615 Background: Small bowel and bladder toxicities (bleeding, obstruction, perforation, and stricture) are rare but serious late complications of pelvic radiotherapy (RT) related to dose received by these organs. IMRT has been used effectively in other pelvic malignancies (prostate and gynecologic) to decrease the dose to normal tissues when compared to 3D-CRT. Few studies have examined the use of IMRT in rectal cancer to assess whether a similar dose reduction is feasible.METHODSEight consecutively treated patients with T2/T3 and N0/N1 rectal adenocarcinoma underwent 5-FU based neoadjuvant chemo-RT using 7-field sliding-window IMRT between 2008 and 2010. Retrospectively, conventional 4-field 3D-CRT plans were generated for dosimetric comparison with IMRT treatment plans. Planning target volumes included the gross tumor, rectum, peri-rectal tissues, pre-sacral space, and common and internal iliac lymphatics. Organs at risk included small bowel (contoured as all small bowel identified on the planning CT plus a 1 cm symmetrical expansion), bladder, and femoral heads. Small bowel, bladder, and femoral head mean doses and volumes receiving 45 Gy (V45) were compared between conventional and IMRT plans, respectively. Paired Student's t-test was used for statistical analysis.RESULTSMean prescription dose was 52.9 ± 3.3 Gy. Compared to 3D-CRT, IMRT plans had an 11% lower mean dose delivered to the bladder (38.2 ± 4.5 Gy vs 43.1 ± 1.9 Gy, p = 0.028) and 24% lower mean dose to the small bowel (24.0 ± 2.9 Gy vs 31.7 ± 7.7 Gy, p = 0.014). IMRT plans also had a 55% lower bladder V45 (27 ± 19% vs 61 ± 22%, p = 0.0077) and a 96% lower small bowel V45 (1 ± 0% vs 21± 20%, p = 0.021). The femoral heads received a nonsignificant higher mean dose (19.2 ± 3.9 Gy vs 16.6 ± 3.0 Gy, p = 0.069).CONCLUSIONSSmall bowel and bladder volume receiving 45 Gy and mean dose were significantly lower using IMRT compared with 3D-CRT planning. More stringent volumetric planning constraints may be necessary to further reduce the dose to the femoral heads. Further study is warranted to examine the clinical benefit of these dosimetric findings. No significant financial relationships to disclose.

