Measuring the digital divide among people with severe mental ill health using the essential digital skills framework.

AIMS: Amid the vast digitalisation of health and other services during the pandemic, people with no digital skills are at risk of digital exclusion. This risk might not abate by the end of the pandemic. This article seeks to understand whether people with severe mental ill health (SMI) have the necessary digital skills to adapt to these changes and avoid digital exclusion. METHODS: Two hundred and forty-nine adults with SMI across England completed a survey online or offline. They provided information on their digital skills based on the Essential Digital Skills (EDS) framework, sociodemographic information, and digital access. This is the first time that the EDS is benchmarked in people with SMI. RESULTS: 42.2% had no Foundation Skills, and 46.2% lacked skills for daily life (lacking Foundation or Life Skills). 23.0% of those working lacked skills for professional life (lacking Foundation or Work Skills). The most commonly missing skills were handling passwords and using the device settings (Foundation Skills) and online problem solving (Skills for Life). People were interested in learning more about approximately half of the skills they did not have. People were more likely to lack Foundation Skills if they were older, not in employment, had a psychosis-spectrum disorder, or had no Internet access at home. CONCLUSION: A significant portion of people with SMI lacked Foundation Skills in this objective and benchmarked survey. This points to a high risk for digital exclusion and the need for focused policy and tailored health sector support to ensure people retain access to key services and develop digital skills and confidence. To our knowledge, this is the first time this has been described using the EDS framework. Services, including the National Health Service (NHS), need to be aware of and mitigate the risks.

Risk factors for Klebsiella pneumoniae carbapenemase (KPC) gene acquisition and clinical outcomes across multiple bacterial species.

INTRODUCTION: Risk factors for carbapenemase-producing Enterobacterales (CPE) acquisition/infection and associated clinical outcomes have been evaluated in the context of clonal, species-specific outbreaks. Equivalent analyses for complex, multi-species outbreaks, which are increasingly common, are lacking. METHODS: Between December 2010 and January 2017, a case-control study of Klebsiella pneumoniae carbapenemase (KPC)-producing organism (KPCO) acquisition was undertaken using electronic health records from inpatients in a US academic medical centre and long-term acute care hospital (LTACH) with ongoing multi-species KPCO transmission despite a robust CPE screening programme. Cases had a first KPCO-positive culture >48 h after admission, and included colonizations and infections (defined by clinical records). Controls had at least two negative perirectal screens and no positive cultures. Risk factors for KPCO acquisition, first infection following acquisition, and 14-day mortality following each episode of infection were identified using multi-variable logistic regression. RESULTS: In 303 cases (89 with at least one infection) and 5929 controls, risk factors for KPCO acquisition included: longer inpatient stay, transfusion, complex thoracic pathology, mechanical ventilation, dialysis, and exposure to carbapenems and ß-lactam/ß-lactamase inhibitors. Exposure to other KPCO-colonized patients was only a risk factor for acquisition in a single unit, suggesting that direct patient-to-patient transmission did not play a major role. There were 15 species of KPCO; 61 (20%) cases were colonized/infected with more than one species. Fourteen-day mortality following non-urinary KPCO infection was 20% (20/97 episodes) and was associated with failure to achieve source control. CONCLUSIONS: Healthcare exposures, antimicrobials and invasive procedures increased the risk of KPCO colonization/infection, suggesting potential targets for infection control interventions in multi-species outbreaks. Evidence for patient-to-patient transmission was limited.

Genomic dynamics of species and mobile genetic elements in a prolonged blaIMP-4-associated carbapenemase outbreak in an Australian hospital.

