[Qualitative ranking of medical curricula is useless]. / Kwalitatieve ranglijsten van medische opleidingen zijn onbruikbaar.

Saying that a qualitative ranking of medical schools would be helpful implies that it is feasible. There are two reasons why this may not be the case. Firstly, any medical school can be characterised by many aspects of varying quality and importance, not necessarily 'good' or 'bad', resulting in an arbitrary assessment of overall quality. Secondly, evaluation of an aspect results in a score on an ordinal scale, which is not suitable for current arithmetic operations. Since the introduction of the visitation system, the qualitative differences between schools have decreased. Therefore, an objective description of each of the medical schools, including its special characteristics, would be more useful for the aspirant student than ranking.

Randomised controlled trial of magnetic-resonance pelvimetry in breech presentation at term.

BACKGROUND: Pelvimetry is widely used in women with breech presentation at term to select those for whom planned vaginal delivery is appropriate. However, its clinical value has never been established. We evaluated pelvimetry in a randomised controlled trial. The main outcome measures were the elective and emergency caesarean-section rates and the early condition of the neonate. METHODS: Magnetic-resonance (MR) pelvimetry was done on 235 women. The women were then randomly assigned to two groups--for the study group (n = 118), the pelvimetry results were reported to the responsible obstetricians, who used them as the basis for decisions on whether to schedule elective caesarean or trial of labour; for the control group (n = 117), the pelvimetry results were not disclosed until 8 weeks post partum, and decisions about obstetric management were made on the basis of clinical factors only. FINDINGS: 35 women (15 [13%] study group, 20 [17%] control group) had abnormalities on pelvimetry. The overall caesarean-section rates did not differ significantly between the study and control groups (50 [42%] vs 59 [50%], p = 0.24) but the emergency caesarean-section rate was significantly lower in the study group than in the control group (22 [19%] vs 41 [35%], p = 0.0052). The mean 1 min Apgar scores in the study and control groups were 8.1 and 8.0 (p = 0.93) and the mean 3 min scores 9.5 and 9.4, respectively (p = 0.28). There were no significant differences in the early neonatal outcome for infants born vaginally, by emergency caesarean section, or by elective caesarean section in the two groups, except for a significantly lower Apgar score in the six infants born vaginally to control-group women who had pelvic abnormalities. INTERPRETATION: The use of MR pelvimetry in breech presentation at term did not significantly reduce the overall caesarean-section rate. However, it allowed better selection of the delivery route, with a significantly lower emergency caesarean-section rate. Neonatal outcome was not compromised by use of the pelvimetry data.

The effects of 3g eicosapentaenoic acid daily on recurrence of intrauterine growth retardation and pregnancy induced hypertension.

OBJECTIVE: To study the effects of addition of 3 g eicosapentaenoic acid daily to the diet, on recurrence rate of intrauterine growth retardation and pregnancy induced hypertension in a high risk population. DESIGN: Prospective, double blind, randomised multicentre study. Eicosapentaenoic acid or placebo were given from 12 to 14 weeks of gestation onwards. SETTING: University Hospital and regional hospitals in the north of the Netherlands. SUBJECTS: Sixty-three women with a history of intrauterine growth retardation (birthweight < 10th centile) with or without pregnancy induced hypertension in the previous pregnancy. MAIN OUTCOME MEASURES: Birthweight centiles and signs of pregnancy induced hypertension in current pregnancy. RESULTS: One-third of the women developed pregnancy induced hypertension and one-third of the infants had a birthweight below the 10th centile. There were no differences between eicosapentaenoic acid and placebo group. CONCLUSION: Addition of 3 g eicosapentaenoic acid daily does not prevent recurrence of intrauterine growth retardation or pregnancy induced hypertension in a high risk population.

[Status of the job market of physicians who started their education in Groningen in 1982 and 1983]. / De plaats op de arbeidsmarkt van artsen die in 1982 en 1983 in Groningen gingen studeren.

OBJECTIVE: To determine the working experience and desires of doctors, who started their medical training approximately 10 years ago. DESIGN: Telephone inquiry. SETTING: University of Groningen, the Netherlands. METHOD: In the summer of 1993, 98% of medical graduates who started their training at the University of Groningen in 1982 of 1983 were questioned about working experience and wishes for the future. RESULTS: Over 70% worked as medical assistants in hospitals; most of them were not (yet) in training. Almost all male subjects and 4 out of 5 female subjects worked full time. Half of them wished to keep a full time job (two-thirds of the men, one-third of the women). CONCLUSION: When all working desires would be fulfilled, the future work time per doctor would be 86%. There is a great need for specialist training places.