Purpose/Objective(s)Reducing cardiopulmonary toxicity from breast irradiation continues to be an active area of study. Strategies toward this endeavor have included the reduction of irradiated volume and treatment during deep inspiration breath-hold. This study investigates whether deep inspiration breath-hold (BH) can reduce cardiopulmonary irradiation compared with free breathing (FB) in accelerated partial breast irradiation (APBI).Materials/MethodsBetween December 2005 through February 2008, seven patients with left-sided breast cancers were treated with APBI during deep inspiratory breath-hold. For each patient, both a free breathing scan and a deep inspiratory breath-hold scan were obtained with a GE Lightspeed CT simulator. The Varian Real-time Position Management system was used to obtain breath-hold scans. Typically, four non-coplanar 6MV photon beams were utilized, except for one patient who was treated with a mixed-beam plan of 6MV photons and 9 MeV electrons. All cardiac and left lungs were contoured by a single physician according to NSABP B-39 guidelines for consistency. Retrospectively, each treatment plan was overlaid on the corresponding free-breathing scan obtained at simulation for each patient. Cardiac and left lung doses were compared and analyzed.ResultsPatient characteristics include: age (range, 31-75-years-old), histology (DCIS (n = 2), infiltrating ductal carcinoma (n = 4), invasive mucinous carcinoma (n = 1)), tumor size (0.6-2.9 cm), and location of tumor (superior lateral (n = 5), superior central (n = 1), superior medial (n = 1)). On average, mean and maximum cardiac doses with BH were reduced compared with FB 43.1% (50.6 cGy vs. 95.2 cGy, p = 0.038) and 45.4% (266.2 cGy vs. 518.0 cGy, p = 0.038), respectively (range, reduction in mean cardiac dose: 16.8-68.9%, reduction in maximum cardiac dose: 8.9-74.2%). Cardiac volume decreased with BH versus FB, on average, 11.0% (range, -3.5 to 39.0%). Average reduction in mean left lung dose was 11.3% (235.0 cGy BH vs. 273.5 cGy FB, p = 0.25), while there was minimum change in maximum left lung dose (3,684.1 cGy BH vs. 3476.8 cGy FB). Due to small patient numbers, no definite conclusions could be made regarding the impact from the location of the tumor on cardiopulmonary irradiation.ConclusionsOverall, cardiac and lung doses during APBI treatment appear to be relatively low, and can be reduced further with deep inspiratory breath-hold. Further study and follow-up may clarify the impact of individual cardiac anatomy, tumor location, treatment plan characteristics, and delivered dose on cardiopulmonary toxicity. Purpose/Objective(s)Reducing cardiopulmonary toxicity from breast irradiation continues to be an active area of study. Strategies toward this endeavor have included the reduction of irradiated volume and treatment during deep inspiration breath-hold. This study investigates whether deep inspiration breath-hold (BH) can reduce cardiopulmonary irradiation compared with free breathing (FB) in accelerated partial breast irradiation (APBI). Reducing cardiopulmonary toxicity from breast irradiation continues to be an active area of study. Strategies toward this endeavor have included the reduction of irradiated volume and treatment during deep inspiration breath-hold. This study investigates whether deep inspiration breath-hold (BH) can reduce cardiopulmonary irradiation compared with free breathing (FB) in accelerated partial breast irradiation (APBI). Materials/MethodsBetween December 2005 through February 2008, seven patients with left-sided breast cancers were treated with APBI during deep inspiratory breath-hold. For each patient, both a free breathing scan and a deep inspiratory breath-hold scan were obtained with a GE Lightspeed CT simulator. The Varian Real-time Position Management system was used to obtain breath-hold scans. Typically, four non-coplanar 6MV photon beams were utilized, except for one patient who was treated with a mixed-beam plan of 6MV photons and 9 MeV electrons. All cardiac and left lungs were contoured by a single physician according to NSABP B-39 guidelines for consistency. Retrospectively, each treatment plan was overlaid on the corresponding free-breathing scan obtained at simulation for each patient. Cardiac and left lung doses were compared and analyzed. Between December 2005 through February 2008, seven patients with left-sided breast cancers were treated with APBI during deep inspiratory breath-hold. For each patient, both a free breathing scan and a deep inspiratory breath-hold scan were obtained with a GE Lightspeed CT simulator. The Varian Real-time Position Management system was used to obtain breath-hold scans. Typically, four non-coplanar 6MV photon beams were utilized, except for one patient who was treated with a mixed-beam plan of 6MV photons and 9 MeV electrons. All cardiac and left lungs were contoured by a single physician according to NSABP B-39 guidelines for consistency. Retrospectively, each treatment plan was overlaid on the corresponding free-breathing scan obtained at simulation for each patient. Cardiac and left lung doses were compared and analyzed. ResultsPatient characteristics include: age (range, 31-75-years-old), histology (DCIS (n = 2), infiltrating ductal carcinoma (n = 4), invasive mucinous carcinoma (n = 1)), tumor size (0.6-2.9 cm), and location of tumor (superior lateral (n = 5), superior central (n = 1), superior medial (n = 1)). On average, mean and maximum cardiac doses with BH were reduced compared with FB 43.1% (50.6 cGy vs. 95.2 cGy, p = 0.038) and 45.4% (266.2 cGy vs. 518.0 cGy, p = 0.038), respectively (range, reduction in mean cardiac dose: 16.8-68.9%, reduction in maximum cardiac dose: 8.9-74.2%). Cardiac volume decreased with BH versus FB, on average, 11.0% (range, -3.5 to 39.0%). Average reduction in mean left lung dose was 11.3% (235.0 cGy BH vs. 273.5 cGy FB, p = 0.25), while there was minimum change in maximum left lung dose (3,684.1 cGy BH vs. 3476.8 cGy FB). Due to small patient numbers, no definite conclusions could be made regarding the impact from the location of the tumor on cardiopulmonary irradiation. Patient characteristics include: age (range, 31-75-years-old), histology (DCIS (n = 2), infiltrating ductal carcinoma (n = 4), invasive mucinous carcinoma (n = 1)), tumor size (0.6-2.9 cm), and location of tumor (superior lateral (n = 5), superior central (n = 1), superior medial (n = 1)). On average, mean and maximum cardiac doses with BH were reduced compared with FB 43.1% (50.6 cGy vs. 95.2 cGy, p = 0.038) and 45.4% (266.2 cGy vs. 518.0 cGy, p = 0.038), respectively (range, reduction in mean cardiac dose: 16.8-68.9%, reduction in maximum cardiac dose: 8.9-74.2%). Cardiac volume decreased with BH versus FB, on average, 11.0% (range, -3.5 to 39.0%). Average reduction in mean left lung dose was 11.3% (235.0 cGy BH vs. 273.5 cGy FB, p = 0.25), while there was minimum change in maximum left lung dose (3,684.1 cGy BH vs. 3476.8 cGy FB). Due to small patient numbers, no definite conclusions could be made regarding the impact from the location of the tumor on cardiopulmonary irradiation. ConclusionsOverall, cardiac and lung doses during APBI treatment appear to be relatively low, and can be reduced further with deep inspiratory breath-hold. Further study and follow-up may clarify the impact of individual cardiac anatomy, tumor location, treatment plan characteristics, and delivered dose on cardiopulmonary toxicity. Overall, cardiac and lung doses during APBI treatment appear to be relatively low, and can be reduced further with deep inspiratory breath-hold. Further study and follow-up may clarify the impact of individual cardiac anatomy, tumor location, treatment plan characteristics, and delivered dose on cardiopulmonary toxicity.

