: To establish whether there is an association between preterm delivery and either group B streptococcal urinary infection or the presence of urinary antibodies to group B streptococcal or E. coli antigens. DESIGN: A prospective study with urine culture and antibody measurement performed at the first antenatal visit and at 28 weeks gestation. SETTING: Ninewells Hospital, Dundee. SUBJECTS: Two thousand and forty-three women registering consecutively at an antenatal clinic. MAIN OUTCOME MEASURE: Delivery at less than 37 weeks gestation. RESULTS: No increase in preterm delivery was observed in women with positive urine cultures for group B streptococci either at booking or at 28 weeks, even when confirmed by positive repeat cultures. Preterm delivery was more common in women with elevated urinary antibodies to E. coli antigens at booking (relative risk 1.81, 95% CI 1.22-2.68, P = 0.005) and at 28 weeks (relative risk 2.36, 95% CI 1.60-3.48, P < 0.0001) and to group B streptococcal antigens at 28 weeks (relative risk 2.24, 95% CI 1.46-3.43, P = 0.0003). CONCLUSIONS: These data do not support previous reports that positive urine cultures for group B streptococci are associated with an increased risk of preterm delivery. Our report of an association between elevated levels of urinary antibodies and preterm delivery is a new finding consistent with the possibility that a local inflammatory response to uro-genital infection may be important in stimulating the onset of preterm labour. The results suggest that screening for urinary antibodies at 28 weeks gestation might help to identify a group of women at increased risk of prematurity.

Neurodevelopmental disability--a sibling-control study.

The antecedents of a population of children with neurodevelopmental disability were examined in a sibling-control study: siblings were used to control for the effect of the family environment on development. Of 294 children with neurodevelopmental disability, 228 who had normally developing siblings were matched with the sibling of nearest ordinal position in the family. There was a significantly higher incidence of prenatal complications among disabled children than among their matched siblings, even after correction for gestational age at birth. Prenatal complications and delayed onset of regular respiration were predictive of disability. These data confirm the authors' observation that the relation between prenatal complications and neurodevelopmental disability is independent of social class and gestational age at birth.