General practitioners' and community pharmacists' beliefs and practices on opioids for non-malignant pain.

BACKGROUND: In Europe, opioid use has surged, largely due to prescriptions for chronic non-malignant pain (CNMP). General practitioners (GPs) and community pharmacists (CPs) play a major role in opioid prescribing for non-malignant pain. Exploring their personal beliefs and practices might reveal underlying mechanisms to identify measures that could halt the further escalation of opioid use. METHODS: Guided by the health belief model, a survey was designed and distributed nationwide to examine the practices and beliefs of GPs and CPs in the domains: threats, benefits, barriers and self-efficacy. The results of GPs and CPs were compared at the statement level using chi-square analysis. RESULTS: Of 214 GPs and 212 CPs who completed the survey, the majority agreed that too many opioids are used in the treatment of chronic non-malignant pain (66.8% GPs and 66.5% CPs). Furthermore, they were concerned about the addictive potential of opioids (83.1% GPs and 71.7% CPs). In general, both professions have concerns about opioid use. GPs report a slightly higher degree of self-efficacy and perceive fewer benefits from opioids in treating CNMP. GPs and CPs valued the recommended measures to reduce opioid prescribing, yet less than half actively implement these strategies in their clinics. CONCLUSION: GPs and CPs believe that opioids are being used too frequently to treat CNMP. However, both professions lack the actions to improve opioid-related care. GPs and CPs require education, collaboration and tools to implement guidelines on non-malignant pain and opioids. SIGNIFICANCE: This study, guided by the health belief model, reveals that general practitioners and community pharmacists have serious concerns about opioid use in chronic non-malignant pain. Despite shared concerns, both professions differ in their beliefs about opioid benefits and perceived self-efficacy. Both professions have in common that they value recommended measures to reduce opioid prescribing. Also, they both struggle to implement strategies, emphasizing the urgent need for education, collaboration and tools to align practices with guidelines on non-malignant pain and opioids.

Next generation physiologically based kinetic (NG-PBK) models in support of regulatory decision making.

The fields of toxicology and chemical risk assessment seek to reduce, and eventually replace, the use of animals for the prediction of toxicity in humans. In this context, physiologically based kinetic (PBK) modelling based on in vitro and in silico kinetic data has the potential to a play significant role in reducing animal testing, by providing a methodology capable of incorporating in vitro human data to facilitate the development of in vitro to in vivo extrapolation of hazard information. In the present article, we discuss the challenges in: 1) applying PBK modelling to support regulatory decision making under the toxicology and risk-assessment paradigm shift towards animal replacement; 2) constructing PBK models without in vivo animal kinetic data, while relying solely on in vitro or in silico methods for model parameterization; and 3) assessing the validity and credibility of PBK models built largely using non-animal data. The strengths, uncertainties, and limitations of PBK models developed using in vitro or in silico data are discussed in an effort to establish a higher degree of confidence in the application of such models in a regulatory context. The article summarises the outcome of an expert workshop hosted by the European Commission Joint Research Centre (EC-JRC) - European Union Reference Laboratory for Alternatives to Animal Testing (EURL ECVAM), on "Physiologically-Based Kinetic modelling in risk assessment - reaching a whole new level in regulatory decision-making" held in Ispra, Italy, in November 2016, along with results from an international survey conducted in 2017 and recently reported activities occurring within the PBK modelling field. The discussions presented herein highlight the potential applications of next generation (NG)-PBK modelling, based on new data streams.

Detection of titanium particles in human liver and spleen and possible health implications.

BACKGROUND: Titanium dioxide (TiO2) is produced at high volumes and applied in many consumer and food products. Recent toxicokinetic modelling indicated the potential of TiO2 to accumulate in human liver and spleen upon daily oral exposure, which is not routinely investigated in chronic animal studies. A health risk from nanosized TiO2 particle consumption could not be excluded then. RESULTS: Here we show the first quantification of both total titanium (Ti) and TiO2 particles in 15 post-mortem human livers and spleens. These low-level analyses were enabled by the use of fully validated (single particle) inductively coupled plasma high resolution mass spectrometry ((sp)ICP-HRMS) detection methods for total Ti and TiO2 particles. The presence of TiO2 in the particles in tissues was confirmed by Scanning Electron Microscopy with energy dispersive X-ray spectrometry. CONCLUSIONS: These results prove that TiO2 particles are present in human liver and spleen, with ≥24% of nanosize (< 100 nm). The levels are below the doses regarded as safe in animals, but half are above the dose that is deemed safe for liver damage in humans when taking into account several commonly applied uncertainty factors. With these new and unique human data, we remain with the conclusion that health risks due to oral exposure to TiO2 cannot be excluded.