Purpose/Objective(s)In obtaining CT scans for external beam radiotherapy planning for prostate cancer, various degrees of rectal distension are observed. We investigated if the degree of daily isocenter shifts guided by intraprostatic fiducial gold seeds correlated with the amount of rectal distension present at the time of CT simulation prior to treatment.Materials/Methods41 consecutive patients with prostatic adenocarcinoma had intraprostatic gold seed-guided IGRT treatments in a community-hospital setting. Patients were instructed to empty bladder and rectum prior to simulation and daily treatments. Based on gold seed markers, daily shifts from the isocenter were performed with an onboard kV imager and recorded in X, Y, and Z dimensions. Standard deviations of shifts in all 3 dimensions were calculated. Patients with the five highest and five lowest standard deviations of shifts in each of the 3 dimensions were further analyzed by calculating individual rectal and bladder volumes at the time of CT simulation. In an effort to characterize rectal distension, rectal volumes were further divided into 3 parts: a) superior rectum, defined as located superior to the prostate up to the level of the recto-sigmoid junction, b) middle rectum, defined as located at the level of the prostate, and c) inferior rectum, defined as located inferior to the prostate up to 2 cm and may include anal canal. A single physician contoured all bladder, rectal, and prostate volumes for reproducibility. The correlation between degree of daily shifts throughout the treatment and contoured volumes were analyzed.ResultsRange of standard deviations of isocenter shifts in the X, Y, and Z directions were 0.4–1.28 cm, 0.24–0.82 cm, and 0.16–0.62 cm, respectively. Overall rectal volume did not correlate with standard deviation of shifts among all 3 dimensions (r = −0.148, p = 0.435, df = 28). Superior, middle, and inferior rectal volumes each did not correlate with standard deviation of shifts in all 3 dimensions, nor did the ratio of combined superior and middle rectal volumes to inferior rectal volumes (r = −0.081, p = 0.672). Similarly, there was no correlation between standard deviation of shifts and greatest rectal width on axial images (r = −0.245, p = 0.192). Finally, other parameters such as overall bladder (r = 0.176, p = 0.352) and prostate (r = −0.259, p = 0.167) volumes did not correlate with standard deviation of shifts among all 3 dimensions.ConclusionsThere was no correlation between parameters such as rectal or bladder distension at the time of simulation and IGRT shifts guided by gold seed fiducial markers. This lack of correlation may suggest that other factors are also influencing the degree of isocenter shifts. Rectal or bladder distension at the time of CT simulation may reflect patient-specific properties that can be consistent throughout an external radiation treatment course. With the spectrum of isocenter shifts observed in this study, our data underscores the importance of daily localization of the prostate for accurate delivery of radiotherapy. Purpose/Objective(s)In obtaining CT scans for external beam radiotherapy planning for prostate cancer, various degrees of rectal distension are observed. We investigated if the degree of daily isocenter shifts guided by intraprostatic fiducial gold seeds correlated with the amount of rectal distension present at the time of CT simulation prior to treatment. In obtaining CT scans for external beam radiotherapy planning for prostate cancer, various degrees of rectal distension are observed. We investigated if the degree of daily isocenter shifts guided by intraprostatic fiducial gold seeds correlated with the amount of rectal distension present at the time of CT simulation prior to treatment. Materials/Methods41 consecutive patients with prostatic adenocarcinoma had intraprostatic gold seed-guided IGRT treatments in a community-hospital setting. Patients were instructed to empty bladder and rectum prior to simulation and daily treatments. Based on gold seed markers, daily shifts from the isocenter were performed with an onboard kV imager and recorded in X, Y, and Z dimensions. Standard deviations of shifts in all 3 dimensions were calculated. Patients with the five highest and five lowest standard deviations of shifts in each of the 3 dimensions were further analyzed by calculating individual rectal and bladder volumes at the time of CT simulation. In an effort to characterize rectal distension, rectal volumes were further divided into 3 parts: a) superior rectum, defined as located superior to the prostate up to the level of the recto-sigmoid junction, b) middle rectum, defined as located at the level of the prostate, and c) inferior rectum, defined as located inferior to the prostate up to 2 cm and may include anal canal. A single physician contoured all bladder, rectal, and prostate volumes for reproducibility. The correlation between degree of daily shifts throughout the treatment and contoured volumes were analyzed. 