Psychological impact of early miscarriage and client satisfaction with treatment: comparison between expectant management and misoprostol treatment in a randomized controlled trial.

OBJECTIVES: To compare the short- and long-term emotional distress (grief, anxiety and depressive symptoms) after early miscarriage and satisfaction with treatment between women randomized to expectant management vs vaginal misoprostol treatment. METHODS: This was a preplanned analysis of data collected during a randomized controlled trial comparing expectant management with misoprostol treatment in women with early anembryonic or embryonic miscarriage and vaginal bleeding. If the miscarriage was not complete on day 31 after inclusion, surgical evacuation was recommended. The main outcomes were levels of anxiety and grief, depressive symptoms and client satisfaction with the treatment, which were assessed using the following validated psychometric self-assessment instruments: Spielberger State-Trait Anxiety Inventory (STAI, Form Y), Perinatal Grief Scale (PGS), Montgomery-Åsberg Depression Rating Scale (MADRS-S; self-reported version) and Client Satisfaction Questionnaire (CSQ-8). All women were assessed at four timepoints: on the day of randomization, on the day when the miscarriage was judged to be complete, and at 3 months and 14 months after complete miscarriage. The psychometric and client satisfaction scores were compared between the misoprostol group and the expectant-management group at each assessment. Analysis was performed by the intention-to-treat principle. RESULTS: Ninety women were randomized to expectant management and 94 to misoprostol treatment. The psychometric and client satisfaction scores were similar in the two treatment groups at all assessment timepoints. At inclusion, 41% (35/86) of the women managed expectantly and 37% (34/92) of those treated with misoprostol had a STAI-state score of > 46 ('high level of anxiety'), and 9% (8/86) and 10% (9/91), respectively, had symptoms of moderate or severe depression (MADRS-S score ≥ 20). In both treatment groups, symptom scores for anxiety and depression were significantly higher at inclusion than after treatment and remained low until 14 months after complete miscarriage. Grief reactions were mild in both groups, with a median PGS score of 40.0 at 3 months and 37.0 at 14 months after complete miscarriage in both treatment groups. Four women treated with misoprostol and two women managed expectantly had a PGS score of > 90 (indicating deep grief) 3 months after complete miscarriage, while one woman managed expectantly had a PGS score of > 90 14 months after complete miscarriage. Women in both treatment groups were satisfied with their management, as indicated by a median CSQ-8 score of > 25 at each assessment. More than 85% of participants in each of the two groups reported that they would recommend the treatment they received to a friend. CONCLUSIONS: The psychological response to and recovery after early miscarriage did not differ between women treated with misoprostol and those managed expectantly. Satisfaction with treatment was high in both treatment groups. Our findings support patient involvement when deciding on the management of early miscarriage. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Farm-specific failure costs of production disorders in European organic dairy herds.

On-farm decision support in animal health management requires a tailor-made failure costs (FCs) assessment of production disorders for the individual farm. In our study we defined a generic framework to estimate the FC of production disorders in dairy cows. We converted the framework to a practical tool in which the farm-specific FC of mastitis, ketosis, lameness and metritis were estimated for 162 organic dairy farms in four European countries. Along with the structure of the framework, the FC estimation required three distinct types of model input: performance input (related to herd performance parameters), consequential input (related to the consequences of the disorders) and economic input (related to price levels). Input was derived from official herd recordings (e.g. test-day records and animal health recordings) and farmers' responses (e.g. questionnaire replies). The average FC of mastitis, ketosis, lameness and metritis amounted to € 96, € 21, € 43 and € 10 per cow per year, respectively. The variation in FC outcomes was high among farmers and countries. Overall ranking of the disorders based on absolute values was the same for all countries, with mastitis being the costliest disorder followed in order by lameness, ketosis, and metritis. Farm specific estimates can be used to rank production related disorders in terms of their associated failure costs and thus provide valuable insights for herd health management. The practical calculation tool developed in this study should be considered by farmers or herd health advisors to support their animal health practices or advice.