Use of the Threshold of Toxicological Concern (TTC) approach for deriving target values for drinking water contaminants.

Ongoing pollution and improving analytical techniques reveal more and more anthropogenic substances in drinking water sources, and incidentally in treated water as well. In fact, complete absence of any trace pollutant in treated drinking water is an illusion as current analytical techniques are capable of detecting very low concentrations. Most of the substances detected lack toxicity data to derive safe levels and have not yet been regulated. Although the concentrations in treated water usually do not have adverse health effects, their presence is still undesired because of customer perception. This leads to the question how sensitive analytical methods need to become for water quality screening, at what levels water suppliers need to take action and how effective treatment methods need to be designed to remove contaminants sufficiently. Therefore, in the Netherlands a clear and consistent approach called 'Drinking Water Quality for the 21st century (Q21)' has been developed within the joint research program of the drinking water companies. Target values for anthropogenic drinking water contaminants were derived by using the recently introduced Threshold of Toxicological Concern (TTC) approach. The target values for individual genotoxic and steroid endocrine chemicals were set at 0.01 µg/L. For all other organic chemicals the target values were set at 0.1 µg/L. The target value for the total sum of genotoxic chemicals, the total sum of steroid hormones and the total sum of all other organic compounds were set at 0.01, 0.01 and 1.0 µg/L, respectively. The Dutch Q21 approach is further supplemented by the standstill-principle and effect-directed testing. The approach is helpful in defining the goals and limits of future treatment process designs and of analytical methods to further improve and ensure the quality of drinking water, without going to unnecessary extents.

Time-resolved characterization of primary emissions from residential wood combustion appliances.

Primary emissions from a log wood burner and a pellet boiler were characterized by online measurements of the organic aerosol (OA) using a high-resolution time-of-flight aerosol mass spectrometer (HR-TOF-AMS) and of black carbon (BC). The OA and BC concentrations measured during the burning cycle of the log wood burner, batch wise fueled with wood logs, were highly variable and generally dominated by BC. The emissions of the pellet burner had, besides inorganic material, a high fraction of OA and a minor contribution of BC. However, during artificially induced poor burning BC was the dominating species with ∼80% of the measured mass. The elemental O:C ratio of the OA was generally found in the range of 0.2-0.5 during the startup phase or after reloading of the log wood burner. During the burnout or smoldering phase, O:C ratios increased up to 1.6-1.7, which is similar to the ratios found for the pellet boiler during stable burning conditions and higher than the O:C ratios observed for highly aged ambient OA. The organic emissions of both burners have a very similar H:C ratio at a given O:C ratio and therefore fall on the same line in the Van Krevelen diagram.

Online characterization of regulated and unregulated gaseous and particulate exhaust emissions from two-stroke mopeds: a chemometric approach.

Two-stroke mopeds are a popular and convenient mean of transport in particular in the highly populated cities. These vehicles can emit potentially toxic gaseous and aerosol pollutants due to their engine technology. The legislative measurements of moped emissions are based on offline methods; however, the online characterization of gas and particulate phases offers great possibilities to understand aerosol formation mechanism and to adapt future emission standards. The purpose of this work was to study the emission behavior of two mopeds complying with different European emission standards (EURO-1 and EURO-2). A sophisticated set of online analyzers was applied to simultaneously monitor the gas phase and particulate phase of exhaust on a real time basis. The gaseous emission was analyzed with a high resolution Fourier transform infrared spectrometer (FTIR; nitrogen species) and a resonance-enhanced multiphoton ionization time-of-flight mass spectrometer (REMPI-ToF-MS; polycyclic aromatic hydrocarbons: PAH), whereas the particulate phase was chemically characterized by a high-resolution time-of-flight aerosol mass spectrometer (HR-ToF-AMS; organic, nitrate and chloride aerosol) and a multiangle absorption photometer (MAAP; black carbon). The physical characterization of the aerosol was carried out with a condensation particle counter (CPC; particle number concentration) and a fast mobility particle sizer (FMPS; size distribution in real time). In order to extract underlying correlation between gas and solid emissions, principal component analysis was applied to the comprehensive online dataset. Multivariate analysis highlighted the considerable effect of the exhaust temperature on the particles and heavy PAH emissions. The results showed that the after-treatment used to comply with the latest EURO-2 emission standard may be responsible for the production of more potentially harmful particles compared to the EURO-1 moped emissions.