41 consecutive patients with prostatic adenocarcinoma had intraprostatic gold seed-guided IGRT treatments in a community-hospital setting. Patients were instructed to empty bladder and rectum prior to simulation and daily treatments. Based on gold seed markers, daily shifts from the isocenter were performed with an onboard kV imager and recorded in X, Y, and Z dimensions. Standard deviations of shifts in all 3 dimensions were calculated. Patients with the five highest and five lowest standard deviations of shifts in each of the 3 dimensions were further analyzed by calculating individual rectal and bladder volumes at the time of CT simulation. In an effort to characterize rectal distension, rectal volumes were further divided into 3 parts: a) superior rectum, defined as located superior to the prostate up to the level of the recto-sigmoid junction, b) middle rectum, defined as located at the level of the prostate, and c) inferior rectum, defined as located inferior to the prostate up to 2 cm and may include anal canal. A single physician contoured all bladder, rectal, and prostate volumes for reproducibility. The correlation between degree of daily shifts throughout the treatment and contoured volumes were analyzed. ResultsRange of standard deviations of isocenter shifts in the X, Y, and Z directions were 0.4–1.28 cm, 0.24–0.82 cm, and 0.16–0.62 cm, respectively. Overall rectal volume did not correlate with standard deviation of shifts among all 3 dimensions (r = −0.148, p = 0.435, df = 28). Superior, middle, and inferior rectal volumes each did not correlate with standard deviation of shifts in all 3 dimensions, nor did the ratio of combined superior and middle rectal volumes to inferior rectal volumes (r = −0.081, p = 0.672). Similarly, there was no correlation between standard deviation of shifts and greatest rectal width on axial images (r = −0.245, p = 0.192). Finally, other parameters such as overall bladder (r = 0.176, p = 0.352) and prostate (r = −0.259, p = 0.167) volumes did not correlate with standard deviation of shifts among all 3 dimensions. Range of standard deviations of isocenter shifts in the X, Y, and Z directions were 0.4–1.28 cm, 0.24–0.82 cm, and 0.16–0.62 cm, respectively. Overall rectal volume did not correlate with standard deviation of shifts among all 3 dimensions (r = −0.148, p = 0.435, df = 28). Superior, middle, and inferior rectal volumes each did not correlate with standard deviation of shifts in all 3 dimensions, nor did the ratio of combined superior and middle rectal volumes to inferior rectal volumes (r = −0.081, p = 0.672). Similarly, there was no correlation between standard deviation of shifts and greatest rectal width on axial images (r = −0.245, p = 0.192). Finally, other parameters such as overall bladder (r = 0.176, p = 0.352) and prostate (r = −0.259, p = 0.167) volumes did not correlate with standard deviation of shifts among all 3 dimensions. ConclusionsThere was no correlation between parameters such as rectal or bladder distension at the time of simulation and IGRT shifts guided by gold seed fiducial markers. This lack of correlation may suggest that other factors are also influencing the degree of isocenter shifts. Rectal or bladder distension at the time of CT simulation may reflect patient-specific properties that can be consistent throughout an external radiation treatment course. With the spectrum of isocenter shifts observed in this study, our data underscores the importance of daily localization of the prostate for accurate delivery of radiotherapy. There was no correlation between parameters such as rectal or bladder distension at the time of simulation and IGRT shifts guided by gold seed fiducial markers. This lack of correlation may suggest that other factors are also influencing the degree of isocenter shifts. Rectal or bladder distension at the time of CT simulation may reflect patient-specific properties that can be consistent throughout an external radiation treatment course. With the spectrum of isocenter shifts observed in this study, our data underscores the importance of daily localization of the prostate for accurate delivery of radiotherapy.