Effects of a participatory approach, with systematic impact matrix analysis in herd health planning in organic dairy cattle herds.

The animal health and welfare status in European organic dairy production does not in all aspects meet the organic principles and consumers' expectations and needs to be improved. To achieve this, tailored herd health planning, targeted to the specific situation of individual farms could be of use. The aim of this study was to apply herd health planning in a structured participatory approach, with impact matrix analysis, not previously used in this context, in European organic dairy farms and to assess changes in animal health and welfare. Herd health planning farm visits were conducted on 122 organic dairy farms in France, Germany and Sweden. The farmer, the herd veterinarian and/or an advisor took part in the farm discussions. The researcher served as facilitator. Baseline data on the animal health status of the individual farm, collected from national milk recording schemes, were presented as an input for the discussion. Thereafter a systematic impact matrix analysis was performed. This was to capture the complexity of individual farms with the aim to identify the farm-specific factors that could have a strong impact on animal health. The participants (i.e. farmer, veterinarian and advisor) jointly identified areas in need of improvement, taking the health status and the interconnected farm system components into account, and appropriate actions were jointly identified. The researcher took minutes during the discussions, and these were shared with the participants. No intervention was made by the researcher, and further actions were left with the participants. The number of actions per farm ranged from 0 to 22. The change in mortality, metabolic diseases, reproductive performance and udder health was assessed at two time points, and potential determinators of the change were evaluated with linear regression models. A significant association was seen between change in udder health, as measured by the somatic cell count, and country. At the first follow-up, a significant association was also found between change in the proportion of prolonged calving interval and the farmers' desire to improve reproductive health as well as with an increase in herd size, but this was not seen at the second follow-up. The degree of implementation of the actions was good (median 67%, lower quartile 40%, upper quartile 83%). To conclude, the degree of implementation was quite high, improvement of animal health could not be linked to the herd health planning approach. However, the approach was highly appreciated by the participants and deserves further study.

Evaluation of the impact of a Herd Health and Production Management programme in organic dairy cattle farms: a process evaluation approach.

Animal health planning activities are not always providing a satisfactory positive impact on herd health and welfare. Moreover, evaluating the impact of advisory programmes is complex due to multiple interacting elements that influence its outcome. Therefore, measuring solely health outcomes is not sufficient: the whole process of the implementation and use of such programmes should be evaluated. In order to evaluate the impact of an intervention with a Herd Health and Production Management (HHPM) programme a process evaluation framework was designed and used. The intervention involved 20 organic dairy cattle farmers and their advisors, in both France and Sweden. In both countries 20 organic dairy farms were selected as control herds. The evaluation of the HHPM programme was based on: (a) the compliance to the programme; (b) the programme's functions influencing herd health management practices and stimulating dialogue between farmers and advisors; (c) its effectiveness in terms of improving herd health compared with control farms. Complete compliance to the programme was fulfilled by 21 out of 40 farmers-advisors. Results from a questionnaire showed that the programme functioned as intended (e.g. by allowing early identification of herd health problems), stimulated change in farmers' herd health management practices and farmer-advisor dialogue. Even though the majority of the users perceived that the programme contributed to herd health improvements, no significant differences in health outcomes were found when compared with control farms 12 months after the start of the intervention. The programme allowed creating an environment promoting the exchange of information between farmers and advisors, necessary to define pertinent advice in a farm-specific situation. Future research should aim at improving methods for the evaluation of the effect of advisory programmes, by identifying early indicators for effective advice and developing methods to evaluate the quality of advisory situations without interfering with them.

Acetic acid as a decontamination method for sink drains in a nosocomial outbreak of metallo-ß-lactamase-producing Pseudomonas aeruginosa.

