Ayrshire Central Hospital

BACKGROUND: Obesity in pregnancy is increasing and is a risk factor for metabolic pathology such as preeclampsia. In the nonpregnant, obesity is associated with dyslipidemia, vascular dysfunction, and low-grade chronic inflammation. AIM: Our aim was to measure microvascular endothelial function in lean and obese pregnant women at intervals throughout their pregnancies and at 4 months after delivery. Plasma markers of endothelial function, inflammation, and placental function and their association with microvascular function were also assessed. METHODS: Women in the 1st trimester of pregnancy were recruited, 30 with a body mass index (BMI) less than 30 kg/m(2) and 30 with a BMI more than or equal to 30 kg/m(2) matched for age, parity, and smoking status. In vivo endothelial-dependent and -independent microvascular function was measured using laser Doppler imaging in the 1st, 2nd, and 3rd trimesters of pregnancy and at 4 months postnatal. Plasma markers of endothelial activation [soluble intercellular cell adhesion molecule-1 (sVCAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1), von Willebrand factor (vWF), and plasminogen activator inhibitor (PAI)-1], inflammation (IL-6, TNFalpha, C-reactive protein, and IL-10), and placental function (PAI-1/PAI-2 ratio) were also assessed at each time point. RESULTS: The pattern of improving endothelial function during pregnancy was the same for lean and obese, but endothelial-dependent vasodilation was significantly lower (P < 0.05) in the obese women at each trimester (51, 41, and 39%, respectively). In the postpartum period, the improvement in endothelial-dependent vasodilation persisted in the lean women but declined to near 1st trimester levels in the obese (lean/obese difference, 115%; P < 0.01). There was a small but significant difference in endothelial-independent vasodilation between the two groups, lean response being greater than obese (P = 0.021), and response declined in both groups in the postpartum period. In multivariate analysis, time of sampling had the most impact on endothelial-independent function [18.5% (adjusted sum of squares expressed as a percentage of total means squared), P < 0.001 for sodium nitroprusside response; 9.8%, P < 0.001 for acetylcholine response], and obesity had the most impact on endothelial-dependent microvascular function (1.7%, P = 0.046 for sodium nitroprusside response; 19.3%, P < 0.001 for acetylcholine response). Time of sampling (11.2%, P < 0.001), IL-6 (4.0%, P = 0.002), and IL-10 (2.4%, P = 0.018) were significant independent contributors to variation in endothelial-dependent microvascular function. When obesity was entered into the model, the association with IL-6 and IL-10 was no longer significant, and obesity explained 6.8% (P < 0.001) of the variability in endothelial-dependent microvascular function. In the 1st trimester, obese women had a significantly higher PAI-1/PAI-2 ratio [obese median (interquartile range), 0.87 (0.54-1.21) vs. lean 0.30 (0.21-0.47), P < 0.001), reflecting the lower PAI-2 levels in obese pregnant women. In a multivariate analysis, 1st trimester BMI (7.6%, P = 0.012), IL-10 (8.2%, P < 0.001), and sVCAM-1 (0.73%, P = 0.007) contributed to the 1st trimester PAI-1/PAI-2 ratio. CONCLUSION: Obese mothers have a lower endothelium-dependent and -independent vasodilation when compared with lean counterparts. There was a higher PAI-1/ PAI-2 ratio in the 1st trimester in obese women, which improved later in pregnancy. Obese pregnancy is associated with chronic preexisting endothelial activation and impairment of endothelial function secondary to increased production of inflammatory T-helper cells-2 cytokines.