Materno-foetal complications have an increased prevalence in pregnancies complicated by diabetes. Ethnicity and cultural background may further affect these outcomes. In this study, we compared labour and foetal outcomes in Afro-Caribbean and Caucasian women with diabetes in pregnancy, using the Birmingham computerised database of diabetes in pregnancy. A retrospective analysis, covering the period 1990-2002, was employed. Foetal outcomes included early foetal loss, neonatal and perinatal mortality, congenital malformations and infant size at delivery. Labour outcomes assessed were mode and time of delivery. Overall, Afro-Caribbean women achieve similar results to Caucasian women. No significant differences were seen in foetal outcomes between the two cohorts or between diabetic subtypes. Afro-Caribbean women were more likely to have a vaginal delivery, but present later for their first antenatal visit compared with Caucasian women. Variations in culture or access to health care may account for these differences. An awareness of the specific needs of ethnic minorities is essential to ensure that this encouraging trend continues.

Background Although delivery is widely used for preterm babies failing to thrive in utero, the effect of altering delivery timing has never been assessed in a randomised controlled trial. We aimed to compare the effect of delivering early with delaying birth for as long as possible.Methods 548 pregnant women were recruited by 69 hospitals in 13 European countries. Participants had fetal compromise between 24 and 36) weeks, an umbilical-artery doppler waveform recorded, and clinical uncertainty about whether immediate delivery was indicated. Before birth, 588 babies were randomly assigned to immediate delivery (n=296) or delayed delivery until the obstetrician was no longer uncertain (n=292). The main outcome was death or disability at or beyond 2 years of age. Disability was defined as a Griffiths developmental quotient of 70 or less or the presence of motor or perceptual severe disability. Analysis was by intention-to-treat. This trial has been assigned the International Standard Randomised Controlled Trial Number ISRCTN41358726.Findings Primary outcomes were available on 290 (98%) immediate and 283 (97%) deferred deliveries. Overall rate of death or severe disability at 2 years was 55 (19%) of 290 immediate births, and 44 (16%) of 283 delayed births. With adjustment for gestational age and umbilical-artery doppler category, the odds ratio (95% CrI) was 1.1 (0.7-1.8). Most of the observed difference was in disability in babies younger than 31 weeks of gestation at randomisation: 14 (13%) immediate versus five (5%) delayed deliveries. No important differences in the median Griffiths developmental quotient in survivors was seen.Interpretation The lack of difference in mortality suggests that obstetricians are delivering sick preterm. babies at about the correct moment to minimise mortality. However, they could be delivering too early to minimise brain damage. These results do not lend support to the idea that obstetricians can deliver before terminal hypoxaemia to improve brain development.

Deterioration of retinopathy is a recognized complication of pregnancy in Type 1 diabetes. We discuss management issues relating to a case of rapid sight-threatening progression of retinopathy in pregnancy complicated by pregestational diabetes.

OBJECTIVES To develop, implement and test the cost-effectiveness of redesigned postnatal care compared with current care on women's physical and psychological health. DESIGN A cluster randomised controlled trial, with general practice as the unit of randomisation. Recruited women were followed up by postal questionnaire at 4 and 12 months postpartum and further data collected from midwife and general practice sources. SETTING Thirty-six randomly selected general practice clusters in the West Midlands Health Region, UK. PARTICIPANTS All women expected to be resident within recruited practices for postnatal care were eligible for inclusion. Attached midwives recruited 1087 women in the intervention and 977 in the control practice clusters. INTERVENTIONS The systematic identification and management of women's health problems, led by midwives with general practitioner contact only when required. Symptom checklists and the Edinburgh Postnatal Depression Scale (EPDS) were used at various times to maximise the identification of problems, and individual care and visit plans based on needs. Evidence-based guidelines were used to manage needs. Care was delivered over a longer period. MAIN OUTCOME MEASURES Women's health at 4 and 12 months, assessed by the Physical and Mental Component Scores (PCS and MCS) of the Short-Form 36 (SF-36) and the EPDS. Women's views about care, reported morbidity at 12 months, health service usage during the year, 'good practice' indicators and health professionals' views about care were secondary outcomes. RESULTS At 4 and 12 months postpartum the mean MCS and EPDS scores were significantly better in the intervention group and the proportion of women with an EPDS score of 13+ (indicative of probable depression) was significantly lower relative to controls. The physical health score (PCS) did not differ. Health service usage was significantly less in the intervention group as well as reported psychological morbidity at 12 months. Women's views about care were either more positive or did not differ. Intervention midwives were more satisfied with redesigned care than control midwives were with standard care. Intervention care was cost-effective since outcomes were better and costs did not differ substantially. CONCLUSIONS The redesigned community postnatal care led by midwives and delivered over a longer period, resulted in an improvement in women's mental health at 4 months postpartum, which persisted at 12 months and at equivalent overall cost. It is suggested that further research should focus on: the identification of postnatal depression through screening; whether fewer adverse longer term effects might be demonstrated among the children of the women who had the intervention care relative to the controls; testing interventions to reduce physical morbidity, including studies to validate measures of physical health in postpartum women. Further research is also required to investigate appropriate postnatal care for ethnic minority groups.

