Second Stage Labor: What Is Normal?

Traditional management of second stage labor has come under scrutiny because of improved understanding of what normally occurs when second stage labor is allowed to proceed of its own accord without direction from birth attendants. When women bear down spontaneously as they feel the urge to push, either holding their breath briefly or with short exhalation of air, normal maternal and fetal physiological status is maintained and second stage labor does not appear to be lengthened. Using a variety of maternal positions during second stage labor can optimize physiologic functioning and increase maternal comfort.     

Infant-feeding Practices Mothers'' Decision Making

Fifty-one primarily low-income, single, black mothers completed a questionnaire. More than one-half of the sample population reported that decisions about infant feeding were made by the end of the first trimester. Almost one-third of the mothers decided to breastfeed. Of that group, one-half supplemented breastfeeding with formula. More than one-half of the sample reported that external factors influenced their final decisions about infant feeding. More than one-half of the sample population reported that a nurse never discussed infant feeding with them. The role of nursing in infant-feeding decisions and patient teaching needs to be reevaluated.     

Synchronous Ventricular Pacing without Crossing the Tricuspid Valve or Entering the Coronary Sinus—Preliminary Results

Background: Right ventricular apical (RVA) pacing promotes tricuspid regurgitation (TR), electromechanical dyssynchrony, and ventricular dysfunction. We tested a novel intramyocardial bipolar lead to assess whether stimulation of the atrioventricular septum (AVS) produces synchronous ventricular activation without crossing the tricuspid valve (TV). Methods: A lead with an active external helix and central pin was placed on the AVS and the RVA in three dogs. High‐density electroanatomic (EA) mapping was performed of both ventricles endocardially and epicardially. Intracardiac echocardiography was used to access ventricular synchrony. Results: The lead was successfully deployed into the AVS in all cases with consistent capture of the ventricular myocardium without atrial capture or sensing. The QRS duration was less with AVS compared with RVA pacing (89 ± 4 ms vs. 100 ± 11 ms [P < 0.0001, GEE P = 0.03]). There was decreased delay between color Doppler M‐mode visualized peak contraction of the septum and the mid left ventricular free wall with AVS compared with RVA pacing (89 ± 91 ms vs. 250 ± 11 ms [P < 0.0001, GEE P = 0.006]). Activation time between the mid septum and mid free wall was shorter with AVS versus RVA pacing (20.4 ± 7.7 vs. 30.8 ± 11.6 [P = 0.01, GEE P = 0.07]). The interval between QRS onset to earliest free wall activation was shorter with AVS vs. RVA pacing (19.2 ± 6.4 ms vs. 31.1 ± 11.7 ms [P = 0.005, GEE P = 0.02]). Conclusion: The AVS was successfully paced in three dogs resulting in synchronous ventricular activation without crossing the TV.     

Cellular Immunity During Pregnancy. II. Response to T and B Cell Mitogens*

ABSTRACT: Immune reactivity of primiparous pregnant C57B1/6J mice was investigated using in vitro assays of mitogen reactivity. The response to the T cell mitogens phytohemagglutinin (PHA) and concanavalin A of cells from the paraaortic (PA) lymph nodes, which drain the uterus, was decreased in pregnant animals. Reactivity to lipopolysaccharide, a B cell mitogen, was normal. The decreased PHA response was seen with PA cells from mice bearing syngeneic or allogeneic (to DBA/2J) fetuses. It was not due to a change in sensitivity to PHA dose or to active suppression (as demonstrated by mixing experiments). Phytohemagglutinin reactivity of cells from inguinal nodes of pregnant mice showed a more variable depression of response in comparison to that seen with cells from the draining PA nodes. The response of axillary and brachial node cells was similar to virgin values. This study demonstrates that pregnant mice (syngeneic or allogeneic) show only a decrease in T proliferative capacity localized to the area of the uterus Statistical analysis revealed no differences in the average number of PA lymphocytes or fetuses per mouse between mice bearing syngeneic or allogeneic fetuses. This parallels the similarities found between syngeneic and allogeneic matings in in vitro functional assays.     

Association between symptoms and subtypes of attention‐deficit hyperactivity disorder and sleep problems/disorders

This study aimed to investigate the association between attention‐deficit hyperactivity disorder (ADHD) symptoms and subtypes, and sleep schedules, daytime inadvertent napping, and sleep problems/disorders in children and adolescents with and without ADHD. The sample included 325 patients with ADHD, aged 10–17 years [male: 81.5%; combined type (ADHD‐C): 174; predominantly inattentive type (ADHD‐I): 130; predominantly hyperactive‐impulsive type (ADHD‐HI): 21], and 257 children and adolescents without lifetime ADHD (non‐ADHD). We conducted psychiatric interviews with the participants and their mothers before making the diagnoses of ADHD, other psychiatric disorders, and sleep problems or disorders. We also collected the medication treatment data and parent and teacher reports of ADHD symptoms. Multi‐level models were used for data analyses controlling for sex, age, psychiatric comorbidities, and treatment with methylphenidate. The ADHD‐C and ADHD‐I groups had more daytime inadvertent napping. In general, the three subtypes were associated with increased rates of sleep problems/disorders. Specifically, ADHD‐C rather than ADHD‐I was associated with circadian rhythm problems, sleep‐talking, nightmares (also ADHD‐HI), and ADHD‐I was associated with hypersomnia. The most‐related sleep schedules and problems for inattention and hyperactivity‐impulsivity were earlier bedtime, later rise time, longer nocturnal sleep, more frequent daytime napping, insomnia, sleep terrors, sleep‐talking, snoring, and bruxism across informants. The findings imply that in addition to the dichotomous approach of ADHD and considering the psychiatric comorbid conditions, ADHD subtypes and symptom dimensions need to be considered in clinical practice and in the research regarding the association between ADHD and sleep problems/disorders.     

