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(Abstracted from BJOG2019;126:1354–1361)During the 1960s and 1970s, intermittent auscultation was replaced by the alternative method of continuous electronic fetal monitoring (EFM) and cardiotocography (electronic monitoring of the fetal heart rate [FHR] and uterine contractions, or CTG). Meta-analyses have reported a 59% drop in intrapartum deaths attributable to hypoxia and a reduced risk of neonatal seizures, but a 2017 Cochrane review concluded that while EFM did reduce the rates of neonatal seizures, it did not provide “clear differences in cerebral palsy, infant mortality, or other standard measures of neonatal well-being.” Human error in interpreting the FHR pattern is a possible explanation for the ineffectiveness of EFM.

(Lancet. 2019;394:849–860)Intrahepatic cholestasis of pregnancy is the most common pregnancy-specific liver disorder and is associated with increased rates of preterm birth, meconium-stained amniotic fluid, neonatal intensive care unit (NICU) admission, and, for women with peak serum bile acid concentrations of ≥100 μmol/L, stillbirth. Ursodeoxycholic acid, a naturally occurring bile acid, is used to treat hepatobiliary disorders in nonpregnant patients and is widely recommended for the treatment of intrahepatic cholestasis of pregnancy. However, there is only a small amount of evidence available supporting its use for this pregnancy disorder. This current trial aimed to investigate whether the use of ursodeoxycholic acid for intrahepatic cholestasis of pregnancy reduced adverse perinatal outcomes, and examined its effects on other short-term maternal and neonatal outcomes.

(Lancet. 2019;394:1181–1190)Preeclampsia occurs in 2% to 3% of pregnant women and is associated with substantial maternal and neonatal morbidity and mortality. Prompt delivery is the recommended management for preeclamptic women after 37 weeks’ gestation, as this will decrease the risk of maternal complications while minimally affecting risk to the neonate at this gestational age. However, it is unclear what the best management strategy is for women who develop preeclampsia between 34 and 37 weeks’ gestation. In these cases, complications related to expectant management (EM), such as stillbirth or worsening fetal growth restriction and increased maternal morbidity associated with continuing the pregnancy, must be weighed against the neonatal complications associated with early delivery (infant immaturity). Current guidelines in the UK recommend EM until 37 weeks’ gestation, with earlier delivery if severe preeclampsia or other complications arise. This study from the UK compared earlier initiation of delivery with EM in women diagnosed with preeclampsia between 34 and <37 weeks gestation.

The authors investigated whether cases of sporadic Creutzfeldt–Jakob disease (CJD) had lived closer to one another at some time in life than individuals without sporadic CJD. Such a phenomenon would be compatible with some cases resulting from transmission.

Objectives. To obtain prevalence rates of hip and knee pain in elderly people and compare combinations of symptoms with overall health status.Methods. We performed a cross-sectional postal survey of a random sample of 5500 Oxfordshire residents aged 65 yr and older. Prevalence estimates were based on the screening question: ‘During the past 12 months, have you had pain in or around either of your hip/knee joints on most days for one month or longer?’ Overall health status was assessed with the SF-36 questionnaire.Results. The response rate was 66.3% (3341/5039 eligible people), and was highest (∼∽72%) for the 65–74 yr age-group. The percentage reporting hip pain was 19.2% [95% confidence interval (CI) 17.9–20.6], and 32.6% (95% CI 31.0–34.3) reported knee pain. The percentage reporting hip and knee pain was 11.3%, and 40.7% reported hip or knee pain. Less than half (48%) of the symptomatic respondents had unilateral problems affecting one hip or knee joint only. SF-36 scores worsened as the number of symptomatic hip and knee joints increased (P<0.001 for physical function, physical role limitation and bodily pain).Conclusions. Patterns of hip and knee symptoms are complex in older people. Amongst the symptomatic, most have more than one hip/knee affected. This has implications for treatment and health status measurement. In the absence of hip and knee symptoms, general health status scores of elderly people are similar to those of people aged under 65 yr.

