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The cost-effectiveness of eight strategies for screening for gestational diabetes (including no screening) was estimated with respect to the level of individual patient risk.Cost-utility analysis using a decision analytic model populated with efficacy evidence pooled from recent randomised controlled trials, from the funding perspective of the National Health Service in England and Wales. Seven screening strategies using various combinations of screening and diagnostic tests were tested in addition to no screening. The primary outcome measure was the incremental cost per quality-adjusted life-year (QALY) over a lifetime.The strategy that has the greatest likelihood of being cost-effective is dependent on the risk of gestational diabetes mellitus for each individual woman. When gestational diabetes mellitus risk is1% then the no screening/treatment strategy is cost-effective; where risk is between 1.0% and 4.2% fasting plasma glucose followed by OGTT is most likely to be cost-effective; and where risk is4.2%, universal OGTT is most likely to be cost-effective. However, acceptability of the test alters the most cost-effective strategy.Screening for gestational diabetes can be cost-effective. The best strategy is dependent on the underlying risk of each individual and the acceptability of the tests used. The current study suggests that if a woman's individual risk of gestational diabetes could be accurately predicted, then healthcare resource allocation could be improved by providing an individualised screening strategy.

Osteoprotegerin (OPG) is a soluble decoy receptor that inhibits bone resorption by binding to receptor activator of nuclear factor κB ligand. Murine studies suggest that OPG is elevated in pregnancy, but its role in human pregnancy is unknown. We evaluated the relationship among OPG, bone turnover, and bone density in a longitudinal study of planned human pregnancy and lactation (n = 17; age, 20–36 yr). Samples were collected before conception; at 16, 26, and 36 wk gestation; and at 2 and 12 wk postpartum. Indexes of bone resorption included serum β C-terminal and urinary N-terminal (uNTX) telopeptides of type I collagen. OPG increased by 110 ± 16% (mean ± sem) at 36 wk (P < 0.001), followed by a rapid postpartum decline in both lactating and nonlactating women. Bone resorption was elevated at 36 wk (serum β C-terminal telopeptides by 76 ± 17%; urinary N-terminal telopeptides by 219 ± 41%; P < 0.001). The tissue source of OPG in pregnancy is unknown. Human breast milk contains large amounts of OPG (162 ± 58 ng/ml in milk vs. 0.42 ± 0.03 ng/ml in nonpregnant serum). However, the rapid postpartum decline in serum OPG and the low serum OPG in neonates suggest a placental source. There was no correlation between change in OPG and bone turnover or bone mineral density (P > 0.05), and the physiological importance of elevated OPG in human pregnancy remains uncertain.

One aim of antenatal preparation is developing coping strategies for use (luring labour. However, the existing literature suggests that attendance at classes is not associated with lower pain or distress, possibly because receiving training cannot be assumed to be associated with subsequent practice. This study aimed to assess whether attenders at classes actually used their taught strategies in their labours, whether use was associated with psychological benefits and whether antenatal measures could predict subsequent use. Concepts from the theories of planned behaviour and self efficacy were used to attempt to predict use of three types of coping strategy. Use was high for breathing strategies but poor for relaxation and posture. Proportion of use of breathing and relaxation showed weak associations with lower fear. Whilst intentions did act as significant predictors for use of posture and relaxation only small proportions of the variance were accounted for and other antenatal measures showed l...

Summary Aims To investigate the use of amniotic fluid insulin (AFI) as a predictor of neonatal morbidity in the macrosomic newborn of the diabetic mother, in view of the fact that raised AFI levels are a marker for fetal hyperinsulinaemia. Methods AFI was measured by radioimmunoassay in a group of pregnant diabetic women (n = 63) with normal (n = 41) or accelerated fetal growth (n = 22). Results Using log transformed data, liquor insulin was found to be significantly higher in pregnant women with Type 1 and Type 2 diabetes mellitus (17.6 mU/l; 95% confidence interval (CI) 11.7–26.4) compared with women with gestational diabetes mellitus (GDM) (8.2 mU/l; 95% CI 4.8–13.8, P = 0.02) or impaired glucose tolerance (IGT) (6.2 mU/l; 95% CI 4.9–8.0, P = 0.0001). In the group with macrosomic fetuses (birth weight > 90th centile for gestational age), there was a significantly higher incidence of elective Caesarean section (CS) and emergency CS (12/22) compared to those with appropriate for gestational age (AGA) fetal weights (birth weight > 10th and

AIMS To examine the relation between maternal body fat and fetal metabolism. METHODS In this observational study, cord blood samples were collected from 60 infants of healthy women for the measurement of insulin and C peptide concentrations. Maternal weight, height, body mass index (BMI) and body composition (skinfold thickness measurements and bioelectrical impedance) were assessed at 13–15 weeks of gestation. Twenty five of the volunteers agreed to have a 75 g oral glucose tolerance test at 28–31 weeks of gestation. RESULTS Positive correlations were observed with both cord insulin or C peptide concentrations and maternal early pregnancy BMI (r=0.44, p=0.002 and r=0.33, p=0.008, respectively). There was no significant correlation between cord insulin or C peptide concentrations and birthweight or birth weight centiles. CONCLUSION Maternal BMI could be a predictor of fetal cord insulin concentration.