AIM:Twelve years' outcome analysis of pregnancies in women with Type 2 diabetes in a multiethnic geographically defined area.METHODS:Information about 182 women delivered between 1990 and 2002 was ascertained from a regional computerized database. The main outcome measures were rates of miscarriage, stillbirth, neonatal/postnatal deaths, congenital malformations, birth weight, mode of delivery, and neonatal unit care as well as maternal morbidities of polyhydramnios, postpartum haemorrhage, pregnancy-induced hypertension/pre-eclampsia.RESULTS:Among 182 singleton pregnancies, 161 (88%) resulted in a live outcome. There were 16 (8.8%) spontaneous miscarriages, two (1.2%) stillbirths, and three (1.6%) terminations. Congenital malformations occurred in 18 pregnancies (99/1000). There were two early and one late neonatal deaths and two further deaths in the postnatal period. Twenty-eight percent of infants were large for gestational age, with 15 (9.3%) greater than 4 kg. Fifty-three percent were delivered by caesarean section and 68 (37%) required admission to neonatal unit (NNU) care. Hypertension/pre-eclampsia was two times, polyhydramnios three times, and postpartum haemorrhage six times more common than in non-diabetic women.CONCLUSIONS:Women with Type 2 diabetes have a less satisfactory pregnancy outcome compared with the general population. Infants have a two-fold greater risk of stillbirth, a 2.5-fold greater risk of a perinatal mortality, a 3.5-fold greater risk of death within the first month and a six-fold greater risk of death up to 1 year compared with regional/national figures. They have an 11 times greater risk of a congenital malformation. We need to develop better educational and screening strategies if we are to improve.

BACKGROUND:Much postpartum physical and psychological morbidity is not addressed by present care, which tends to focus on routine examinations. We undertook a cluster randomised controlled trial to assess community postnatal care that has been redesigned to identify and manage individual needs.METHODS:We randomly allocated 36 general practice clusters from the West Midlands health region of the UK to intervention (n=17) or control (19) care. Midwives from the practices recruited women and provided care. 1087 (53%) of 2064 women were in practices randomly assigned to the intervention group, with 977 (47%) women in practices assigned to the control group. Care was led by midwives, with no routine contact with general practitioners, and was extended to 3 months. Midwives used symptom checklists and the Edinburgh postnatal depression scale (EPDS) to identify health needs and guidelines for the management of these needs. Primary outcomes at 4 months were obtained by postal questionnaire and included the women's short form 36 physical (PCS) and mental (MCS) component summary scores and the EPDS. Secondary outcomes were women's views about care. Multilevel analysis accounted for possible cluster effects.FINDINGS:801 (77%) of 1087 women in the intervention group and 702 (76%) of 977 controls responded at 4 months. Women's mental health measures were significantly better in the intervention group (MCS, 3.03 [95% CI 1.53-4.52]; EPDS -1.92 [-2.55 to -1.29]; EPDS 13+ odds ratio 0.57 [0.43-0.76]) than in controls, but the physical health score did not differ.INTERPRETATION:Redesign of care so that it is midwife-led, flexible, and tailored to needs, could help to improve women's mental health and reduce probable depression at 4 months' postpartum.

Objectives To compare the effect of delivering early to pre-empt terminal hypoxaemia with delaying for as long as possible to increase maturity.Design A randomised controlled trial.Setting 69 hospitals in 13 European countries.Participants Pregnant women with fetal compromise between 24 and 36 weeks, an umbilical artery Doppler waveform recorded and clinical uncertainty whether immediate delivery was indicated.Methods The interventions were 'immediate delivery' or 'delay until the obstetrician is no longer uncertain'. The data monitoring and analysis were Bayesian.Main outcome measures 'Survival to hospital discharge' and 'developmental quotient at two years of age', this latter to be reported later.Results Of 548 women (588 babies) recruited, outcomes were available on 547 mothers.(587 babies). The median time-to-delivery intervals were 0.9 days in the immediate group and 4.9 days in the delay group. Total deaths prior to discharge were 29 (10%) in the immediate group versus 27 (9%) in the delay group (odds ratio 1.1, 95% CI 0.61-1.8). Total caesarean sections were 249 (91%) in the immediate group versus 217 (79%) in the delay group: (OR 2.7; 95% CI 1.6-4.5). These odds ratios were similar for those randomised at gestational ages above or below 30 weeks.Interpretation The lack of difference in overall mortality suggests that clinicians participating in this trial were on average prepared to randomise at about the correct equivocal threshold between delivery and delay. However, there was insufficient evidence to convince enthusiasts for either immediate or delayed delivery that they were wrong.