BACKGROUND: Pseudomonas aeruginosa may colonize water systems via biofilm formation. In hospital environments, contaminated sinks have been associated with nosocomial transmission. Here we describe a prolonged outbreak of a metallo-ß-lactamase-producing P. aeruginosa (Pae-MBL) associated with sink drains, and propose a previously unreported decontamination method with acetic acid. AIM: To describe a nosocomial outbreak of Pae-MBL associated with hospital sink drains and to evaluate acetic acid as a decontamination method. METHODS: The outbreak was investigated by searching the microbiology database, microbiological sampling and strain typing. Antibacterial and antibiofilm properties of acetic acid were evaluated in vitro. Pae-MBL-positive sinks were treated with 24% acetic acid once weekly and monitored with repeated cultures. FINDINGS: Fourteen patients with positive cultures for Pae-MBL were identified from 2008 to 2014. The patients had been admitted to three wards, where screening discovered Pae-MBL in 12 sink drains located in the patient bathrooms. Typing of clinical and sink drain isolates revealed identical or closely related strains. Pae-MBL biofilm was highly sensitive to acetic acid with a minimum biofilm eradication concentration of 0.75% (range: 0.19-1.5). Weekly treatment of colonized sink drains with acetic acid resulted in negative cultures and terminated transmission. CONCLUSION: Acetic acid is highly effective against Pae-MBL biofilms, and may be used as a simple method to decontaminate sink drains and to prevent nosocomial transmission.

A participatory approach to design monitoring indicators of production diseases in organic dairy farms.

Production diseases have an important negative effect on the health and welfare of dairy cows. Although organic animal production systems aim for high animal health levels, compliance with European organic farming regulations does not guarantee that this is achieved. Herd health and production management (HHPM) programs aim at optimizing herd health by preventing disease and production problems, but as yet they have not been consistently implemented by farmers. We hypothesize that one reason is the mismatch between what scientists propose as indicators for herd health monitoring and what farmers would like to use. Herd health monitoring is a key element in HHPM programs as it permits a regular assessment of the functioning of the different components of the production process. Planned observations or measurements of these components are indispensable for this monitoring. In this study, a participatory approach was used to create an environment in which farmers could adapt the indicators proposed by scientists for monitoring the five main production diseases on dairy cattle farms. The adaptations of the indicators were characterized and the farmers' explanations for the changes made were described. The study was conducted in France and Sweden, which differ in terms of their national organic regulations and existing advisory services. In both countries, twenty certified organic dairy farmers and their animal health management advisors participated in the study. All of the farmers adapted the initial monitoring plan proposed by scientists to specific production and animal health situation on their farm. This resulted in forty unique and farm-specific combinations of indicators for herd health monitoring. All but three farmers intended to monitor five health topics simultaneously using the constructed indicators. The qualitative analysis of the explanations given by farmers for their choices enabled an understanding of farmers' reasons for selecting and adapting indicators. This is valuable information for scientists involved in the design of HHPM programs. Advisors in the field also can benefit from this participatory approach because it transforms monitoring tools provided by scientists into farm-specific tools.

Psychological differences between early- and late-onset psoriasis: a study of personality traits, anxiety and depression in psoriasis.

BACKGROUND: Onset of psoriasis may occur at any age. Early negative experiences often influence personality development, and may lead to physical disease, anxiety and depression in adulthood. Knowledge about onset of psoriasis and psychopathology is limited. OBJECTIVES: To examine whether patients with early-onset psoriasis differ psychologically from patients with late-onset psoriasis, regarding personality traits, anxiety and depression. METHODS: A descriptive cross-sectional study was conducted among 101 consecutively recruited outpatients with psoriasis. A psychosocial interview was performed followed by self-assessment of validated questionnaires: Swedish Universities Scales of Personality (SSP), Spielberger State-Trait Anxiety Inventory and Beck Depression Inventory. Psoriasis severity was assessed by the Psoriasis Area and Severity Index. RESULTS: Patients with early-onset psoriasis (age < 20 years) were significantly more anxious and depressed than patients with late-onset psoriasis. In multiple linear regression models, younger age at onset of psoriasis was a significant determinant of higher scores of four personality traits: SSP-embitterment, -trait irritability, -mistrust and -verbal trait aggression. CONCLUSIONS: Our results indicate that early detection of psychological vulnerability when treating children and adolescents with psoriasis seems to be of great importance. Traits of psychological vulnerability and pessimistic personality traits were found to be significantly associated with the early onset of psoriasis, but not with disease duration in this study. These traits may be seen as a consequence of psoriasis, and/or as individual traits modulating and impairing clinical course and efforts to cope with psoriasis.

