Terminal care: improving teamwork in primary care using Significant Event Analysis

Significant Event Analysis can be used to improve the effectiveness of a Primary Health Care Team caring for terminally ill patients. A method of doing this is described in detail. Positive team qualities were confirmed and enhanced. Significant areas for improvement were identified: insufficient information had been given to some key workers, changes in medication had been poorly planned, continuity of care, and emotional and professional support of team members were inadequate. A strategy for change was developed and implemented. Performance was reviewed a year later. It was found that the Significant Event Analysis had caused changes in team practices, and was valid and reliable enough to be used as a tool for improving teamwork in primary care in future.     

Antepartum Screening and Non-selective Intrapartum Chemoprophylaxis for Group B Streptococcus

Summary: The efficacy of antibiotic chemoprophylaxis in labour for all maternal carriers of Group B streptococcus with respect to the neonatal mortality and morbidity was analyzed. The intervention consisted of a policy of maternal screening for Group B streptococcus at 28 weeks' gestation by a low vaginal swab, cultured on to nonselective media. If positive, all carriers were treated with intrapartum ampicillin regardless of other obstetric risk factors. The main outcome measures were studied prospectively for 16 months before and for 32 months after instituting the intervention. These included the incidence of early-onset Group B streptococcal infection as defined by either a blood culture or a symptomatic neonate with a positive urinary streptococcal antigen test, the mortality and the morbidity.
Intrapartum ampicillin significantly reduced the incidence of early-onset Group B streptococcal disease, from 2.0 to 0.37 per 1,000 livebirths for neonates with a positive blood culture (p < 0.03), and from 4.9 to 1.5 per 1,000 livebirths for symptomatic infants with a positive urinary antigen test (p < 0.004) and the attributable morbidity, namely, neonates who were: admitted to a level 2 or 3 unit (p < 0.004); treated with antibiotics (p < 0.004); preterm (p < 0.04); ventilated (p < 0.01). Seventy five per cent of the maternal population was overall actually screened and the carriage rate was 12%. No serious adverse reactions to ampicillin were observed.
Significant reduction in early-onset neonatal Group B streptococcal disease has occurred concurrent with antepartum screening and nonselective intrapartum chemoprophylaxis.     

Clomiphene Citrate and Pregnancy Outcome

Summary: Data from Australia and elsewhere have shown consistently that adverse perinatal outcomes such as preterm birth and perinatal mortality are more common in pregnancies resulting from assisted conception with IVF and GIFT than normally conceived pregnancies. Factors that may contribute to the excess of poor outcomes include maternal factors, the assisted conception procedures themselves and possibly the influence of drugs used to induce superovulation. This review examines the medical literature describing pregnancies following ovulation induction with one of the drugs used to induce superovulation, clomiphene citrate, and compares their outcomes with Australian IVF and GIFT pregnancy outcomes.
The review shows that whilst some studies have suggested higher rates of ectopic pregnancy, spontaneous abortion and congenital malformations in clomiphene citrate induced pregnancies, the findings are inconsistent and the data are flawed. There are only very poor data available on the incidence of preterm birth. Multiple pregnancy is a well-recognized adverse outcome of clomiphene citrate induced pregnancies. Attempts to improve perinatal outcomes of pregnancies following assisted conception will be helped by a better understanding of the relative contributions of maternal and treatment factors and further studies of pregnancy outcome after ovulation induction are needed.     

Malnutrition as a prognostic factor in lymphoblastic leukaemia: a multivariate analysis

One hundred and twenty eight Brazilian children with lymphoblastic leukaemia were intensively treated with a Berlin-Frankfurt-Munich based protocol. More children had a white cell count above 50 x 10(9)/l (31%) then observed in developed countries. After a median follow up of 31 months (11-58 months), the estimated probability of relapse free survival was 41% (7%) for the whole group. After adjustment in the Cox's multivariate model, malnutrition was the most significant adverse factor affecting duration of complete remission. Age above 8 years and high peripheral white cell count were also significant adverse factors. Among the nutritional indices, the height for age and weight for age z scores were both significant, whether the cut off points of z-2 or z = -1.28 were chosen to define malnutrition. A strong statistical association between the two indices was found; the contribution of height for age z score to the prediction of relapse free survival was more significant. Children with height for age z score < -2 had a relapse risk of 8.2 (95% confidence interval 3.1 to 21.9) relative to children with z score > -2. The results of this study suggest that socioeconomic and nutritional factors should be considered in the prognostic evaluation of children with leukaemia in developing countries.     