OBJECTIVE: Multiple sclerosis (MS) is associated with chronic symptoms, including muscle stiffness, spasms, pain and insomnia. Here we report the results of the Multiple Sclerosis and Extract of Cannabis (MUSEC) study that aimed to substantiate the patient based findings of previous studies. PATIENTS AND METHODS: Patients with stable MS at 22 UK centres were randomised to oral cannabis extract (CE) (N=144) or placebo (N=135), stratified by centre, walking ability and use of antispastic medication. This double blind, placebo controlled, phase III study had a screening period, a 2 week dose titration phase from 5 mg to a maximum of 25 mg of tetrahydrocannabinol daily and a 10 week maintenance phase. The primary outcome measure was a category rating scale (CRS) measuring patient reported change in muscle stiffness from baseline. Further CRSs assessed body pain, spasms and sleep quality. Three validated MS specific patient reported outcome measures assessed aspects of spasticity, physical and psychological impact, and walking ability. RESULTS: The rate of relief from muscle stiffness after 12 weeks was almost twice as high with CE than with placebo (29.4% vs. 15.7%; OR 2.26; 95% CI 1.24 to 4.13; p=0.004, one sided). Similar results were found after 4 weeks and 8 weeks, and also for all further CRSs. Results from the MS scales supported these findings. CONCLUSION: The study met its primary objective to demonstrate the superiority of CE over placebo in the treatment of muscle stiffness in MS. This was supported by results for secondary efficacy variables. Adverse events in participants treated with CE were consistent with the known side effects of cannabinoids. No new safety concerns were observed. TRIAL REGISTRATION NUMBER: NCT00552604.

BACKGROUND: Excessively heavy menstrual bleeding (HMB) or menorrhagia is an important cause of ill health in women. Eighty per cent of women treated for HMB have no anatomical pathology, which makes medical therapy, with the avoidance of possibly unnecessary surgery, an attractive alternative. Of the wide variety of medications used to reduce heavy menstrual bleeding, oral progestogens are the most commonly prescribed. This review assesses the effectiveness of two different regimens of oral progestogens in reducing ovulatory HMB. OBJECTIVES: The primary objective of this review was to investigate the effectiveness of oral progestogen therapy taken either during the luteal phase or for a longer course of 21 days in achieving a reduction in menstrual blood loss in women of reproductive years with heavy menstrual bleeding (HMB). SEARCH STRATEGY: We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched April 2007), MEDLINE (1966 to April 2007) and EMBASE (1985 to April 2007). Attempts were also made to identify trials from citation lists of review articles. In most cases, the first author of each included trial was contacted. SELECTION CRITERIA: The inclusion criteria were randomised comparisons of oral progestogen therapy versus placebo or other medical treatments in women of reproductive years with regular heavy periods measured either objectively or subjectively and with no pathological or iatrogenic causes for their heavy menstrual blood loss. DATA COLLECTION AND ANALYSIS: Seven randomised controlled trials (RCTs) were identified that fulfilled the inclusion criteria. The review authors extracted the data independently. Odds ratios for dichotomous outcomes and weighted mean differences for continuous outcomes were estimated from the data. MAIN RESULTS: No RCTs comparing progestogen treatment with placebo were identified. Comparisons between oral progestogens and other medical therapies were assessed separately according to dosage regimen.Progestogen therapy during the luteal phase was significantly less effective at reducing menstrual blood loss when compared with tranexamic acid, danazol and the progesterone-releasing intrauterine system (IUS). Duration of menstruation was significantly longer with the progesterone IUS when compared with oral progestogen therapy but significantly shorter with danazol treatment. Adverse events were significantly more likely with danazol when compared with progestogen treatment. Progestogen therapy from day 5 to day 26 of the menstrual cycle was significantly less effective at reducing menstrual blood loss than the IUS. A significantly higher proportion of norethisterone (NET) patients taking progestogens found their treatment unacceptable compared to IUS patients. However, the adverse effects of breast tenderness and intermenstrual bleeding were more likely in women with the IUS. AUTHORS' CONCLUSIONS: Progestogens administered from day 15 or 19 to day 26 of the cycle offer no advantage over other medical therapies such as danazol, tranexamic acid, non-steroidal anti-inflammatory drugs (NSAIDs) and the IUS in the treatment of menorrhagia in women with ovulatory cycles. Progestogen therapy for 21 days of the cycle results in a significant reduction in menstrual blood loss, although women found the treatment less acceptable than intrauterine levonorgestrel. This regimen of progestogen may have a role in the short-term treatment of menorrhagia.