A longitudinal 2-year follow-up of quality of life in women referred for colposcopy after an abnormal cervical smear.

OBJECTIVE: To evaluate the long-term impact on quality of life (QoL) in women referred for colposcopy after an abnormal cervical smear. STUDY DESIGN: One hundred consecutive women referred for colposcopy for the first time subsequent to receiving notification of an abnormal cervical smear. Women in the study group completed the Swedish Health Survey Short Form-36 (SF-36), the State/Trait Anxiety Inventory (STAI, Form Y), and the Montgomery Asberg Depression Rating Scale, Self-rate (MADRS-S). The women had follow-up visits at 6 months and 2 years. RESULTS: The baseline mean for the mental component summary score and for all mental subscale scores on the SF-36 were statistically significantly lower than Swedish normative data for women. At the end of 2 years, the mental component summary scale and vitality were still significantly lower than such data. There were no differences in QoL between women having had treatment with Large Loop Excision of the Transformation Zone (LLETZ) compared to those who did not. When studied separately, non-depressed women felt no impact on QoL whereas women with higher depression scores judged their mental health QoL worse. CONCLUSIONS: Women experienced long-lasting negative effects on their mental health, but not on their physical health after referral for colposcopy. LLETZ had no measurable influence on QoL at any of the visits. This indicates that it is not the severity of the lesions or the treatment itself that affects women but the fact of having had an abnormal cervical smear identified. Depressive mood may be a major variable for the perception of low QoL.

A 2-year follow-up study of anxiety and depression in women referred for colposcopy after an abnormal cervical smear.

OBJECTIVES: The aim of this study was to determine if there were any long-lasting elevated anxiety levels in women attending colposcopy after an abnormal cervical smear. DESIGN: Prospective study. SETTING: Department of Obstetrics and Gynaecology, Malmö University Hospital, Sweden. POPULATION: One hundred consecutive women were invited to participate when referred for colposcopy. METHODS: Women in the study group completed the State-Trait Anxiety Inventory, the Montgomery-Asberg Depression Rating Scale-self-rate (MADRS-S) and had a psychosocial interview prior to colposcopy at their two follow-up visits. MAIN OUTCOME MEASURES: State anxiety levels and depression scores at first visit, 6 months and 2 years. RESULTS: At follow up, levels of state anxiety and the depression scores of the women studied had decreased and were comparable to those of Swedish normative data. Two variables from the MADRS-S, 'ability to focus on different activities' and 'emotional involvement with others and in activities' were the most prominent for women with moderate to severe depression. At the 2-year visit, 30% of the women still had a fear of cancer. CONCLUSIONS: Referral for colposcopy after an abnormal cervical smear does not seem to result in long-lasting anxiety and depression. However, a subgroup of women, with the initially highest depression scores, still had at 2-year state anxiety levels and depression scores significantly higher than normal. Almost one-third of the women still had a fear of cancer in spite of lower 2-year state anxiety levels.

A longitudinal study of sexual functioning in women referred for colposcopy: a 2-year follow up.