BACKGROUND: Hospital outbreaks of carbapenemase-producing organisms, such as blaIMP-4-containing organisms, are an increasing threat to patient safety. OBJECTIVES: To investigate the genomic dynamics of a 10 year (2006-15) outbreak of blaIMP-4-containing organisms in a burns unit in a hospital in Sydney, Australia. METHODS: All carbapenem-non-susceptible or MDR clinical isolates (2006-15) and a random selection of equivalent or ESBL-producing environmental isolates (2012-15) were sequenced [short-read (Illumina), long-read (Oxford Nanopore Technology)]. Sequence data were used to assess genetic relatedness of isolates (Mash; mapping and recombination-adjusted phylogenies), perform in silico typing (MLST, resistance genes and plasmid replicons) and reconstruct a subset of blaIMP plasmids for comparative plasmid genomics. RESULTS: A total of 46/58 clinical and 67/96 environmental isolates contained blaIMP-4. All blaIMP-4-positive organisms contained five or more other resistance genes. Enterobacter cloacae was the predominant organism, with 12 other species mainly found in either the environment or patients, some persisting despite several cleaning methods. On phylogenetic analysis there were three genetic clusters of E. cloacae containing both clinical and environmental isolates, and an additional four clusters restricted to either reservoir. blaIMP-4 was mostly found as part of a cassette array (blaIMP-4-qacG2-aacA4-catB3) in a class 1 integron within a previously described IncM2 plasmid (pEl1573), with almost complete conservation of this cassette across the species over the 10 years. Several other plasmids were also implicated, including an IncF plasmid backbone not previously widely described in association with blaIMP-4. CONCLUSIONS: Genetic backgrounds disseminating blaIMP-4 can persist, diversify and evolve amongst both human and environmental reservoirs during a prolonged outbreak despite intensive prevention efforts.

A Large, Refractory Nosocomial Outbreak of Klebsiella pneumoniae Carbapenemase-Producing Escherichia coli Demonstrates Carbapenemase Gene Outbreaks Involving Sink Sites Require Novel Approaches to Infection Control.

Carbapenem-resistant Enterobacteriaceae (CRE) represent a health threat, but effective control interventions remain unclear. Hospital wastewater sites are increasingly being highlighted as important potential reservoirs. We investigated a large Klebsiella pneumoniae carbapenemase (KPC)-producing Escherichia coli outbreak and wider CRE incidence trends in the Central Manchester University Hospital NHS Foundation Trust (CMFT) (United Kingdom) over 8 years, to determine the impact of infection prevention and control measures. Bacteriology and patient administration data (2009 to 2017) were linked, and a subset of CMFT or regional hospital KPC-producing E. coli isolates (n = 268) were sequenced. Control interventions followed international guidelines and included cohorting, rectal screening (n = 184,539 screens), environmental sampling, enhanced cleaning, and ward closure and plumbing replacement. Segmented regression of time trends for CRE detections was used to evaluate the impact of interventions on CRE incidence. Genomic analysis (n = 268 isolates) identified the spread of a KPC-producing E. coli outbreak clone (strain A, sequence type 216 [ST216]; n = 125) among patients and in the environment, particularly on 2 cardiac wards (wards 3 and 4), despite control measures. ST216 strain A had caused an antecedent outbreak and shared its KPC plasmids with other E. coli lineages and Enterobacteriaceae species. CRE acquisition incidence declined after closure of wards 3 and 4 and plumbing replacement, suggesting an environmental contribution. However, ward 3/ward 4 wastewater sites were rapidly recolonized with CRE and patient CRE acquisitions recurred, albeit at lower rates. Patient relocation and plumbing replacement were associated with control of a clonal KPC-producing E. coli outbreak; however, environmental contamination with CRE and patient CRE acquisitions recurred rapidly following this intervention. The large numbers of cases and the persistence of blaKPC in E. coli, including pathogenic lineages, are of concern.

Characterizations of handwashing sink activities in a single hospital medical intensive care unit.

BACKGROUND: Handwashing sink drains are increasingly implicated as a potential reservoir of antibiotic-resistant bacteria in hospital outbreaks; however, usage patterns that may promote this source remain unknown. AIM: To understand behaviours in the intensive care unit (ICU) that may facilitate establishment and nosocomial transmission of multidrug-resistant Gram negatives from a sink-trap reservoir to a patient. METHODS: Motion-sensitive cameras captured anonymized activity paired with periodic in-person observations during a quality investigation from four ICU sinks (two patient rooms and two patient bathrooms) in a university hospital. FINDINGS: We analysed 4810 sink videos from 60 days in patient rooms (3625) and adjoining bathrooms (1185). There was a false-positive rate of 38% (1837 out of 4810) in which the camera triggered but no sink interaction occurred. Of the 2973 videos with analysed behaviours there were 5614 observed behaviours which were assessed as: 37.4% medical care, 29.2% additional behaviours, 17.0% hand hygiene, 7.2% patient nutrition, 5.0% environmental care, 4.2% non-medical care. Handwashing was only 4% (224 out of 5614) of total behaviours. Sub-analysis of 2748 of the later videos further categorized 56 activities where a variety of nutrients, which could promote microbial growth, were disposed of in the sink. CONCLUSION: Several non-hand hygiene activities took place regularly in ICU handwashing sinks; these may provide a mechanism for nosocomial transmission and promotion of bacterial growth in the drain. Redesigning hospital workflow and sink usage may be necessary as it becomes apparent that sink drains may be a reservoir for transmission of multidrug-resistant bacteria.