# 1. WHAT DO THE PUBLIC THINK ABOUT THE USE OF THEIR HEALTH INFORMATION? PATIENT ELECTRONIC RECORD: INFORMATION AND CONSENT—THE PERIC PROJECT {#article-title-2} 3921 adults randomly selected from across Great Britain were interviewed. Subjects were asked to assess a selection of 10 out of 200

OBJECTIVES:To assess the effect of nurse assessment with reinforcement of pelvic floor muscle training exercises and bladder training compared with standard management among women with persistent incontinence three months postnatally.DESIGN:Randomised controlled trial with nine months' follow up.SETTING:Community intervention in three centres (Dunedin, New Zealand; Birmingham; Aberdeen).PARTICIPANTS:747 women with urinary incontinence three months postnatally, allocated at random to intervention (371) or control (376) groups.INTERVENTION:Assessment by nurses of urinary incontinence with conservative advice on pelvic floor exercises at five, seven, and nine months after delivery supplemented with bladder training if appropriate at seven and nine months.MAIN OUTCOME MEASURES:Primary: persistence and severity of urinary incontinence 12 months after delivery. Secondary: performance of pelvic floor exercises, change in coexisting faecal incontinence, wellbeing, anxiety, and depression.RESULTS:Women in the intervention group had significantly less urinary incontinence: 167/279 (59.9%) v 169/245 (69.0%), difference 9.1% (95% confidence interval 1.0% to 17.3%, P=0.037) for any incontinence and 55/279 (19.7%) v 78/245 (31.8%), difference 12.1% (4.7% to 19.6%, P=0.002) for severe incontinence. Faecal incontinence was also less common: 12/273 (4.4%) v 25/237 (10.5%), difference 6.1% (1.6% to 10.8%, P=0.012). At 12 months women in the intervention group were more likely to be performing pelvic floor exercises (218/278 (79%) v 118/244 (48%), P<0.001).CONCLUSIONS:A third of women may have some urinary incontinence three months after childbirth. Conservative management provided by nurses seems to reduce the likelihood of urinary and coexisting faecal incontinence persisting 12 months postpartum. Further trials for faecal incontinence are needed.