Neurobehavioural relationships after the onset of puberty.

The behavioural and cognitive development were studied of 68 children with and 259 without minor neurological function (MND) at 14 years, when the majority of children showed three or more physical signs of puberty. MND was differentiated into fine manipulative disability, co-ordination problems, choreiform dyskinesia and hypotonia. The normal group was subdivided into those who had been normal at 12 years and those who had had MND. All types of MND were related to cognitive and behavioural problems. Fine manipulative disability was related to behavioural and cognitive difficulties; co-ordination problems to learning difficulties; and choreiform dyskinesia and hypotonia were related to attention difficulties and school failure, notwithstanding normal IQ. Besides MND, socio-economic class, family adversities and female gender contributed to the development of behavioural and cognitive problems. The behaviour of children with MND at 12 years who were normal at 14 years did not differ from that of normal children.

Is minor neurological dysfunction at 12 years related to behaviour and cognition?

Behavioural and cognitive development at 12 years were studied in 172 children with and 174 children without minor neurological dysfunction (MND). MND could be differentiated into fine manipulative disability, co-ordination problems, hypotonia and choreiform dyskinesia. Fine manipulative disability related significantly to problems of cognition and behaviour; co-ordination problems to cognitive problems; and hypotonia and choreiform dyskinesia to behavioural problems, the former more than the latter. Socio-economic status and family adversity contributed to the risk for development of both cognitive and behavioural problems; gender did not. The onset of puberty seemed to change these relationships: follow-up is needed for definite conclusions.

Minor neurological dysfunction after the onset of puberty: association with perinatal events.

In order to study the hypotheses that puberty is related to a decrease of minor neurological dysfunction (MND) and that persisting MND is associated with perinatal factors, two groups (174 normal, 172 MND) of the Groningen Perinatal Project were followed from 12 to 14 years. At 14 years almost all the children had entered puberty (n = 329) defined as the presence of three or more puberty signs. In the MND group 55% of the children were normal at 14 years and in 45% MND signs were still present, though in a less extensive form. The latter phenomenon was most clear in children who had just begun puberty. The effect of puberty was similar in both sexes. MND which persisted into puberty was related to neonatal neurological deviancy, lower social class, lower obstetrical optimality score and male sex. After differentiation with specific MND clusters, it appeared that fine manipulative disability was associated with neonatal neurological deviancy, with minor physical anomalies and with lower social class; choreiform dyskinesia with asphyxia; hypotonia with constitutionally related factors; and coordination problems with pre-maturity (< 32 weeks).

Obstetrical condition and neonatal neurological outcome in Dominica, the Caribbean. A comparative study.

Risk factors during pregnancy and delivery and neurological morbidity of newborns were assessed in a birth cohort in Dominica, the Caribbean. The data were compared with two reference groups, one from Grenada, the Caribbean, and the other from Groningen, the Netherlands. Despite variations in cultural and socio-economic situation, the similarities in obstetrical conditions, neonatal neurological morbidity and perinatal relationships between the three groups were more striking than the differences. The Dominican group showed a significantly higher rate of preterm births than the two other groups. Preterm birth was associated with a significant increase in neurological deviancy. In general motility and muscle tone were found to be lower in the Caribbean region than in the Netherlands.

Minor neurological dysfunction from birth to 12 years. I: Increase during late school-age.

To study the hypothesis that the frequency of minor neurological dysfunction (MND) stabilizes around the age of nine years, two groups of the Groningen Perinatal Project (GPP) were re-examined at 12 years. The study group (N = 174) was selected on the basis of the presence of MND at nine years; the control group comprised 172 neurologically normal children. The hypothesis was rejected: extrapolation of the findings to the total GPP population showed that the over-all rate of MND increased. Control children who developed MND were mainly boys who had been neurologically abnormal at birth or were born preterm and/or had experienced an adversity in combination with asphyxia. Interval complications between nine and 12 years were related to the emergence of MND.

Minor neurological dysfunction from birth to 12 years. II: Puberty is related to decreased dysfunction.