Genomic epidemiology of global Klebsiella pneumoniae carbapenemase (KPC)-producing Escherichia coli.

The dissemination of carbapenem resistance in Escherichia coli has major implications for the management of common infections. bla KPC, encoding a transmissible carbapenemase (KPC), has historically largely been associated with Klebsiella pneumoniae, a predominant plasmid (pKpQIL), and a specific transposable element (Tn4401, ~10 kb). Here we characterize the genetic features of bla KPC emergence in global E. coli, 2008-2013, using both long- and short-read whole-genome sequencing. Amongst 43/45 successfully sequenced bla KPC-E. coli strains, we identified substantial strain diversity (n = 21 sequence types, 18% of annotated genes in the core genome); substantial plasmid diversity (≥9 replicon types); and substantial bla KPC-associated, mobile genetic element (MGE) diversity (50% not within complete Tn4401 elements). We also found evidence of inter-species, regional and international plasmid spread. In several cases bla KPC was found on high copy number, small Col-like plasmids, previously associated with horizontal transmission of resistance genes in the absence of antimicrobial selection pressures. E. coli is a common human pathogen, but also a commensal in multiple environmental and animal reservoirs, and easily transmissible. The association of bla KPC with a range of MGEs previously linked to the successful spread of widely endemic resistance mechanisms (e.g. bla TEM, bla CTX-M) suggests that it may become similarly prevalent.

Electrophilic nitro-fatty acids suppress allergic contact dermatitis in mice.

BACKGROUND: Reactions between nitric oxide (NO), nitrite (NO2-), and unsaturated fatty acids give rise to electrophilic nitro-fatty acids (NO2 -FAs), such as nitro oleic acid (OA-NO2 ) and nitro linoleic acid (LNO2 ). Endogenous electrophilic fatty acids (EFAs) mediate anti-inflammatory responses by modulating metabolic and inflammatory signal transduction reactions. Hence, there is considerable interest in employing NO2 -FAs and other EFAs for the prevention and treatment of inflammatory disorders. Thus, we sought to determine whether OA-NO2 , an exemplary nitro-fatty acid, has the capacity to inhibit cutaneous inflammation. METHODS: We evaluated the effect of OA-NO2 on allergic contact dermatitis (ACD) using an established model of contact hypersensitivity in C57Bl/6 mice utilizing 2,4-dinitrofluorobenzene as the hapten. RESULTS: We found that subcutaneous (SC) OA-NO2 injections administered 18 h prior to sensitization and elicitation suppresses ACD in both preventative and therapeutic models. In vivo SC OA-NO2 significantly inhibits pathways that lead to inflammatory cell infiltration and the production of inflammatory cytokines in the skin. Moreover, OA-NO2 is capable of enhancing regulatory T-cell activity. Thus, OA-NO2 treatment results in anti-inflammatory effects capable of inhibiting ACD by inducing immunosuppressive responses. CONCLUSION: Overall, these results support the development of OA-NO2 as a promising therapeutic for ACD and provides new insights into the role of electrophilic fatty acids in the control of cutaneous immune responses potentially relevant to a broad range of allergic and inflammatory skin diseases.

Horizontal Transfer of Carbapenemase-Encoding Plasmids and Comparison with Hospital Epidemiology Data.

Carbapenemase-producing organisms have spread worldwide, and infections with these bacteria cause significant morbidity. Horizontal transfer of plasmids carrying genes that encode carbapenemases plays an important role in the spread of multidrug-resistant Gram-negative bacteria. Here we investigate parameters regulating conjugation using an Escherichia coli laboratory strain that lacks plasmids or restriction enzyme modification systems as a recipient and also using patient isolates as donors and recipients. Because conjugation is tightly regulated, we performed a systematic analysis of the transfer of Klebsiella pneumoniae carbapenemase (blaKPC)-encoding plasmids into multiple strains under different environmental conditions to investigate critical variables. We used four blaKPC-carrying plasmids isolated from patient strains obtained from two hospitals: pKpQIL and pKPC-47e from the National Institutes of Health, and pKPC_UVA01 and pKPC_UVA02 from the University of Virginia. Plasmid transfer frequency differed substantially between different donor and recipient pairs, and the frequency was influenced by plasmid content, temperature, and substrate, in addition to donor and recipient strain. pKPC-47e was attenuated in conjugation efficiency across all conditions tested. Despite its presence in multiple clinical species, pKPC_UVA01 had lower conjugation efficiencies than pKpQIL into recipient strains. The conjugation frequency of these plasmids into K. pneumoniae and E. coli patient isolates ranged widely without a clear correlation with clinical epidemiological data. Our results highlight the importance of each variable examined in these controlled experiments. The in vitro models did not reliably predict plasmid mobilization observed in a patient population, indicating that further studies are needed to understand the most important variables affecting horizontal transfer in vivo.