OBJECTIVE: To determine cancer morbidity in members of the armed forces who took part in tests of chemical warfare agents from 1941 to 1989. Design Historical cohort study, with cohort members followed up to December 2004. DATA SOURCE: Archive of UK government research facility at Porton Down, UK military personnel records, and national death and cancer records. Participants All veterans included in the cohort study of mortality, excluding those known to have died or been lost to follow-up before 1 January 1971 when the UK cancer registration system commenced: 17 013 male members of the UK armed forces who took part in tests (Porton Down veterans) and a similar group of 16 520 men who did not (non-Porton Down veterans). MAIN OUTCOME MEASURES: Cancer morbidity in each group of veterans; rate ratios, with 95% confidence intervals, adjusted for age group and calendar period. RESULTS: 3457 cancers were reported in the Porton Down veterans compared with 3380 cancers in the non-Porton Down veterans. While overall cancer morbidity was the same in both groups (rate ratio 1.00, 95% confidence interval 0.95 to 1.05), Porton Down veterans had higher rates of ill defined malignant neoplasms (1.12, 1.02 to 1.22), in situ neoplasms (1.45, 1.06 to 2.00), and those of uncertain or unknown behaviour (1.32, 1.01 to 1.73). CONCLUSION: Overall cancer morbidity in Porton Down veterans was no different from that in non-Porton Down veterans.

OBJECTIVE: To investigate any long term effects on mortality in participants in experimental research related to chemical warfare agents from 1941 to 1989. Design Historical cohort study. DATA SOURCES: Archive of UK government research facility at Porton Down, UK military personnel records, and national death and cancer records. Participants 18 276 male members of the UK armed forces who had spent one or more short periods (median 4 days between first and last test) at Porton Down and a comparison group of 17 600 non-Porton Down veterans followed to 31 December 2004. MAIN OUTCOME MEASURES: Mortality rate ratio of Porton Down compared with non-Porton Down veterans and standardised mortality ratio of each veteran group compared with the general population. Both ratios adjusted for age group and calendar period. RESULTS: Porton Down veterans were similar to non-Porton Down veterans in year of enlistment (median 1951) but had longer military service (median 6.2 v 5.0 years). After a median follow-up of 43 years, 40% (7306) of Porton Down and 39% (6900) of non-Porton Down veterans had died. All cause mortality was slightly greater in Porton Down veterans (rate ratio 1.06, 95% confidence interval 1.03 to 1.10, P<0.001), more so for deaths outside the UK (1.26, 1.09 to 1.46). Of 12 cause specific groups examined, rate ratios in Porton Down veterans were increased for deaths attributed to infectious and parasitic (1.57, 1.07 to 2.29), genitourinary (1.46, 1.04 to 2.04), circulatory (1.07, 1.01 to 1.12), and external (non-medical) (1.17, 1.00 to 1.37) causes and decreased for deaths attributed to in situ, benign, and unspecified neoplasms (0.60, 0.37 to 0.99). There was no clear relation between type of chemical exposure and cause specific mortality. The mortality in both groups of veterans was lower than that in the general population (standardised mortality ratio 0.88, 0.85 to 0.90; 0.82, 0.80 to 0.84). CONCLUSIONS: Mortality was slightly higher in Porton Down than non-Porton Down veterans. With lack of information on other important factors, such as smoking or service overseas, it is not possible to attribute the small excess mortality to chemical exposures at Porton Down.

&lt;it>Objectives&lt;/it>. To estimate the national prevalence and incidence of adults consulting for a shoulder condition and to investigate patterns of diagnosis, treatment, consultation and referral 3 yr after initial presentation. &lt;it>Methods&lt;/it>. Prevalence and incidence rates were estimated for 658469 patients aged 18 and over in the year 2000 using a primary care database, the IMS Disease Analyzer–Mediplus UK. A cohort of 9215 incident cases was followed-up prospectively for 3 yr beyond the initial consultation. &lt;it>Results&lt;/it>. The annual prevalence and incidence of people consulting for a shoulder condition was 2.36&percnt; [95&percnt; confidence interval (CI) 2.32–2.40&percnt;] and 1.47&percnt; (95&percnt; CI 1.44–1.50&percnt;), respectively. Prevalence increased linearly with age whilst incidence peaked at around 50 yr then remained static at around 2&percnt;. Around half of the incident cases consulted once only, while 13.6&percnt; were still consulting with a shoulder problem during the third year of follow-up. During the 3 yr following initial presentation, 22.4&percnt; of patients were referred to secondary care, 30.8&percnt; were prescribed non-steroidal anti-inflammatory drugs and 10.6&percnt; were given an injection by their general practitioner (GP). GPs tended to use a limited number of generalized codes when recording a diagnosis; just five of 426 possible Read codes relating to shoulder conditions accounted for 74.6&percnt; of the diagnoses of new cases recorded by GPs. &lt;it>Conclusions&lt;/it>. The prevalence of people consulting for shoulder problems in primary care is substantially lower than community-based estimates of shoulder pain. Most referrals occur within 3 months of initial presentation, but only a minority of patients are referred to orthopaedic specialists or rheumatologists. GPs may lack confidence in applying precise diagnoses to shoulder conditions.