OBJECTIVE: To elucidate psychosexual problems in women referred for colposcopy after an abnormal cervical smear and a 6-month and 2-year follow up. DESIGN: Prospective study. SETTING: Department of Gynaecology, Malmö University Hospital, Sweden. POPULATION: One hundred consecutive women referred for colposcopy for the first time subsequent to receiving notification of an abnormal cervical smear. METHODS: The women completed the State-Trait Anxiety Inventory, a psychosexual questionnaire and had one psychosocial interview prior to colposcopy at all three visits. MAIN OUTCOME MEASURES: Depending upon the result of the cervical biopsy, women had either a loop electrosurgical excision procedure (LEEP) or not. Psychosexual variables, anxiety measures, and psychosocial variables were used to estimate sexual functioning at the beginning of the study and at follow up. Differences in sexual functioning between LEEP and non-LEEP groups were estimated. RESULTS: 'Spontaneous interest in sex', 'frequency of intercourse', and 'sexual arousal' were reported to be statistically significant lower at 6 months compared with the first visit, and at 2 years, 'spontaneous interest in sex' and 'frequency of intercourse' still remained low. There was no difference in sexual functioning between the LEEP and non-LEEP groups at follow up. CONCLUSIONS: Two years after referral for colposcopy, women still had an effect on sexual functioning, that is, lesser 'spontaneous interest' and decreased 'frequency of intercourse'. We found no support for a relationship between treatment of cervical intraepithelial neoplasia by LEEP and deterioration in sexual functioning.

Clonal success of piliated penicillin nonsusceptible pneumococci.

Antibiotic resistance in pneumococci is due to the spread of strains belonging to a limited number of clones. The Spain(9V)-3 clone of sequence type (ST)156 is one of the most successful clones with reduced susceptibility to penicillin [pneumococci nonsusceptible to penicillin (PNSP)]. In Sweden during 2000-2003, a dramatic increase in the number of PNSP isolates was observed. Molecular characterization of these isolates showed that a single clone of sequence type ST156 increased from 40% to 80% of all serotype 14, thus causing the serotype expansion. Additionally, during the same time period, we examined the clonal composition of two serotypes 9V and 19F: all 9V and 20% of 19F isolates belonged to the clonal cluster of ST156, and overall approximately 50% of all PNSP belonged to the ST156 clonal cluster. Moreover, microarray and PCR analysis showed that all ST156 isolates, irrespective of capsular type, carried the rlrA pilus islet. This islet was also found to be present in the penicillin-sensitive ST162 clone, which is believed to be the drug-susceptible ancestor of ST156. Competitive experiments between related ST156 serotype 19F strains confirmed that those containing the rlrA pilus islet were more successful in an animal model of carriage. We conclude that the pilus island is an important biological factor common to ST156 isolates and other successful PNSP clones. In Sweden, a country where the low antibiotic usage does not explain the spread of resistant strains, at least 70% of all PNSP isolates collected during year 2003 carried the pilus islet.

A Palaeolithic diet improves glucose tolerance more than a Mediterranean-like diet in individuals with ischaemic heart disease.

AIMS/HYPOTHESIS: Most studies of diet in glucose intolerance and type 2 diabetes have focused on intakes of fat, carbohydrate, fibre, fruits and vegetables. Instead, we aimed to compare diets that were available during human evolution with more recently introduced ones. METHODS: Twenty-nine patients with ischaemic heart disease plus either glucose intolerance or type 2 diabetes were randomised to receive (1) a Palaeolithic ('Old Stone Age') diet (n = 14), based on lean meat, fish, fruits, vegetables, root vegetables, eggs and nuts; or (2) a Consensus (Mediterranean-like) diet (n = 15), based on whole grains, low-fat dairy products, vegetables, fruits, fish, oils and margarines. Primary outcome variables were changes in weight, waist circumference and plasma glucose AUC (AUC Glucose(0-120)) and plasma insulin AUC (AUC Insulin(0-120)) in OGTTs. RESULTS: Over 12 weeks, there was a 26% decrease of AUC Glucose(0-120) (p = 0.0001) in the Palaeolithic group and a 7% decrease (p = 0.08) in the Consensus group. The larger (p = 0.001) improvement in the Palaeolithic group was independent (p = 0.0008) of change in waist circumference (-5.6 cm in the Palaeolithic group, -2.9 cm in the Consensus group; p = 0.03). In the study population as a whole, there was no relationship between change in AUC Glucose(0-120) and changes in weight (r = -0.06, p = 0.9) or waist circumference (r = 0.01, p = 1.0). There was a tendency for a larger decrease of AUC Insulin(0-120) in the Palaeolithic group, but because of the strong association between change in AUC Insulin(0-120) and change in waist circumference (r = 0.64, p = 0.0003), this did not remain after multivariate analysis. CONCLUSIONS/INTERPRETATION: A Palaeolithic diet may improve glucose tolerance independently of decreased waist circumference.