Bronchial hyperresponsiveness to methacholine with asthma-like symptoms ("ski asthma") is frequent in elite cross-country skiers. To further the understanding of "ski asthma", 10 nonasthmatic, nonatopic controls and 30 adolescent elite skiers were investigated by bronchoscopy and bronchoalveolar lavage (BAL). Nine skiers were atopic without allergy symptoms. Compared with controls, the macroscopic inflammatory index in the proximal airways in skiers was three-fold greater (median (interquartile range) 3.0 (2.0-5.0) versus 1.0 (0.8-2.3), p=0.008). In the BAL fluid, skiers had significantly greater total cell (p<0.05) and percentage lymphocyte (p<0.01) and mast cell counts (p<0.05). Neutrophil and eosinophil counts were not significantly different and eosinophil cationic protein was not detected. Tumour necrosis factor-alpha and myeloperoxidase were detected in 12 (40%) and six (20%) skiers, respectively. In skiers with ski asthma, the inflammatory index was greater than in nonasthmatic skiers. Lymphocyte subtypes and activation markers, and concentration of albumin, fibronectin and hyaluronan were not different from those in controls. Cross-country skiers have a minor to moderate degree of macroscopic inflammation in the proximal airways at bronchoscopy and a bronchoalveolar lavage fluid profile which differs in several respects from healthy controls. Skiers with ski asthma tend to show even higher degrees of bronchial inflammation.

Objectives The present review aimed to assess the quality, content and evidence of efficacy of universally delivered (to all pupils aged 5–16 years), school-based, mental health interventions designed to promote mental health/well-being and resilience, using a validated outcome measure and provided within the UK in order to inform UK schools-based well-being implementation. Design A systematic review of published literature set within UK mainstream school settings. Data sources Embase, CINAHL, MEDLINE, PsycINFO, PsychArticles, ASSIA and Psychological and Behavioural Sciences published between 2000 and April 2016. Eligibility criteria Published in English; universal interventions that aimed to improve mental health/emotional well-being in a mainstream school environment; school pupils were the direct recipients of the intervention; pre-post design utilised allowing comparison using a validated outcome measure. Data extraction and synthesis 12 studies were identified including RCTs and non-controlled pre-post designs (5 primary school based, 7 secondary school based). A narrative synthesis was applied with study quality check. 1 Results Effectiveness of school-based universal interventions was found to be neutral or small with more positive effects found for poorer quality studies and those based in primary schools (pupils aged 9–12 years). Studies varied widely in their use of measures and study design. Only four studies were rated ‘excellent’ quality. Methodological issues such as small sample size, varying course fidelity and lack of randomisation reduced overall study quality. Where there were several positive outcomes, effect sizes were small, and methodological issues rendered many results to be interpreted with caution. Overall, results suggested a trend whereby higher quality studies reported less positive effects. The only study that conducted a health economic analysis suggested the intervention was not cost-effective. Conclusions The current evidence suggests there are neutral to small effects of universal, school-based interventions in the UK that aim to promote emotional or mental well-being or the prevention of mental health difficulties. Robust, long-term methodologies need to be pursued ensuring adequate recording of fidelity, the use of validated measures sensitive to mechanisms of change, reporting of those lost to follow-up and any adverse effects. Further high-quality and large-scale research is required across the UK in order to robustly test any long-term benefits for pupils or on the wider educational or health system.

An outbreak of waterborne cryptosporidiosis affecting 27 persons, diagnosed stool positive, occurred in Ayrshire in April 1988. Twenty-one in 27 confirmed cases required some form of fluid replacement therapy. Local general practitioners indicated a two- to fivefold increase in diarrhoeal disease during the outbreak, and following enquiries made by Environmental Health Officers it became apparent that many hundreds of people had suffered a diarrhoeal illness at that time. Cryptosporidium spp. oocysts were detected in the treated chlorinated water supply system, in the absence of faecal bacterial indicators. Oocyst contamination of a break-pressure tank containing final water for distribution was the cause of this waterborne outbreak. An irregular seepage of oocyst-containing water, which increased during heavy rains, was the cause of the break-pressure tank contamination, rather than a failure of the water-treatment processes. The waterborne route should be considered when clusters of cryptosporidiosis-associated with potable water occur. Waterborne cryptosporidiosis can occur in the absence of other faecal indicators of contamination.