To determine whether puberty is related to decreased minor neurological dysfunction (MND), 174 children from the Groningen Perinatal Project who had had MND at nine years were re-examined at 12 years. No signs of MND could be demonstrated in 39 of the children, 33 of whom showed at least three signs of puberty. The presence of minor physical anomalies was associated with persisting MND. The authors hypothesise that puberty is related to a decrease in MND, and discuss the role of hormonal changes in relation to the decrease in minor signs. Re-examination at 14 years will be necessary to confirm this hypothesis, since 68 per cent of the children had not yet reached puberty. Children with MND reached puberty no later than those without.

Fatty acid composition of serum lipids of mothers and their babies after normal and hypertensive pregnancies.

The biochemical essential fatty acid (EFA) status of neonates born after normal and hypertensive pregnancies (PIH) and that of their mothers was assessed by measuring the fatty acid composition of phospholipids (PL), triglycerides (TG) and cholesterol esters (CE) of umbilical cord serum and maternal serum, respectively. Relative contents of linoleic acid of serum PL and CE were significantly lower in mothers with PIH compared to normal pregnancies. Most other (n-6) polyenes in PL tended to be higher under hypertensive conditions. Total maternal (n-3) polyenes of serum PL were significantly higher in PIH, mainly due to clupanodonic acid, 22:5 (n-3), and cervonic acid, 22:6 (n-3). Total maternal (n-7) and (n-9) fatty acids were also significantly higher in PIH (PL and CE). The results indicate that PIH is associated with a relative increased unsaturation of maternal serum PL, which might facilitate the placental transfer of long-chain, polyunsaturated fatty acids. As a result, the neonatal EFA status after PIH only slightly differs from normal.

Nocturnal enuresis and minor neurological dysfunction at 12 years: a follow-up study.

On follow-up at 12 years to assess the relationship between minor neurological dysfunction (MND) and primary nocturnal enuresis (NE), the frequency of NE was found to be significantly higher in children with MND (N = 167) than in those who were neurologically normal (N = 174). There was no relationship between NE and sex in the MND group, nor with the neonatal neurological condition. Among MND children, those with NE more often had language comprehension and arithmetic problems and they required special help for behavioural problems more than did those without such problems. The relationship between NE and MND was affected by socio-economic class and family history. It is concluded that children with MND are more vulnerable to NE, particularly in the presence of lower social class and a positive family history.

Antiepileptic medication in pregnancy: late effects on the children's central nervous system development.

In a follow-up study long-term effects of antenatal exposure to two anticonvulsant drugs, phenobarbital and carbamazepine on central nervous system development were evaluated. Children aged 6 to 13 years of epileptic mothers who used phenobarbital (n = 13), carbamazepine (n = 12), phenobarbital plus carbamazepine (n = 12), or no medication (n = 24) during pregnancy were studied. None of the mothers had seizures during pregnancy. A control group carefully matched for confounding variables was selected of children of nonepileptic mothers (n = 61). Minor and major congenital anomalies appeared to be more related to mother's epilepsy than to maternal medication. There were no neurologic differences between the groups. Exposure to phenobarbital was associated with smaller head circumference. An accompanying negative effect of phenobarbital on cognitive development was suggested. Further research on this intriguing phenomenon seems warranted.

Biochemical EFA status of mothers and their neonates after normal pregnancy.

The essential fatty acid (EFA) status of neonates was compared with that of their mothers by determining the fatty acid compositions of phospholipids (PL), isolated from umbilical arterial and venous tissue, blood cells (BC) and plasma, from maternal venous plasma and BC, and from non-infarcted placental tissue. The PL of umbilical arterial tissue (efferent fetal vessels) contained fewer fatty acids of the (n-6) family and more of the (n-9) family than umbilical venous tissue (afferent fetal vessel). The relative amounts of (n-6) and (n-3) fatty acids were less in arterial than in venous plasma. Mead acid, 20:3(n-9), the presence of which indicates a poor EFA status, was 5 times higher in the efferent than in afferent cord vessels. In neonatal plasma and BC it was twice as high as compared with maternal levels. In general, the fatty acid composition of the placenta PL showed a comparable pattern as neonatal venous plasma PL. These findings demonstrate that the biochemical EFA status of neonates after a normal pregnancy is not optimal. The significant correlations between neonatal and maternal EFAs indicate that the neonatal EFA status depends on the EFA content of the maternal diet.