A prospective Swedish cohort study on psychosocial factors influencing anxiety in women referred for colposcopy.

OBJECTIVES: To elucidate risk factors for high state anxiety in women referred for colposcopy. DESIGN: Prospective cohort study. SETTING: Department of Gynaecology, Malmö University Hospital, Sweden. POPULATION: A total of 100 consecutive women referred for colposcopy for the first time after an abnormal cervical smear. METHODS: Women in the study group completed prior to colposcopy the State-Trait Anxiety Inventory, the Montgomery-Asberg Depression Rating Scale-self-rate, and were interviewed about their psychosocial situation. MAIN OUTCOME MEASURES: Variables related to high state anxiety were determined in bivariate and multiple logistic regression analysis. RESULTS: High depression scores and the wording of the referral letter for colposcopy were related to high state anxiety in a multivariate analysis. Women with high depression scores had a nine-fold risk for higher levels of state anxiety and did not respond with lower state anxiety levels after information and examination. Women who received a letter stating 'some changes' were at a five-fold increased risk for high levels of state anxiety than those who received a letter stating 'light changes'. CONCLUSION: A depressive mood and the wording of the referral letter for colposcopy after an abnormal smear were predictive of high state anxiety levels.

Clonal and capsular types decide whether pneumococci will act as a primary or opportunistic pathogen.

BACKGROUND: Streptococcus pneumoniae is a major cause of morbidity and mortality worldwide. The role of the different capsular and clonal types in invasive disease severity remains to be defined. METHODS: Disease severity and disease type were correlated to age, underlying disease, capsular serotype, and clonal type of the causative agent for 494 adult patients with invasive pneumococcal disease. RESULTS: Pneumococcal isolates of serotypes 1 and 7F were genetically homogenous, had the highest potential to infect previously healthy individuals, and were not causing deaths. Also, type 1 isolates were only found among younger adults, whereas other serotypes were mainly found among elderly persons (e.g., type 23F). Some serotypes and/or clones were more prone to cause more-severe disease, as observed by high APACHE II scores calculated at admission, and were also associated with a high mortality (e.g., clones of type 3 and 11A). We found no evidence of an impact of penicillin resistance on disease severity and disease type. CONCLUSIONS: We suggest that clones with capsular types 1 and 7F, which are known to have a high invasive disease potential, behave as primary pathogens, whereas clones with other capsular types with a lower relative risk of causing invasive disease are more opportunistic, primarily affecting patients with underlying disease. Disease caused by the latter group, however, was more severe, even in previously healthy individuals.

Effect of clonal and serotype-specific properties on the invasive capacity of Streptococcus pneumoniae.