A single-center experience with infections due to daptomycin-nonsusceptible Enterococcus faecium in liver transplant recipients.

BACKGROUND: Infections caused by vancomycin-resistant Enterococcus faecium (VRE) are a major cause of morbidity and mortality in the liver transplant population. Daptomycin (DAP) is often used to treat infections caused by VRE, but DAP nonsusceptibility in Enterococcus is increasing. METHOD: Patients with DAP-nonsusceptible Enterococcus (DNSE) infections who had undergone liver transplantation between January 1, 2010 and July 31, 2014 were retrospectively reviewed. A convenience sample of DNSE isolates was analyzed by pulsed-field gel electrophoresis (PFGE). RESULTS: We identified 14 liver transplant recipients (LTRs) who developed DNSE infections post transplantation. Postoperative complications were common, and most patients required repeat abdominal surgery within 90 days of transplantation. The initial DNSE culture was taken a median of 74.5 days post transplant and was secondary to an intra-abdominal infection in all but 1 patient. Half of patients were VRE colonized before or at the time of organ transplantation, and all those who were not VRE colonized at the time of transplantation later became colonized, a median of 27 days post transplant. Overall mortality in this cohort was 71%. PFGE did not demonstrate genetic relatedness among DNSE isolates. CONCLUSION: This study, the largest published series to our knowledge of DNSE infections in LTRs, demonstrates that these infections occur in patients with serious surgical complications and are associated with high morbidity and mortality. Established risk factors for VRE infection were common, as was DAP exposure. Although many risk factors for DNSE infection cannot be changed, this case series identifies several potentially modifiable variables. Further work is needed to identify interventions to decrease the risk of developing DNSE infections in this complex patient population.

Selenium in commercial beer and losses in the brewing process from wheat to beer.

There is increasing interest in enhancing the micronutrient composition of cereals through fertilization. The aims of this study were (1) to determine the Se concentration of commercial beers retailing in the UK, and (2) to test if the transfer of Se, from biofortified grain to final beer product, is <10% under UK cultivation conditions, as seen previously under Mediterranean conditions. The Se concentration of 128 commercial beers was measured, using inductively coupled plasma-mass spectrometry (ICP-MS). The selenium content of commercial beers varied 6.5-fold, with beers originating from America having higher Se concentrations than those from Europe. Laboratory-scale brewing trials with isotopically-enriched (77)Se wheat, sampled from UK field-sites, showed that most (77)Se losses in the brewing process occurred during mashing (54%), with fermented beer containing ∼ 10% of the (77)Se initially present in the wheat grain. Total N values in wort and malt were positively correlated with the (77)Se content of the wheat grain.

Fatal cross infection by carbapenem-resistant Klebsiella in two liver transplant recipients.

Members of the family Enterobacteriaceae including Klebsiella have re-emerged as major pathogens in solid organ transplantation. The recent appearance and dissemination of carbapenemase-producing Enterobacteriaceae in Europe and the northeastern United States represents a major challenge to the treatment of enteric gram-negative bacterial infections in immunocompromised patients; however, few reports have detailed the outcomes of such infections. Here we report 2 cases of Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella infections in orthotopic liver transplant recipients, which were the index case and initial secondary case for an outbreak of KPC-producing Enterobacteriaceae in our institution. In both instances, the pathogens were initially misidentified as being carbapenem sensitive, the infections recurred after cessation of directed therapy, and the patients ultimately succumbed to their infections.

Variations in the investigation and management of group B streptococcus in Scotland.