Neonatal neurological morbidity in relation to obstetrical and social conditions in Grenada (Caribbean).

Neonatal morbidity, in particular neurological morbidity is a more relevant measure of the effectiveness of obstetrical care than perinatal mortality. Neurological morbidity was assessed in a birth cohort in Grenada, and appeared to be lower than in a reference group examined in Groningen, the Netherlands, in 1975-1978. Perinatal mortality, however, was higher. The results support the thesis that some children may have died who, if they would have survived, would have been neurologically abnormal. It is concluded that whereas a decrease in perinatal deaths is an essential goal in Grenada, a concomitant increase in morbidity should be carefully avoided.

[Ante and perinatal factors and behavior and functional disorders in 6-to-9-year-old children]. / Ante- en perinatale factoren en gedrags- en functiestoornissen bij kinderen van 6-9 jaar.

A follow-up study at six and/or nine years of age was carried out on subpopulations of the three years cohort of the Groningen Perinatal Project. Neurological handicap and minor neurological dysfunction (MND) were associated with different sets of risk factors. The findings suggest a temporal difference in potentially harmful factors. At nine years of age two different kinds of MND could be distinguished, each of them related in a specific way to perinatal risk factors and behavioural and cognitive development. The finding that social factors, sex and present neurological condition of the child appeared to be more important than pre- and perinatal events for the development of learning and behavioural problems illustrates the complex aetiology of the latter.

The use of DNA flow cytometry in the diagnosis of triploidy in human abortions.

The ploidy of placental tissue from 59 abortions was determined using DNA flow cytometry. The specimens were also screened histologically for features considered to be characteristic of a partial mole. Triploidy was found in six cases; three of these cases presented histologically as partial moles. From the four specimens histologically classified as partial moles, three appeared to be triploid. The most specific histologic features of triploidy were cystic change of the placental villi and trophoblastic hyperplasia with vacuolation of the syncytiotrophoblast; however, these changes were also found in some of the nontriploid abortions. Irregularity of villous contours was less specific.

Antenatal care; current practice in debate.

The antenatal screening practice of 67 teaching hospitals in the European Community was assessed by use of a written questionnaire. There were minor differences in mean numbers of tests performed in different countries, but only limited agreement was found on the selection of tests that were performed. There was no unity of practice within the countries. No correlations were found between the number of screening tests performed and the size of the units, or the composition of the attending staff.

Perinatal risk factors and minor neurological dysfunction: significance for behaviour and school achievement at nine years.

A prospective study was carried out on 133 neurologically deviant infants, 205 with mild abnormalities and 230 normal newborns to compare behavioural and cognitive development with neonatal and nine-year-old neurological condition. Overtly handicapped children were excluded. Major determinants of school failure were the severity of minor neurological dysfunction (MND) and social class. Main risk factors for distractable and clumsy behaviour were MND classification and male sex; for troublesome behaviour male sex and interval complications after two years of age; and for timid behaviour, family adversity. Definite neonatal neurological deviancy contributed both directly and by its association with MND to problems in behaviour and scholastic abilities. Mild neonatal neurological abnormalities and adverse obstetrical events contributed only indirectly to behavioural and learning problems. Preterm birth (less than 34 weeks) was the sole obstetric variable directly related to some of the outcome variables. The difference between home and school perception of the children's behaviour is emphasized.

Perinatal correlates of major and minor neurological dysfunction at school age: a multivariate analysis.

A prospective study was carried out on 747 infants: 147 neurologically abnormal, 300 with mild neurological abnormalities and 300 normal infants. They were re-examined at nine years of age, with special attention being paid to minor neurological dysfunction (MND). Extensive data on obstetrical history, neonatal course and interval complications were collected. Neurological handicap was not found on follow-up in the group of normal newborns. Other than neonatal neurological abnormality, risk factors contributing significantly to later handicap were low one-minute Apgar scores, a disturbed neonatal course, low social-class and interval complications; obstetrical events were conspicuous by their absence. Two aetiologically and clinically distinct kinds of MND were distinguished on the basis of a neurological cluster profile: MND-1 (one or two abnormal clusters) was only associated with a birthweight below the 2.3 centile and male gender, and MND-2 (more than two abnormal clusters) was associated with neonatal neurological findings, social class, obstetrical optimality score and gender.