The present study compares the molecular epidemiology of Streptococcus pneumoniae causing invasive disease and carriage, respectively, in one geographic area (Stockholm, Sweden) during a specific point in time (the year 1997). A total of 273 invasive isolates (257 from adults and 16 from children) obtained from the 2 major hospitals in Stockholm, as well as 246 nasopharyngeal isolates recovered from children attending 16 day-care centers in the Stockholm area, were analyzed by serotyping, molecular typing (by pulsed-field gel electrophoresis and multilocus sequence typing), and antibiotic susceptibility testing. Of the 34 different serotypes plus nontypeable strains identified in the present study, 12 were never found among the 246 colonizing isolates, whereas only 3 were never found among the 273 invasive isolates. The isolates formed 2 major classes: 1 class that was found mainly among invasive isolates (type 1, 4, 7F, and 9V isolates) and was clonally highly related and 1 class that caused invasive disease but was also common in carriage (including type 6A, 6B, 14, and 19F isolates) and was genetically more diverse. Clones were found that belonged to the same serotype but had different abilities to cause invasive disease. Also, isolates belonging to the same clone were found, although they had different capsules because of serotype switch, and were found to have the same disease potential. Hence, properties associated with a particular clonal type, in addition to capsular serotype, are likely to be important for the potential of pneumococci to cause invasive disease.

Association of Mycoplasma genitalium with nongonococcal urethritis in heterosexual men.

Chlamydia trachomatis and Neisseria gonorrhoeae are universally acknowledged as urethral pathogens, yet the etiology in the majority of cases of urethritis is unclear. Our case-control study assessed the association of Mycoplasma genitalium, Ureaplasma urealyticum, and other potential pathogens with acute nongonococcal urethritis (NGU) in heterosexual men presenting to an urban sexually transmitted diseases clinic. M. genitalium was detected in 27 (22%) of 121 NGU case patients and in 5 (4%) of 117 control subjects (P<.01). Although C. trachomatis was detected in 36 (30%) of 121 NGU case patients and in 4 (3%) of 117 control subjects (P<.01), only 3 men with NGU were infected with both C. trachomatis and M. genitalium. U. urealyticum was not associated with NGU. By multivariate analyses, controlling for age, race, history of prior urethritis, and chlamydial infection, M. genitalium was associated with a 6.5-fold increased risk of urethritis (95% confidence interval, 2.1-19.5), which supports a role of this organism in the etiology of NGU.

Sparfloxacin selects gyrase mutations in first-step Mycoplasma hominis mutants, whereas ofloxacin selects topoisomerase IV mutations.

The role of mutations in the genes for GyrA and ParC in quinolone resistance in Mycoplasma hominis was studied. Selection with sparfloxacin gave mutations at GyrA83 (Ser-->Leu; Escherichia coli numbering) or GyrA87 (Glu-->Lys), and mutants had increased levels of resistance to sparfloxacin (8- to 16-fold) but not to ofloxacin. Selection with ofloxacin gave changes at ParC80 (Ser-->Ile) or ParC84 (Glu-->Lys), and mutants were four- to eightfold more resistant to ofloxacin but not to sparfloxacin. Selection of second-step mutants from strains with ParC mutations with either quinolone yielded double mutants with additional mutations at GyrA83 (Ser-->Trp or Ser-->Leu) or GyrA87 (Glu-->Lys). Second-step selection of GyrA mutants gave additional mutations at ParC80 (Ser-->Ile) or ParC84 (Glu-->Lys). Two-step mutants showed high levels of resistance to ofloxacin (MICs, 64 to 128 microg/ml) and moderate levels of resistance to sparfloxacin (MICs, 2 to 8 microg/ml). The primary target of ofloxacin in first-step mutants of Mycoplasma hominis was ParC, whereas that for sparfloxacin was GyrA.

Do pre-, early, and mid-pregnancy life events influence gestational length?