International round-robin study on the Ames fluctuation test.

An international round-robin study on the Ames fluctuation test [ISO 11350, 2012], a microplate version of the classic plate-incorporation method for the detection of mutagenicity in water, wastewater and chemicals was performed by 18 laboratories from seven countries. Such a round-robin study is a precondition for both the finalization of the ISO standardization process and a possible regulatory implementation in water legislation. The laboratories tested four water samples (spiked/nonspiked) and two chemical mixtures with and without supplementation of a S9-mix. Validity criteria (acceptable spontaneous and positive control-induced mutation counts) were fulfilled by 92-100%, depending on the test conditions. A two-step method for statistical evaluation of the test results is proposed and assessed in terms of specificity and sensitivity. The data were first subjected to powerful analysis of variance (ANOVA) after an arcsine-square-root transformation to detect significant differences between the test samples and the negative control (NC). A threshold (TH) value based on a pooled NC was then calculated to exclude false positive test results. Statistically, positive effects observed by the William's test were considered negative, if the mean of all replicates of a sample did not exceed the calculated TH. By making use of this approach, the overall test sensitivity was 100%, and the test specificity ranged from 80 to 100%.

Formation and removal of genotoxic activity during UV/H(2)O(2)-GAC treatment of drinking water.

The objective of this study was to determine the genotoxic activity of water after UV/H(2)O(2) oxidation and GAC filtration. Pre-treated surface water from three locations was treated with UV/H(2)O(2) with medium pressure (MP) lamps and passed through granulated activated carbon (GAC). Samples taken before and after each treatment step were extracted and concentrated by solid phase extraction (SPE) and analyzed for genotoxicity using the Comet assay with HepG2 cells and the Ames II assay. The Comet assay showed no genotoxic response in any of the samples. In the Ames II, no genotoxic response was obtained with the TAMix (a mix of six strains), but the TA98 strain showed an increase in genotoxic activity after MP-UV/H(2)O(2) for all three locations. GAC post treatment effectively reduced the activities to control levels at two of the three locations and to below the level of the pre-treated water at one site. The results indicate that UV/H(2)O(2) treatment may lead to the formation of genotoxic by-products, which can be removed by subsequent GAC filtration.

Application of modern online instrumentation for chemical analysis of gas and particulate phases of exhaust at the European Commission heavy-duty vehicle emission laboratory.

The European Commission recently established a novel test facility for heavy-duty vehicles to enhance more sustainable transport. The facility enables the study of energy efficiency of various fuels/scenarios as well as the chemical composition of evolved exhaust emissions. Sophisticated instrumentation for real-time analysis of the gas and particulate phases of exhaust has been implemented. Thereby, gas-phase characterization was carried out by a Fourier transform infrared spectrometer (FT-IR; carbonyls, nitrogen-containing species, small hydrocarbons) and a resonance-enhanced multiphoton ionization time-of-flight mass spectrometer (REMPI-TOFMS; monocyclic and polycyclic aromatic hydrocarbons). For analysis of the particulate phase, a high-resolution time-of-flight aerosol mass spectrometer (HR-TOF-AMS; organic matter, chloride, nitrate), a condensation particle counter (CPC; particle number), and a multiangle absorption photometer (MAAP; black carbon) were applied. In this paper, the first application of the new facility in combination with the described instruments is presented, whereby a medium-size truck was investigated by applying different driving cycles. The goal was simultaneous chemical characterization of a great variety of gaseous compounds and particulate matter in exhaust on a real-time basis. The time-resolved data allowed new approaches to view the results; for example, emission factors were normalized to time-resolved consumption of fuel and were related to emission factors evolved during high speeds. Compounds could be identified that followed the fuel consumption, others showed very different behavior. In particular, engine cold start, engine ignition (unburned fuel), and high-speed events resulted in unique emission patterns.