The Distress Thermometer (DT) is a well validated screening tool, demonstrably sensitive and reasonably specific to the construct of distress in cancer. Its brevity makes it ideal to incorporate into a system of distress management. To ascertain how far this idea has been developed in practice, and to support future research, a literature review was undertaken. Medline, CINAHL, PsyclNFO, Embase, ASSIA, British Nursing Index, AMED, CCTR, and HMIC were systematically searched. Forty studies were reviewed that examined the function of the DT alone, together with the problem list (PL), and/or other validated measures. The majority of studies validated the DT against other robust measures of distress in order to establish ‘caseness’ in these populations, and establish factors associated with distress. Many of the studies recommended that further research should test their findings in clinical practice. A small section of the literature focused on the clinical utility of the DT as a facilitator of consultations, and found it to have potential in this regard. It is concluded that there is enough validation research, and in line with the majority of these studies’ recommendations, future research should focus on the utility of DT as part of a structured distress management programme.

It is estimated that 10% of children and young people have mental health problems so significant that they impact not only on their day-to-day life but, if left untreated, they will continue into adulthood. In this article, the author discusses mental health issues affecting children and young people and examines evidence-based early intervention and prevention programmes that have been shown to support better outcomes for children, young people and their families.

Spasticity is a common and often disabling symptom associated with multiple sclerosis (MS). Transcutaneous electrical nerve stimulation (TENS) has been found effective in reducing spasticity in conditions such as stroke, but there is little evidence to support its use in MS. The aim of this study was to evaluate the effectiveness of TENS on spasticity in MS and, furthermore, to compare two different application times. Thirty-two subjects were randomized into two groups, and a single, blind, crossover design was used to compare two weeks of 60 minutes and 8 hours daily of TENS applications (100 Hz and 0.125 ms pulse width). Outcomes were examined using the Global Spasticity Score (GSS), the Penn Spasm Score (PSS), and a visual analogue scale (VAS) for pain. The results of the study demonstrated that there were no statistically significant differences in the GSS following either 60 minutes or 8 hours daily of TENS (P=0.433 and 0.217, respectively). The 8-hour application time led to a significant reduction in muscle spasm (P=0.038) and pain (P = 0.008). Thus, this study suggests that, whilst TENS does not appear to be effective in reducing spasticity, longer applications may be useful in treating MS patients with pain and muscle spasm.

OBJECTIVES: Low literacy is highly prevalent among UK adults. This study assessed functional health literacy among family planning clinic clients and whether this was associated with sexual health knowledge and behaviours. It also assessed the readability of patient leaflets. METHODS: 505 female family planning clinic attendees aged 16-35 years were interviewed about their sexual behaviour and knowledge. Their reading age was assessed using a validated test (REALM). The readability of leaflets on contraception supplied to clinic users was measured. RESULTS: All respondents had a reading age of 12 years and above, 221 (43.8%) between 12 and 14 years and 284 (56.2%) greater than 14 years. Those in the lower literacy group were significantly more likely to have been aged under 16 years at time of first sexual intercourse, and significantly less likely to know the most fertile time of the menstrual cycle, to identify sexually transmitted infections and to know that sexual infections can be transmitted through oral and anal sex. The reading age of information leaflets in the clinics ranged from 11 to 17 years. Thus, clients with a reading level of 12-14 years would have difficulty in understanding some of the leaflets. CONCLUSIONS: Functional health literacy is related to sexual behaviour and knowledge. Written information should be prepared with this in mind and other routes of communication considered.

Editor—Carriers of paracentric chromosome inversions are usually regarded as being at low risk of having offspring with an unbalanced chromosome complement.1 2Some reports have suggested that rearrangements, such as very small interstitial deletions or duplications arising from unequal crossing over at the base of the inversion loop and deletion or deletion/duplication recombinants, created by the breakage of an unstable dicentric chromosome, can arise from paracentric inversions.3-7 Pettenati et al 8 reviewed 446 cases of paracentric inversions and suggested that carriers of such inversions had a 3.8% risk of having viable offspring with stable recombinant chromosomes. However, this observation has been disputed9 as it is possible that so called paracentric inversions giving rise to monocentric recombinants are actually insertional translocations and the traditional view is that the resulting unbalanced chromosomes arising from a paracentric inversion would involve either a dicentric or acentric chromosome, and therefore be unlikely to be viable.10 We report a liveborn child with mild dysmorphic features who had a dicentric chromosome arising from a maternal paracentric inversion. To our knowledge there have only been two previous reports of this …