The aim of this study was to determine whether the frequency and quality of reported life events during the 6 months before pregnancy to mid-pregnancy influence gestational age at birth. Seventy nulliparous women were studied at 12 and 25 gestational weeks with a 64-item self-rated life event questionnaire developed for obstetric groups. Life events were categorised into eight psychosocial areas according to the diagnostic and statistic manual (DSM-III-R). The women rated each experienced event as strainful or not strainful. Gestational age was determined by ultrasound biometry before 20 gestational weeks. The number of life events during the following periods was recorded from 6 months before pregnancy to 12 gestational weeks, from 12 gestational weeks to 25 gestational weeks, from 6 months before pregnancy to 25 gestational weeks. No significant relationships were found between the number of reported life events and pregnancy duration. Life events in different psychosocial areas also did not influence gestational age at birth. A non-significant relationship (p = 0.06) was found between pregnancy duration and the number of strainful events reported from 6 months before pregnancy to 25 gestational weeks, shorter pregnancy duration being found in women reporting many strainful events. Our findings suggest that life events in general do not influence pregnancy duration. However, if they are perceived as strainful, pregnancy length tends to decrease.

Use of initial risk assessment and recording as the main nursing intervention in identifying risk of falls.

The consequences of falls among hospital patients are a great problem, for the patient, the family and society, and cost billions of dollars. In Sweden, almost one-third of all hip fractures occur in the hospital population. Despite this, very few prevention strategies have been developed and tested. In this study, a risk assessment and recording programme in relation to the risk of falling among patients in a geriatric department at a Swedish hospital was implemented. The records of all patients admitted to a geriatric unit during one year, and a stratified random sample of patient records, constituting the control group from the year before, were reviewed. No recording of assessments regarding the patients' risk of falling, and no preventive nursing interventions, were found in the records of the control group. The study group, however, increased the recording of risk assessment to 96%. Only implemented nursing interventions were found in the patients' records, despite the fact that Swedish law makes it obligatory for the registered nurse to record both the planning and implementation of nursing care. In the study group there were explicit descriptions of problems of concern for nursing regarding the patients' risk of falling in less than one-third of the records, the nursing care plans were rare, and the evaluations were not satisfactory. Nursing interventions consisted mostly of information or education, promotion of patient participation, and structuring of the environment. There was no agreement on any standard-care plan. Recording of falls was found more often in the study group than in the control group (probably due to more careful recording), but the proportion of injuries in relation to falls was higher in the control group. The results of this study may be used as a baseline for developing a nursing strategy and documentation relating to falls.

Clinical expression of Best's vitelliform macular dystrophy in Swedish families with mutations in the bestrophin gene.

OBJECTIVE: To examine the clinical phenotype of three Swedish families with Best's vitelliform macular dystrophy (BMD) and three different mutations in the recently identified bestrophin gene. METHODS: Three families, including 13 patients, were examined clinically using visual acuity testing, electro-oculography, fundus inspection, and fundus photography. The mutations were previously determined by direct sequence analysis of the individual exons in the bestrophin gene. RESULTS: The largest family (SL76), with the Y85K (T357C) mutation in the bestrophin gene, demonstrated a clinical phenotype characterized by a variable degree of visual acuity reduction and a marked intrafamilial variability in macular pathology. The electro-oculograms, however, demonstrated similar results in all patients regardless of the severity of the macular dysfunction. The smallest family (SL3), with the mutation V9A (T130C) in the bestrophin gene, and the family (SL2) with the mutation D104E (C416A) demonstrated a similar clinical phenotype. The majority of patients (11/13 examined subjects) had a binocular visual acuity of 20/63 or better at a late stage of the disease course, indicating a relatively good prognosis for visual acuity in this specific phenotype. The ophthalmoscopic changes were followed in one of the patients for 38 years and in three of the patients for 19 years and showed that the macular appearance seems to be stable after adolescence. CONCLUSIONS: Patients with BMD and mutations in the bestrophin gene have a similar clinical phenotype characterized by a variable, but relatively moderate visual acuity reduction, atrophic changes in the macula, and pathological results of the electro-oculograms. The macular appearance remains essentially unchanged through the atrophic stage (stage IV) in the majority of patients, indicating a stationary disease course associated with this specific genotype.