Evaluation of the particle measurement programme (PMP) protocol to remove the vehicles' exhaust aerosol volatile phase.

European regulation for Euro 5/6 light duty emissions introduced the measurement of non-volatile particles with diameter >23 nm. The volatile phase is removed by using a heated dilution stage (150 degrees C) and a heated tube (at 300-400 degrees C). We investigated experimentally the removal efficiency for volatile species of the specific protocol by conducting measurements with two Euro 3 diesel light duty vehicles, a Euro 2 moped, and a Euro III heavy duty vehicle with the system's heaters on and off. The particle number distributions were measured with a Scanning Mobility Particle Sizer (SMPS) and a Fast Mobility Particle Sizer (FMPS). An Aerosol Mass Spectrometer (AMS) was used to identify the non-refractory chemical composition of the particles. A Multi-Angle Absorption Photometer (MAAP) was used to measure the black carbon concentration. The results showed that the condensed material in the accumulation mode (defined here as particles in the diameter range of approximately 50-500 nm) was removed with an efficiency of 50-90%. The (volatile) nucleation mode was also completely evaporated or was decreased to sizes <23 nm; thus these particles wouldn't be counted from the particle counter, indicating the robustness of the protocol.

Oxidative potential of logwood and pellet burning particles assessed by a novel profluorescent nitroxide probe.

This study reports the potential toxicological impact of particles produced during biomass combustion by an automatic pellet boiler and a traditional logwood stove under various combustion conditions using a novel profluorescent nitroxide probe, BPEAnit. This probe is weakly fluorescent but yields strong fluorescence emission upon radical trapping or redox activity. Samples were collected by bubbling aerosol through an impinger containing BPEAnit solution, followed by fluorescence measurement. The fluorescence of BPEAnit was measured for particles produced during various combustion phases: at the beginning of burning (cold start), stable combustion after refilling with the fuel (warm start), and poor burning conditions. For particles produced by the logwood stove under cold-start conditions, significantly higher amounts of reactive species per unit of particulate mass were observed compared to emissions produced during a warm start. In addition, sampling of logwood burning emissions after passing through a thermodenuder at 250 degrees C resulted in an 80-100% reduction of the fluorescence signal of the BPEAnit probe, indicating that the majority of reactive species were semivolatile. Moreover, the amount of reactive species showed a strong correlation with the amount of particulate organic material. This indicates the importance of semivolatile organics in particle-related toxicity. Particle emissions from the pellet boiler, although of similar mass concentration, were not observed to lead to an increase in fluorescence signal during any of the combustion phases.

[Tertiary obstetric care: the aims of the planning decree on perinatal care of 2001 have not yet been achieved]. / Derdelijns verloskundige zorg: doelstellingen van het 'planningsbesluit bijzondere perinatologische zorg' uit 2001 nog niet gehaald.

OBJECTIVE: To compare the actual situation in tertiary perinatal care in the Netherlands with the objectives laid down in the 2001 decree on perinatal care by the Dutch Ministry of Health, Welfare and Sport. DESIGN: Descriptive, retrospective. METHOD: Data on tertiary perinatal care, the transfer or refusal of women with very endangered pregnancies and the personnel of obstetric high care (OHC) units in 2006 were compared with the targets laid down in the planning decree on perinatal care and in a report by the Dutch Health Council from 2000. Parameters of tertiary perinatal care output were the number of admissions, and the number of beds in OHC units and neonatal intensive care units (NICU). RESULTS: In 2006, 128 of the 250 beds intended for OHC had been obtained. The degree of capacity utilisation was 94%, while the norm is 80%. 312 women were transferred due to lack of capacity of OHC units and NICU. The number of staff, specialised physicians as well as nurses, was considerably lower than the planned capacity. But training for obstetric perinatologists and OHC nurses was given. CONCLUSION: The targets for the number of beds for tertiary obstetric care and associated medical personnel have not been achieved as yet. As a consequence, the number of transfers is still too high. The funding of OHC units is not attuned to the complexity of tertiary perinatal care. Closer supervision of the execution of the planning decree and an adequate financing system are needed to achieve the objectives of the planning decree in the next 3 years.

The Tulip classification of perinatal mortality: introduction and multidisciplinary inter-rater agreement.