This article describes the practice of Scottish obstetricians in terms of their investigation and treatment of group B streptococcus (GBS). This was a postal questionnaire survey of all 125 consultant obstetricians in Scotland. We recorded indications for testing for GBS, categories of women to whom treatment is given empirically and following confirmed infection, type of antibiotic used, and timing and route of administration. No respondents screened all pregnant women but 97% screened some or all of those at highest risk. Three-quarters administered antibiotics empirically to women with intrapartum pyrexia. However, other high-risk groups were unlikely to receive treatment without confirmation of colonisation. Only one-third of respondents gave antibiotics to all women with confirmed GBS, and up to one-half withheld them from some colonised women in high-risk groups. Contrary to US guidelines, only 29% tested for GBS using low vaginal swabs and only 13% administered intrapartum antibiotics intravenously. There are wide variations in investigating and treating GBS throughout Scotland. It is likely that similar variations exist throughout the United Kingdom. UK guidelines are required to reduce variations and ensure appropriate and effective management.

Broad ligament twin pregnancy following in-vitro fertilization.

We report the first case of an ectopic twin pregnancy in the broad ligament following in-vitro fertilization and embryo transfer in a patient with a previous ipsilateral (left) salpingo-oophorectomy. The previous surgery was for endometriosis. We discuss the possible contribution of the embryo transfer technique, limitations of preventive measures and importance of transvaginal ultrasound in establishing the diagnosis.

Lipid and lipoprotein concentrations in pregnancies complicated by intrauterine growth restriction.

Previous studies have shown that in preeclampsia, plasma lipids climb substantially above levels seen in normal pregnancies. Such lipid changes may play a role in the endothelial damage characteristic of preeclampsia. Pregnancies complicated by intrauterine growth restriction (IUGR), without preeclampsia, have similar placental pathology to preeclampsia despite the absence of the maternal systemic manifestations of hypertension and proteinuria. The aim of this study was to perform a cross-sectional study of lipid and lipoprotein concentrations in the third trimester, from normal pregnancies, and those complicated by IUGR without preeclampsia. Our hypothesis was that, in contrast to the exaggerated lipid changes seen in preeclampsia, lipid and lipoprotein concentrations in IUGR would be similar to those of matched healthy pregnant controls. Fasting blood samples for lipids and lipoprotein fractions were taken in the third trimester, from eight women with IUGR; and eight women with uncomplicated pregnancies, matched as a group for age, booking weight, parity, and gestational age at sampling. There were no significant differences (P > 0.05) in the median concentrations of triglyceride, high-density lipoprotein, and very-low-density lipoprotein 1 (VLDL1), between cases and controls. However, women with IUGR pregnancies had significantly lower cholesterol [4.95 mmol/L (3.35-7.10) vs. 7.47 (5.75-8.45); median (range) for IUGR patients and controls, respectively; P < 0.01], low-density lipoprotein (LDL)-cholesterol [2.45 mmol/L (0.95-3.60) vs. 4.25 (3.35-5.60); P < 0.01], VLDL2 mass [59.0 mg/dL (37-87) vs. 103.0 (64-168); P < 0.01], intermediate-density lipoprotein mass [56.0 mg/dL (31-110) vs. 125.6 (91-157); P < 0.01], and total LDL mass [221.0 mg/dL (104-237) vs. 380.3 (267-534); P < 0.01]. In addition, it was noteworthy that, with respect to LDL-cholesterol and total LDL mass, there was little or no overlap in the ranges of concentrations measured between cases and controls. Because VLDL2 and intermediate-density lipoprotein are the synthetic precursors to LDL in the circulation, their significantly lower median concentrations imply a failure of appropriate LDL synthesis in IUGR pregnancies. Whatever the mechanism, if our results are confirmed in larger studies and longitudinal investigations, then LDL-cholesterol measurements (when LDL-cholesterol fails to rise appropriately or is low in the third trimester) may be of use in identifying mothers with, or at risk of, a pregnancy complicated by IUGR.

Prospective study of external cephalic version in Glasgow: patient selection, outcome and factors associated with outcome.

Data were collected prospectively on all 67 women who underwent an attempt at external cephalic version (ECV) over 1 year in the four Glasgow maternity hospitals. Ultrasonography was used in all women. However, tocolytics were used in only two (6%) nulliparous women despite published evidence of their efficacy. Only 25 (37%) women undergoing ECV had a free presenting part which is known to be associated with success. Seventeen (25%) women were less than 37 weeks pregnant despite spontaneous version being common at this stage. ECV was successful in only 26 (39%) women and only 18 (27%) had a vaginal cephalic delivery. These results compare unfavourably with published results of around two-thirds for both end-points. Although publication bias is likely, patient selection, under-usage of tocolytics and lack of experience may also be factors. Consideration should be given to a reduced number of operators who can maximise their throughput and expertise.