OBJECTIVE: To explore the hypothesis that different methods of selecting and printing information for cancer patients could improve emotional support by affecting interaction with others, and so lead to improved psychological wellbeing. DESIGN: Randomised trial with eight groups (three factors, 2x2x2). Data collected at recruitment and three month follow-up. PARTICIPANTS: 400 patients starting radiotherapy, of whom 325 with breast or prostate cancer and complete anxiety and depression data were included in the analysis. INTERVENTIONS: Printed booklets: half had only general information from CancerBACUP about each patient's cancer and half had personalised information from the patient's medical record plus selected general information; half were composed of information chosen interactively by the patient and half were produced automatically with a larger volume of material; and half had additional advice on anxiety management and half did not. MAIN OUTCOME MEASURES: Patients' views of the information, use of their booklets with others; change in reported social support; change in anxiety and depression. RESULTS: The larger booklets produced automatically were more likely to be found useful and to tell patients something new and less likely to be seen as too limited than the booklets produced interactively, but they were also more likely to overwhelm some patients. Personalised booklets were more likely than general booklets to tell patients something new. There was no difference in patients' perceived understanding of their cancer by any of the intervention factors. Patients with personalised information were more likely to show their booklets to others and to think it helped in discussing their cancer or its treatment. There were no major differences in social support, anxiety, or depression by any intervention factors. CONCLUSIONS: Patients were more likely to show personalised information to their confidants than general information. Further research is needed into the effects of sharing information on patients' social support and anxiety. Trial registration US Government Clinical Trials Database NCT00127465.

We report two new cases of Rothmund-Thomson syndrome which emphasize the less well-known non-dermatological complications, namely: hypodontia, soft tissue contractures, proportionate short stature, hypogonadism, anaemia and osteogenic sarcoma. Genetic analysis of these and previously reported pedigrees supports autosomal recessive inheritance.

Although 'meaning' is a construct that has been referred to for many years within psychological research, particularly in work to examine the ways in which individuals respond to crises or illness, it is only relatively recently that this has started to appear within the psychosocial oncology literature. Where the term has been used, there has been much variation in the way in which this has been operationalised and measured (a problem that has been evident within other areas of psychosocial oncology). This article will review some of the self-report measures that have been developed to assess levels of meaning, outlining their background and status regarding psychometric performance. This will be followed by some recommendations on measures that are particularly suited for use in further work. It is suggested that their application to examine conceptual issues of will be more productive if researchers aim to develop existing measures and not to create new measures. Use of those measures with better psychometric properties could in time facilitate larger data sets and allow for cross cultural comparisons of the impact of cancer on global and situational meaning. Specific recommendations are made for measures to be used in the assessment of global and situational meaning in cancer.

Key content Although uncommon, puerperal genital haematomas can be associated with serious maternal morbidity. An abnormally high level of perineal pain following childbirth is a hallmark symptom. The primary aims of treatment are to prevent further blood loss and correct hypovolaemia. There is debate regarding the optimal management of genital haematoma. Learning objectives To understand the aetiology of puerperal genital haematoma. To recognise the signs and symptoms and know how they are classified according to their location. To learn about the most appropriate methods of treatment. Ethical issues How should we choose the most appropriate treatment when research on the condition is scarce? Should resources be used to ensure interventional radiology services are available to all maternity units? Please cite this article as: Mawhinney S, Holman R. Puerperal genital haematoma: a commonly missed diagnosis. The Obstetrician &amp; Gynaecologist 2007;9:195–200.