Nodular fasciitis is a common pathologic entity in the limbs of adults but rare in the head and neck of children. It is defined by the World Health Organization as a benign and probably reactive fibroblastic growth extending as a solitary nodule from superficial fascia into subcutaneous tissue. Treatment is local excision, and recurrence is rare.Case ReportA 3.5-year-old boy was initially seen with a 1-year history of gradually enlarging but otherwise asymptomatic right facial mass. On examination, a firm nodule was palpable anterior to the right ear, and facial movement was symmetrical. Computed tomography showed a rounded, well-defined solid mass continuous with the parotid fascia. The patient underwent superficial parotidectomy without complication. The pathology was reported as nodular fasciitis, and the child has had no clinical recurrence over 2 years.Benign lesions in this region in children may present similarly to malignancies but require much more-conservative treatment.

Monoamniotic twins are rare and are associated with high intrauterine mortality rates. This case appears to represent the first report of liveborn monoamniotic monochorionic twins delivered with a bifurcated umbilical cord. Pathological and angiographic studies of the placenta demonstrated a marginally inserted two-vessel umbilical cord that bifurcated at 8.4 cm from the disk into three-vessel umbilical cords supplying each twin. This probably represents the last opportunity for cleavage of the embryo prior to the formation of conjoined twins. A review of eight prior reports of monoamniotic twins with a single, bifurcating umbilical cord is provided.

Extraspinal ependymomas are a rare type of glioma that may arise in the sacrococcygeal region, presenting as a pelvic mass in an infant or child. Ependymoma presenting in the newborn period has not been described previously. Herein we describe a case of a newborn boy who presented with a perianal ependymoma, which was subsequently found to have presacral extension. The major diagnostic challenge this case presented was to rule out the alternative diagnosis of sacrococcygeal teratoma or a developmental malformation/heterotopia.

Tilapia islets, Brockmann bodies (BBs), transplanted under the kidney capsule (KC) of diabetic nude mice provide long-term normoglycemia, but, when transplanted into euthymic mice, reject in about one week.The present study characterizes the cellular infiltrates at several time points during the xenograft rejection process.Tilapia BBs were harvested, fragmented, cultured overnight, and then transplanted under the KC of streptozotocin-diabetic Balb/c mice. Glucose levels were measured daily until the mice were killed at 1 (n = 2), 2 (n = 2), 3 (n = 3), and 5 days (n = 3) post transplantation and at the time of BB graft rejection (n = 6). Serial frozen sections of graft-bearing kidneys were stained for murine macrophages (MOMA-2, F4/80, M170), CD4+ (L3T4) T-cells (YTS 191.1), and CD8+ (Ly-2) T-cells (YTS 169.4) by indirect immunoperoxidase; the presence of granulocytes and plasma cells was assessed with HE stained sections.At 1 day, the grafts have undergone some central necrosis with macrophage infiltration. By 2 days, these changes are very well-developed and granulocytes, almost exclusively eosinophils, begin to surround the graft. At 3 days, rare CD4+ and CD8+ T-cells are seen at the graft kidney interface. Macrophages massively infiltrate the necrotic foci and pepper the graft. At 5 days and at rejection, macrophages and eosinophils predominated in the center of rejecting grafts while CD8+ T-cells and CD4+ T-cells were present at the periphery. Plasma cells were rare.We conclude that cell-mediated processes and eosinophils play roles in the rejection of cellular xenografts across this very wide phylogenetic barrier.

Summary A case is preseited of a 49-year-old patient who had a pulmonary embolism during ovarian cystectomy. The only evidence of its occurrence was a sudden, marked reduction in arterial oxygen saturation as detected by a pulse oximeter. The diagnosis was confirmed 24 hours later by a chest radiograph and a ventilation perfusion scan. Anticoagulant treatment was instituted.

A 28-year-old woman had labour induced by artificial rupture of membranes and oxytocin infusion for post-maturity. At vaginal examination after 6 h in active labour, her cervix was 6 cm dilated and...

Screening and selection of hybrids producing relevant antibodies in monoclonal technology usually rely on rapid and sensitive adsorption assays of the ELISA type. To identify clones producing antibodies with unexpected specificities direct immunohistological screening may be applied, but this is both tedious and expensive. Histocomposites made from a number of tissue types permit testing of supernatants at the required early stage after fusion. The multiple antigenic specificities displayed in such test specimens ensure detection of a broad range of antibodies. A simple method for production of the histocomposites is described.

