Prediction of lethal pulmonary hypoplasia and chorioamnionitis by assessment of fetal breathing

Summary. Twenty-three pregnancies with fetuses at risk for pulmonary hypoplasia were studied weekly until delivery. The amount of time spent in fetal breathing activity was recorded under controlled conditions during 1 h using real-time ultrasound. An amniotic fluid index was determined. The clinicians and the pathologist were unaware of the ultrasound findings. Eight of 23 fetuses did not breathe at the last ultrasound examination. Three babies died of pulmonary hypoplasia and two of these showed fetal breathing before birth. The three deaths were associated with rupture of the membranes at <20 weeks gestation and of ≥44 days duration. One infant developed bronchopulmonary dysplasia. The amniotic fluid index in these four pregnancies was low and the newborn infants had limb contractures. Chorioamnionitis/funisitis was noted in 13 placentas. Eight fetuses were assessed for fetal breathing within 2 days of birth. The lack of fetal breathing had sensitivity, specificity, positive and negative predictive values of 0.75 for chorioamnionitis/funisitis. In this pilot study the absence of fetal breathing was of no value in predicting lethal pulmonary hypoplasia, but was related to chorioamnionitis/funisitis. We recommend further studies of fetal breathing in relation to fetal/neonatal infections.     

Problem orientated medical records—all or none?

Junior hospital doctors from different medical schools were asked about their experience of the Problem Orientated Medical Record. Few had been introduced to this method of writing notes by their teachers when they were undergraduates, though more had learned about it from other sources. The majority of those with experience of the method found it preferable to the more conventional one. The advantages and disadvantages of the method are discussed and it is suggested that a less rigid format might make it more acceptable. This can be achieved by writing follow-up notes in the usual way and using the problem orientated approach only when the patient is assessed for the first time or when information is passed from one team of doctors to another.     

Satisfaction guaranteed? What clients on methadone and buprenorphine think about their treatment

Introduction and Aims . A consumer satisfaction survey was conducted among clients receiving methadone or buprenorphine treatment for opioid dependence. The survey aimed to assess client perceptions across a number of treatment domains, including the clinic environment, service provision, clinical relationships, medication and treatment outcomes. Design and Methods . Participants were 432 clients receiving treatment at nine public clinics in New South Wales, Australia. An interviewer‐administered questionnaire was utilised, designed by the researchers. Participation was voluntary and anonymous. All participants received $10 remuneration. Results . Seventy‐eight per cent of participants were on methadone treatment. Overall satisfaction with treatment was high (mean: 3.8; very satisfied = 5). Participants were mainly satisfied with service provided by the clinic, although had concerns over the inflexibility associated with the clinic atmosphere, frequency of clinic attendance, dosing hours and lack of takeaway doses. While relationships with prescribers and case managers were rated positively, 16% and 21% of participants wanted to see their prescriber and case manager more often, respectively; 53% reported that they did not have input into their care plan. Regarding the helpfulness of case managers in assisting clients with problems experienced in identified domains of case management (e.g. drug use, physical and mental health, psychosocial supports), the mean rating was 5.2 (excellent = 10). Discussion and Conclusions . While participants reported being mainly satisfied with their treatment, results must be viewed within the context of what a consumer reasonably expects to receive from a service. The concept of ‘expectation’ and ‘relative experience’ is crucial in measuring consumer satisfaction among pharmacotherapy consumers.     

Rate Augmentation and Atrial Arrhythmias in DDDR Pacing

SPENCER, W.H., ET AL.: Rate Augmentation and Atrial Arrhythmias in DDDR Pacing. Dual chamber, rate-modulated pacemakers provide the capability of augmenting the heart rate of patients with chronotropic incompetence but also may cause atrial arrhythmias because of high rate, competitive atrial pacing. We studied ten patients with two consecutive 24-hour Holter monitors during which they were alternately programmed to either DDD or DDDR pacing in random order. Maximum heart rates (max HR) were measured at every 15-minute interval during each 24-hour period. DDDR pacing showed rate augmentation, 80 ± 7 average max HR when compared with DDD pacing, average max HR 76 ± 5. These results were even more striking when waking hours (7 am to 10 pm) were compared: average max HR 86 ± 7 DDDR versus 78 ± 4 average max HR DDD. Several patients showed marked rate augmentation. Seven of ten patients preferred DDDR pacing over DDD pacing. In the entire population, DDDR pacing did not result in an increased number of atrial arrhythmias (1.25 atrial events 124 hour) when compared to DDD pacing (1.75 atrial events/ 24 hour). We conclude that DDDR pacing provides heart rate augmentation during daily life in a clinical population while not resulting in a significant increase in atrial arrhythmias. (PACE, Vol. 13, December, Part 11, 1990)     

Review article: Kidney dendritic cells: Their role in homeostasis, inflammation and transplantation

There is definitive experimental proof that a lattice of dendritic cells (DC) exist within the renal parenchyma. Kidney-resident DC (KDC) are an important constituent of passenger leucocytes that initiate the direct component of allograft rejection in transplantation and form a central element of the innate immune response following injurious stimuli to the kidney. DC are recruited to the kidney in pathophysiological states such as glomerulonephritis and ischaemia–reperfusion injury. However, the exact mechanism for engaging and attracting DC to infectious and transplant antigens, and whether specific DC subsets are involved remains unresolved. In addition, the extent to which resident and infiltrating DC contribute to the propagation of injury or rejection is also unclear. Despite consistently expanding published work regarding DC location, phenotype and function, there are a number of deficiencies in our knowledge base, particularly in relation to KDC.