Increased placental apoptosis in intrauterine growth restriction

OBJECTIVES: Our purpose was to investigate a possible role for apoptosis in the pathophysiologic mechanisms of intrauterine growth restriction. STUDY DESIGN: Placental samples were obtained from 43 uncomplicated third-trimester pregnancies and from 26 pregnancies complicated by intrauterine growth restriction. The definition used to identify cases of intrauterine growth restriction depended on three criteria: clinical evidence of suboptimal growth, ultrasonographic evidence of deviation from an appropriate growth percentile, and individualized birth weight ratios <10th percentile. Light microscopy was used to quantify the incidence of apoptosis. Electron microscopy and TUNEL (terminal deoxynucleotidyl transferase–mediated deoxyuridine triphosphate nick end labeling) staining were used to confirm the occurrence of apoptosis. RESULTS: Quantification of apoptosis (medians and interquartile ranges) resulted in the following values: normal third trimester (n = 43) 0.14% of cells (0.08% to 0.20%) and intrauterine growth restriction third trimester (n  = 26) 0.24% of cells (0.16% to 0.29%). The incidence of apoptosis was significantly higher in placentas from pregnancies with intrauterine growth restriction compared with normal third-trimester placentas (p < 0.01, Mann Whitney U test). CONCLUSIONS: These results suggest that apoptosis may play a role in the pathophysiologic mechanisms of intrauterine growth restriction.(Am J Obstet Gynecol 1997;177:401)     

Ultrasonographic measurement of subarachnoid space in normal infants and children

This study was undertaken to evaluate the sonographic measurement of subarachnoid spaces in normal children and its relationship with age and to define a normal range in a Chinese population and to differentiate normal variant findings from pathologic dilatation. The subarachnoid spaces in 278 normal term neonates, infants, and children were studied with real-time ultrasound using a 7.5-MHz vector transducer. The craniocortical width, sinocortical width, and interhemispheric width were measured in the coronal plane at the level of the foramen of Monro, on either side of the hemispheres. Correlation of sonographic measurements with age was made. The mean widths were plotted against age. A correlation with age was found in all three spaces, with an increasing trend with age until 28 weeks of gestation. Thereafter, a decreasing trend was noted. The normal upper limit of subarachnoid spaces for children is proposed to be the values on the ninety-fifth percentile of the regression curve. Correlation of measurement with age must be considered to decide whether an increase in subarachnoid space is pathologic or not.     

Second Twin: Quality of Survival if Born by Breech Extraction Following Internal Podalic Version

The intrapartum management of the vertex-breech and vertex-transverse twin gestation is controversial. The fall in perinatal mortality rate to a low level has resulted in this parameter failing to be an adequate gauge of the safety of breech extraction and the answer lies in the quality of survival of the infants. Fifty-one twin pairs, collected over 12 years at the Mercy Hospital for Women, Melbourne, occurred where twin 2 was born by breech extraction following internal inversion and the control (twin 1) did not have this procedure performed. In 8 pairs either a stillbirth or neonatal death occurred; in one pair childhood death due to an accident (fire) occurred; in 4 pairs the parents refused entrance to the study as they perceived both twins to be similar; in 2 sets the assessment was incomplete; 11 sets were untraceable leaving 25 sets fully assessed as children ranging in age from 2 to 12 years. Growth, and psychological scores were not significantly different between twins 1 and 2 but 2 children had cerebral palsy and both were born by breech extraction following internal version at 29.2 and 30.1 weeks' gestation, respectively. Because of small numbers the results failed to achieve statistical significance and this study was unable to answer the question regarding the safety of breech extraction following internal version but did show that the majority of infants so born do well.