A multigas concentration analyzer particularly suited for respiratory gas analysis has been developed using a new principle based on the measurement of the intensity of light emitted by excited atoms or ions in a direct current glow discharge. This glow discharge spectral emission gas analyzer (GDSEA), or light spectrometer, simultaneously measures O2, N2, CO2, He, and N2O gas concentrations with a 0–90% response time of 100 ms and a sample rate of less than 20 ml/min in a short gas sample line configuration. Mole accuracy and resolution of the GDSEA using a short sample line were determined in the laboratory to be +/- 0.15 to +/- 0.7% and 0.02–0.05%, respectively. In the clinical setting a comparative evaluation was made with a mass spectrometer in a long sample line, computerized, multibed, respiratory monitoring system. Results indicate a close agreement between the two instruments with differences in mixed inspiratory or expiratory O2 and CO2 concentrations of less than 2% and of derived variables, such as O2 consumption, CO2 production, and respiratory exchange ratio, of less than 5%.

Twenty-one women completed a longitudinal study of glycosylated haemoglobin in normal pregnancy. Glycosylated haemoglobin levels were measured using two independent techniques (ion-exchange column and colorimetric). Concurrent serial oral glucose tolerance tests (75-g glucose load) and erythrocyte indices were obtained. Changes in mean glycosylated haemoglobin were similar with both techniques with a nadir at 17 weeks, a peak at delivery (p less than 0.002 versus 17 weeks) and a fall post-partum. Glycosylated haemoglobin levels in abnormal pregnancies, e.g. diabetic, should be interpreted in the knowledge of these physiological changes.

The site of greatest airway deformation in dog lungs was located during maximum expiratory flow by use of tantalum bronchography, fiberoptic bronchoscopy, and airway pressure measurements. A series of area vs. transmural pressure curves for each of these segments of the airway was produced after stepwise changes in transmural pressure. Measurements of area were made using cinephotography to elucidate the effect of time on airway compliance. The maximum flow rate was calculated using the t = 0.1 s compliance curve of the airway. An equation was derived so that maximum flow (V) could be calculated from the area (A) and transmural pressure (Ptm) of the flow-limiting segment. This equation, V = K-A square root of Ptm, implied that if V were constant then A must vary as Ptm-1/2. It was demonstrated that the area-transmural pressure curve of the flow-limiting segment showed this relationship between A and Ptm and that the flow calculated from this equation and the data from the A-Ptm curve gave flows identical to those measured during maximum expiration. The phenomena of effort-independent flow and negative effort dependence are also explained in terms of the area-transmural pressure curve of the flow-limiting segment.

A six-year survey of pregnancies complicated by diabetes has been performed at the Kenyatta National Hospital, Nairobi. Fifty-five babies were delivered with 14 perinatal deaths — a perinatal mortality rate of 254/1000, which was five times that of the nondiabetic population. There was one maternal death. Diabetes tended to be of short duration compared with similar series reported from developed countries. There were no perinatal deaths within a small sub-group managed according to a simple plan based on early referral for antenatal care, monitoring of diabetic control by blood glucose, and timing of delivery by use of the ‘shake test’.

A prospective study of the use of the injectable contraceptive Norethisterone Oenanthate (NET-OEN) is presented using 96 subjects attending the Family Welfare Centre at the Kenyatta National Hospital, Nairobi, Kenya. 54 subjects had completed 2 years of use and 42 had completed 3 years. 2 pregnancies occured during the study period, giving an incidence of 0.07 per 100 woman months or 0.86 per 100 woman years. Both pregnancies, attributable to method failure, occured after the 5th injection, whereas earlier studies seemed to indicate higher chances of pregnancy within the 3rd month of the 1st injection. There was no marked alteration in body weight and blood pressure. 11% of the subjects with regular cycles at the beginning of the study became amenorrhic at the end of the 3 years. The dropout rate was 56% at 2 years, and 65.7% at 3 years. Thus the continuation rata at 2 and 3 years was 43.9% and 34.3% respectively. 7.2% discontinued for medical reasons, and 35% for social reasons. No patient discontinued use citing amenorrhea as a reason. Bleeding patterns have been analysed and comparisons made with Depo-Provera. This study concludes that NET-OEN is an effective contraceptive agent with relatively few side effects.

Diagnostic studies were carried out in an induction‐heated low‐density supersonic plasma jet. The neutral number densities were obtained from the calibrated intensity of the 4609‐A argon II line excited by a 25‐kV electron beam, and the velocities and heavy particle temperatures were determined by measuring the Doppler shift and Doppler broadening with a Fabry‐Perot interferometer in two linearly independent directions, following a technique developed by Muntz. The contribution to the 4609‐A line due to the plasma self‐emission was found to be negligible. The density, impact pressure, and velocity along the free jet center line all followed the isentropic source flow model up to the Mach disc. The temperature, however, showed an unexpected rise above the isentropic prediction. Ion number densities and electron temperatures were measured with a double Langmuir probe. The fraction of ionization was frozen at about 0.1% along the free jet axis. Calculations of the fraction of the energy of recombination absorbed by the electrons and the fraction lost by radiation from an electron energy balance showed good agreement with an a priori estimate based on collisional‐radiative recombination.