OBJECTIVE: To introduce the pathophysiological Tulip classification system for underlying cause and mechanism of perinatal mortality based on clinical and pathological findings for the purpose of counselling and prevention. DESIGN: Descriptive. SETTING: Tertiary referral teaching hospital. POPULATION: Perinatally related deaths. METHODS: A classification consisting of groups of cause and mechanism of death was drawn up by a panel through the causal analysis of the events related to death. Individual classification of cause and mechanism was performed by assessors. Panel discussions were held for cases without consensus. MAIN OUTCOME MEASURES: Inter-rater agreement for cause and mechanism of death. RESULTS: The classification consists of six main causes with subclassifications: (1) congenital anomaly (chromosomal, syndrome and single- or multiple-organ system), (2) placenta (placental bed, placental pathology, umbilical cord complication and not otherwise specified [NOS]), (3) prematurity (preterm prelabour rupture of membranes, preterm labour, cervical dysfunction, iatrogenous and NOS), (4) infection (transplacental, ascending, neonatal and NOS), (5) other (fetal hydrops of unknown origin, maternal disease, trauma and out of the ordinary) and (6) unknown. Overall kappa coefficient for agreement for cause was 0.81 (95% CI 0.80-0.83). Six mechanisms were drawn up: cardio/circulatory insufficiency, multi-organ failure, respiratory insufficiency, cerebral insufficiency, placental insufficiency and unknown. Overall kappa for mechanism was 0.72 (95% CI 0.70-0.74). CONCLUSIONS: Classifying perinatal mortality to compare performance over time and between centres is useful and necessary. Interpretation of classifications demands consistency. The Tulip classification allows unambiguous classification of underlying cause and mechanism of perinatal mortality, gives a good inter-rater agreement, with a low percentage of unknown causes, and is easily applicable in a team of clinicians when guidelines are followed.

[The practice guideline 'Pregnancy and puerperium' (first revision) from the Dutch College of General Practitioners; a response from the perspective of gynaecology]. / De standaard 'Zwangerschap en kraamperiode' (eerste herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de gynaecologie.

The major benefit of the revised version of the Dutch College of General Practitioners' practice guideline about pregnancy and puerperium is the formal starting point of professional equality of midwives and general practitioners as care providers in antenatal and postpartum care. This thorough evidence-based practice guideline is behind the most recent developments in this field. Scientific evidence on vertical HIV transmission favours screening all pregnant women and not just the selective procedure proposed in this guideline. The restrictive attitude towards routine ultrasound screening during pregnancy hardly seems in line with scientific evidence and the public demand. On the other hand the guideline is very progressive as far as the care of women with thyroid disorders is concerned even though evidence on this subject is meagre. Most importantly the transition of antenatal care from the current almost conveyor belt-like procedure to an efficient but individually-adapted care process was not addressed.

Review on raloxifene: profile of a selective estrogen receptor modulator.

Raloxifene is a selective estrogen receptor modulator approved for prevention and treatment of osteoporosis in postmenopausal women. Raloxifene has an estrogen-agonistic effect on bone, although it is unclear how this effect comes about. It has been proven that raloxifene decreases levels of both bone formation markers and bone resorption markers in postmenopausal women. Moreover, it preserves the bone mineral density at most skeletal sites in these women. Raloxifene decreases the serum levels of low-density lipoprotein cholesterol and total cholesterol. In breast tissue, raloxifene is an estrogen antagonist. It decreases the risk of breast cancer in postmenopausal women. In contrast to estrogen and tamoxifen, raloxifene does not increase the risk of uterine cancer and it does not cause endometrial proliferation. Raloxifene is rapidly absorbed after oral administration, but its bioavailability is only 2% because of an extensive first-past effect. The maximum plasma concentration of 0.5 ng/ml is reached after 6 hours. Raloxifene is more than 95% bound to plasma proteins and the apparent volume of distribution is 2,348 l/kg. The clearance is 40 - 60 l/kg x h and the half-life of raloxifene after multiple dosing is 32.5 h. Less than 0.2% of an oral dose is excreted unchanged in the urine and less than 6% is excreted in urine as glucuronide conjugates. Serious adverse event caused by raloxifene is a 3-fold increase in the risk of thromboembolic events.

[Pregnancy after liver transplantation in Groningen: benign course for mothers and children]. / Zwangerschappen na levertransplantatie in Groningen: gunstig beloop voor moeder en kind.