PRIMARY OBJECTIVE: To appraise recent literature on the topic of perceived needs of family carers of head-injured adult relatives. MEDLINE (1966-2000), EMBASE PSYCHIATRY (1987-1999), CINAHL (1982-January 2000) and PSYCHLIT (1967-1999) databases were searched. MAIN OUTCOMES AND RESULTS: A total of 13 papers were reviewed, of which six employed standardized research methods. The remainder used researcher developed questionnaires. Needs described by carers as important were predominantly related to information. Most unmet needs were linked to the provision of emotional support. There were significant differences in the perceived needs and their fulfilment between parental and spousal carers. In addition, unfulfilled needs could be predicted by behavioural problems in patients. CONCLUSIONS: The design and variation in methodology of most studies reviewed limits the generalization of reported data. Further research is required to fully identify both common and individual needs of family carers of the head-injured.

This paper is in two parts. The first part reviews the available literature describing sleep patterns of people with mental handicap and the nature and prevalence of sleep disorders amongst this client group. Both electroencephalographic studies and informant-based reports are included. The literature is small, particularly in terms of the latter reports, and most of the information from both E.E.G. and informant sources describes populations of children with mental handicap. The need for further investigation of sleep and sleep problems, particularly amongst adults with mental handicap, therefore, becomes evident. The second part presents the results of a detailed sleep survey of 120 adults with mental handicap, approximately half of whom were resident in hospital and half in the community. A descriptive summary of the total sample is provided. Fifteen per cent of the sample presented significant sleep problems, particularly in the form of intermittent wakenings. The results of comparisons between (1) good and poor sleepers (2) hospital and community residents and (3) people with mental handicap and 'normal' adults (using data from another study) are then presented. The relationships between sleep and daytime functioning and the potential usefulness of behavioural approaches to management of sleep pattern are discussed.

A variety of cognitive deficits can lead to difficulties performing complex behavioural sequences and thus, disability in the performance of routine and rehabilitation behaviours. Interventions to date involve increasing support or providing behavioural training. Assistive technologies for cognition have the potential to augment cognitive capacity thus enabling the performance of behavioural sequences. Guide is an assistive technology for cognition that scaffolds task performance by providing verbal prompts and responding to verbal feedback. Guide was used to provide verbal support and guidance for eight amputees (mean age 64), with cognitive impairment of vascular origin, putting on their prosthetic limbs. Participants were referred to the research due to problems learning the correct behavioural sequence. The research used repeated trials with random assignment to intervention and baseline conditions. The voice-mediated assistive technology for cognition resulted in a significant reduction of safety critical errors and omitted steps. Discussion focuses upon the relation between voice-mediated cognitive support for memory and executive function, and suggestions are made for future research.

Mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes is a progressive, multisystem mitochondrial disease affecting children and young adults. Patients acquire disability through stroke-like episodes and have an increased mortality. Eighty per cent of cases have the mitochondrial mutation m.3243A>G which is linked to respiratory transport chain dysfunction and oxidative stress in energy demanding organs, particularly muscle and brain. It typically presents with seizures, headaches and acute neurological deficits mimicking stroke. It is an important differential in patients presenting with stroke, seizures, or suspected central nervous system infection or vasculitis. Investigations should exclude other aetiologies and include neuroimaging and cerebrospinal fluid analysis. Mutation analysis can be performed on urine samples. There is no high quality evidence to support the use of any of the agents reported in small studies. This article summarises the core clinical, biochemical, radiological and genetic features and discusses the evidence for a number of potential therapies.

PRIMARY OBJECTIVE: The incidence of head injury is increasing among younger people with more family members undertaking their life-long care. Many research studies have highlighted the emotional well-being of such family carers and their unmet needs, however only a few consider the formal help provided for carers. Using a longitudinal, mixed variable, within and between-subject design, this pilot study evaluated the impact of an educational programme for family carers and their head-injured relatives in reducing carer and patient psychological distress and improving their coping ability. MAIN OUTCOMES AND RESULTS: The study comprised experimental and control samples each with carer and patient groups. The experimental sample had eight sessions of educational input. All groups were assessed pre- and post-intervention and at 3 months follow-up. The patient sample was further assessed using cognitive measures. There was evidence of reduction in psychological distress in the experimental carer group following the educational input, but these results were not statistically significant. However, the experimental patient population at follow-up assessment showed statistically significant improvements. CONCLUSIONS: A larger scale multi-centre study with a longer follow-up period of assessment is required for the generalization of findings. The pilot study identifies points for consideration in a potential main study.