Variations in the management of singleton breech presentation throughout Scotland.

Breech presentation occurs in 3-5% of deliveries and can be managed by either a trial of vaginal breech delivery (TOVBD), external cephalic version (ECV) or Caesarean section. A postal questionnaire was completed by 82% of Scottish consultant obstetricians and revealed wide variations in practice. Eighteen percent never offered ECV. Among those who did consensus was lacking on some contraindications. One-quarter sometimes performed ECV before 37 weeks gestations despite the possibility of spontaneous version. Only 70% restricted ECV to one or more designated operators thereby maintaining levels of expertise. Variations were demonstrated in the use of tocolytics, and pre and post procedure investigations. Following failed ECV 28% considered a repeat attempt and 56% a TOVBD. TOVBD was not offered as first line management by one-fifth of respondents. Those who did varied in the pre-procedure investigations performed. Guidelines are required to ensure safe, consistent practice and avoid unnecessary Caesarean sections.

An unusual hernia: congenital pericardial effusion associated with liver herniation into the pericardial sac.

To our knowledge there have been only two previous cases of diaphragmatic hernia into the pericardium diagnosed antenatally. We describe our pre- and post-natal radiological findings in such a case, although the final diagnosis eluded us until after delivery.

Uterine rupture during second trimester termination of pregnancy using mifepristone and a prostaglandin.

PIP: At the Glasgow Royal Infirmary in Scotland, a 26-year-old woman requested termination of her 18-week pregnancy. She had no history of cervical or uterine surgery. She was administered under supervision 200 mg oral mifepristone followed 48 hours later by 600 mcg vaginal misoprostol, which was repeated 6 hours later. Four hours later painful uterine contractions developed. She was administered slow intravenous (IV) diamorphine (total 10 mg) for analgesia. She had vaginal bleeding (about 100 ml). 30 minutes later, the fetus was delivered but not the placenta. Severe abdominal pain ensued, requiring 10 mg more IV diamorphine. She then blanched and peripherally shut down. Physicians had to perform emergency manual removal of the placenta under general anesthesia. They then checked the uterine cavity digitally and discovered a large defect in the uterine wall and a palpable ovary (right) within the uterine cavity. A laparotomy revealed an 8 cm right uterine side wall rupture with considerable hemorrhage into the broad ligament and abdominal cavity. The surgeons performed a hysterectomy and right salpingo-oophorectomy to control the bleeding. The patient lost about 4000 ml of blood. She required 7 units of packed red cells, 1500 ml gelofusine, and 2 l crystalloid and 2 units of fresh frozen plasma. She received 1.2 g augmentin and 120 mg gentamicin perioperatively. She recovered uneventfully. Pathological analysis confirmed the 8 cm rupture. It also revealed normal endometrial decidualization and myometrial hypertrophy and no underlying weakness. This case is the first recorded of uterine rupture after administration of oral mifepristone and vaginal misoprostol. Uterine rupture occurs rarely in second trimester medical terminations of pregnancy. Many cases had risk factors associated with uterine rupture. As a result of this 26-year-old case, the physicians have amended their regimen for drug-induced abortion in cases of second trimester termination of pregnancy.^ieng

Midtrimester chorionic villus sampling: an alternative approach?

OBJECTIVE: Our purpose was to audit midtrimester chorionic villus sampling after a positive maternal serum screening test for autosomal trisomy. STUDY DESIGN: From January 1990 until July 1993 chorionic villus sampling was offered to all screened positive women. RESULTS: Five hundred fifty-one mothers had chorionic villus sampling. The mean age was 31.7 years. The mean gestational age was 18.2 weeks. The mean time for direct karyotyping was 4.4 days and for culture results 20.2 days. Results were obtained in 99.6% of samples: direct plus culture results in 94%, direct results alone in 2.3%, and culture results alone in 3.3%. Fourteen pregnancies had abnormal karyotypes. There were five cases of placental mosaicism and one false-positive result. The loss rate was 0.4%. CONCLUSION: Midtrimester chorionic villus sampling, which is easier to perform than cordocentesis, provides a rapid and reliable karyotype. The complication rate is comparable to that of other invasive procedures.