Muscle MRI findings in a three-generation family affected by Bethlem myopathy

We report clinical and muscle magnetic resonance imaging (MRI) findings in three individuals (aged 6, 26 and 73 years) from a three-generation family with Bethlem myopathy, confirmed by molecular genetic analysis which showed an exon skipping mutation in the COL6A1 gene. The clinical severity ranged from mild proximal weakness and distal laxity in the younger patients, to inability to stand or walk and severe contractures in the 76-year-old grandmother. The pattern of muscle involvement showed variable severity in parallel with the severity of motor function impairment. Although there was a marked variability in the severity of the MRI findings, it was possible to recognize a specific pattern of muscle involvement in all three patients. This consisted of involvement of the peripheral region of the vastus lateralis and hamstrings muscles with relative sparing of their central part. This was best appreciated in the third decade of life, but could also be identified both in the younger patient with minimal MRI changes and in the oldest patient, despite her more severe and diffuse muscle involvement. This report suggests that muscle MRI could be used as an additional tool to establish the pattern and the degree of muscle involvement in patients with Bethlem myopathy. Further studies in a larger cohort are needed to evaluate the specificity of these findings.     

LATE ONSET HUNTINGTON'S DISEASE AS A CAUSE OF DEMENTIA: WHERE SHOULD THE CLINICIAN'S INDEX OF SUSPICION LIE?

Our experience with two genetically confirmed cases of late onset Huntington's disease (HD) in a longitudinal dementia research study suggested that clinical misdiagnosis can easily occur. We therefore undertook genetic testing for HD in a further 84 elderly subjects, 81 of whom had come to postmortem; 75 subjects had dementia and nine were normal controls. A quarter of the demented group had demonstrated extrapyramidal symptoms in life but in none had HD formed part of the differential diagnosis. Although no genetically confirmed cases were found in this second group, the original cases serve as a reminder that late onset HD is a cause of dementia. Genetic confirmation should be sought when the condition forms part of the final differential diagnosis. Further studies conducted in the routine clinical setting are now required since it is in this environment that late onset HD is likely to be misdiagnosed in favour of other forms of dementia.     

WHAT BECOMES OF PEOPLE WITH DEMENTIA REFERRED TO COMMUNITY PSYCHOGERIATRIC TEAMS?

Objective: To monitor key processes and outcomes in joint health and social services community psychogeriatric teams. Design: Six month follow-up of new referrals to 4 teams in Cambridge. Data collected from structured clinical assessment forms at baseline and interviews with keyworkers at follow-up. Data for groups with and without dementia were compared. Setting: Two rural and two urban teams in area with relatively large long stay inpatient facility but low independent sector provision. All were routine service teams, rather than run for research purposes. Main outcome measures: The main outcome measures were survival, institutionalisation, key worker assessments of avoidable admissions, appropriateness of placement, unmet needs, carer stress and global outcome for patient and carers. Results: Rates of referral to urban teams were double rural rates. Around forty percent of the dementia group had a social worker as assessor and keyworker. The dementia group was significantly more dependent and received more informal and formal care. After six months, only 54% of the dementia group were alive and living outside institutional care, compared to 79% in the functionally ill group. Unplanned admissions to hospitals or homes were rarely judged avoidable by keyworkers. Outcomes for carers were judged poor in 15% of both groups, and 13% and 11% of carers respectively were judged to be under severe stress. Unmet needs were more common in the dementia group, and related principally to residential care and carer respite. A number of measures, including evidence of geographical inequity and identification of unmet needs, provided an important contribution to local policy development. Further work is needed on the validity of keyworker assessments of carer stress, given the findings of the carer interview sub-study.     

Temazepam misuse in a group of injecting drug users

It is well recognized that many injecting drug users are poly-drug users. The intravenous use of Temazepam has become popular recently. In response to the ease of misuse, the pharmaceutical industry produced a formulation that would be as ‘resistant’ as possible to injecting. The preparation is a gel-fitted formulation, one proprietary name being Temazepam Gelthix. General Practitioners have been encouraged to prescribe gel-filled capsules to potential drug misusers in order to reduce the harm Temasepam can cause by its misuse. This study of 23 Temazepam injectors shows that the group still find the gel-filled preparation readily injectable. It appears to be more problematic in causing medical complications including superficial thrombophlebitis, abscesses and deep venous thrombosis. Temazepam misuse can cause drug users to become more chaotic. The study group recognize this and suggest there should be stricter control on the supply of Temasepam to drug dependents. General Practitioners, who are the main source of Temazepam prescribing, require additional training in prescribing to drug users.