OBJECTIVE: Analysing the course and outcome of pregnancies in liver transplant recipients. DESIGN: Retrospective and descriptive. METHOD: Since 1979 liver transplantations have been performed in the University Hospital Groningen, the Netherlands. Seven female patients conceived 12 times after transplantation. These pregnancies were managed by a team of liver transplantation specialists and obstetricians. Hypertensive disorders, foetal growth, liver function tests and infective disorders were monitored specially. The course and outcome of the pregnancies were determined. RESULTS: The incidence of complications was much lower than in published patient series. The differences in premature deliveries (9 versus 40%) and caesarean births (18 versus 57%) are largely explained by the difference of incidence of hypertensive disorders (18 versus 35%). One woman developed a liver function disorder during pregnancy (9 versus 38%). In the long term the function of the donor liver appeared not to be disturbed; this finding is in accordance with data from other reports. Ten of the 12 pregnancies resulted in the birth of a healthy child. All children were born in good condition and all of them were alive at the completion of the study (minimal follow-up: 10 months). CONCLUSION: After liver transplantation there is no need to advise against pregnancy.

The HELLP syndrome: its association with unexplained elevation of MSAFP and MShCG in the second trimester.

In this study, we examined the relationship between concentrations of maternal serum alpha-fetoprotein (MSAFP) and maternal serum human chorionic gonadotropin (MShCG) in the second trimester and the haemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome. The concentrations of both serum markers, expressed in multiples of the median (MOM), in 16 women with the HELLP syndrome were compared with those in 10443 women without this syndrome who were screened for Down's syndrome and neural tube defects. All the women with a singleton pregnancy and a known pregnancy outcome were included in this study. At a cut-off level of 2.5 MOM, 37.5 per cent of the pregnancies with the HELLP syndrome had an elevated MShCG level, compared with 4.8 per cent in the whole population (P < 0.0001). 12.5 per cent of the women with the HELLP syndrome had an elevated MSAFP level, compared with 1.3 per cent in the whole population (P < 0.025). Women with a combined elevation of MSAFP and MShCG levels (0.3 per cent of the screened population) had a 47 time greater risk of developing the HELLP syndrome than the others (P < 0.01). The HELLP syndrome should be taken into account in the case of unexplained elevated levels of MShCG and MSAFP, especially in the rare event of combined elevation of both markers.

The association between hypertensive disorders of pregnancy and abnormal second-trimester maternal serum levels of hCG and alpha-fetoprotein.

OBJECTIVE: To examine the association between hypertensive disorders of pregnancy and second-trimester maternal serum alpha-fetoprotein (MSAFP) and hCG levels. METHODS: The proportions of abnormal second-trimester MSAFP and hCG levels in the serum samples from 65 women with true pregnancy-induced hypertension or preeclampsia (cases) were compared to the proportions of abnormal levels in all 1943 women without this disorder in the same cohort in a hospital setting. Maternal serum alpha-fetoprotein and hCG levels of the 65 cases also were compared to those of 325 completely uncomplicated matched control pregnancies, selected from the same cohort. Fisher exact test and Student t test were used for statistical analysis and P < .05 was considered statistically significant. RESULTS: An MSAFP level at least 2.5 multiples of the median (MoM) was found in two of 65 cases (3.1%) and in 27 of 1943 women (1.4%) in the rest of the cohort, a nonsignificant difference (relative risk [RR] = 2.2; P = .24). The statistical power to identify a significant difference for this RR was .27. An hCG level of at least 2.5 MoM was found in six cases (9.2%) and in 89 (4.6%) of women in the rest of the cohort, also a nonsignificant difference (RR = 2.0; P = .12). The statistical power to identify a significant difference for this RR was .38. The mean (+/-standard deviation) logarithms of the MSAFP and hCG MoMs in the 65 cases (0.039 +/- 0.191 and 0.048 +/- 0.265, respectively) were not significantly different from those in the 325 matched controls (0.006 +/- 0.148 and -0.010 +/- 0.244, respectively; P = .12 and .08, respectively). CONCLUSION: Although a weak association cannot be excluded, this study found no clinically important increase in risk of developing subsequent hypertensive disorders of pregnancy among women with abnormal second-trimester levels of MSAFP or hCG.