Diabetic MedicineVolume 18, Issue 4 p. 333-334 Approaching St Vincent F. Dunne, F. Dunne *Department of Diabetic Medicine, University Hospital Trust, Birmingham, UK †Department of Obstetrics, Birmingham Women's Trust and ‡School of Mathematics and Statistics, University of Birmingham, Edgbaston, Birmingham, UKSearch for more papers by this authorP. Brydon, P. Brydon *Department of Diabetic Medicine, University Hospital Trust, Birmingham, UK †Department of Obstetrics, Birmingham Women's Trust and ‡School of Mathematics and Statistics, University of Birmingham, Edgbaston, Birmingham, UKSearch for more papers by this authorM. Proffitt, M. Proffitt *Department of Diabetic Medicine, University Hospital Trust, Birmingham, UK †Department of Obstetrics, Birmingham Women's Trust and ‡School of Mathematics and Statistics, University of Birmingham, Edgbaston, Birmingham, UKSearch for more papers by this authorT. Smith, T. Smith *Department of Diabetic Medicine, University Hospital Trust, Birmingham, UK †Department of Obstetrics, Birmingham Women's Trust and ‡School of Mathematics and Statistics, University of Birmingham, Edgbaston, Birmingham, UKSearch for more papers by this authorH. Gee, H. Gee *Department of Diabetic Medicine, University Hospital Trust, Birmingham, UK †Department of Obstetrics, Birmingham Women's Trust and ‡School of Mathematics and Statistics, University of Birmingham, Edgbaston, Birmingham, UKSearch for more papers by this authorR. Holder, R. Holder *Department of Diabetic Medicine, University Hospital Trust, Birmingham, UK †Department of Obstetrics, Birmingham Women's Trust and ‡School of Mathematics and Statistics, University of Birmingham, Edgbaston, Birmingham, UKSearch for more papers by this author F. Dunne, F. Dunne *Department of Diabetic Medicine, University Hospital Trust, Birmingham, UK †Department of Obstetrics, Birmingham Women's Trust and ‡School of Mathematics and Statistics, University of Birmingham, Edgbaston, Birmingham, UKSearch for more papers by this authorP. Brydon, P. Brydon *Department of Diabetic Medicine, University Hospital Trust, Birmingham, UK †Department of Obstetrics, Birmingham Women's Trust and ‡School of Mathematics and Statistics, University of Birmingham, Edgbaston, Birmingham, UKSearch for more papers by this authorM. Proffitt, M. Proffitt *Department of Diabetic Medicine, University Hospital Trust, Birmingham, UK †Department of Obstetrics, Birmingham Women's Trust and ‡School of Mathematics and Statistics, University of Birmingham, Edgbaston, Birmingham, UKSearch for more papers by this authorT. Smith, T. Smith *Department of Diabetic Medicine, University Hospital Trust, Birmingham, UK †Department of Obstetrics, Birmingham Women's Trust and ‡School of Mathematics and Statistics, University of Birmingham, Edgbaston, Birmingham, UKSearch for more papers by this authorH. Gee, H. Gee *Department of Diabetic Medicine, University Hospital Trust, Birmingham, UK †Department of Obstetrics, Birmingham Women's Trust and ‡School of Mathematics and Statistics, University of Birmingham, Edgbaston, Birmingham, UKSearch for more papers by this authorR. Holder, R. Holder *Department of Diabetic Medicine, University Hospital Trust, Birmingham, UK †Department of Obstetrics, Birmingham Women's Trust and ‡School of Mathematics and Statistics, University of Birmingham, Edgbaston, Birmingham, UKSearch for more papers by this author First published: 20 December 2001 https://doi.org/10.1046/j.1464-5491.2001.00429.xCitations: 4Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume18, Issue4April 2001Pages 333-334 RelatedInformation

Maternal diabetes mellitus (types 1 and 2) is the most chronic prevalent medical condition affecting the pregnant population and is associated with a less satisfactory pregnancy outcome for both mother and infant when compared with the non-diabetic population. Most reports have focused on women with type 1 disease, type 2 disease being perceived as a less serious condition. However, type 2 disease is far more common (and is increasing) in some areas of the UK, especially where there is a high proportion of women from the Indian subcontinent. This paper shows that pregnancy complicated by type 2 diabetes mellitus is a high-risk state, with miscarriage and congenital malformations almost twice that seen in type 1 disease. These adverse outcomes are contributed to by poor attendance for pre-pregnancy care, later booking for antenatal clinic and poor glycaemic control at booking. Offspring of pregnancies complicated by type 2 diabetes are more likely to be delivered before 37 weeks gestation and be large in size for gestational age. We must dispel the myth, in women of childbearing age and in their healthcare providers, that diabetes treated with diet and/or tablets (type 2) is a less serious problem than type 1 disease.

Maternal and fetal complications are increased when pregnancy is complicated by diabetes, and this may be further influenced by racial and cultural differences. We examined fetal and maternal outcomes in Indo-Asian and Caucasian women attending the same antenatal diabetes service to see if there were any differences. Women with diabetes mellitus (type 1, type 2 and gestationally-acquired disease) complicating pregnancy, registered at the combined diabetes/antenatal clinic of this University teaching hospital over the period 1990-1998 were included. Fetal outcomes examined were miscarriage <24 weeks, stillbirths, neonatal deaths up to 28 days of life, perinatal mortality, congenital malformations and size for gestational age. Maternal outcomes examined were rates of caesarean section and vaginal deliveries, and number of pre-term deliveries <37 completed weeks of gestation. Outcomes for Indo-Asian and Caucasian women were similar, with a take-home baby rate of 96% and 92%, respectively. There was no perinatal mortality in Indo-Asian women, who were more likely to have a vaginal delivery and less likely to have a baby large for gestational age. Pregnancies complicated by type 2 diabetes in both groups pose the greatest threat to a successful pregnancy outcome. Indo-Asian and Caucasian women attending the same antenatal diabetes service have comparable outcomes. Attendance for pre-pregnancy care needs to be encouraged to combat the high early pregnancy loss and congenital malformation rate identified, particularly in those with type 2 disease, irrespective of ethnicity.

The population biology of the American immigrant triclad Dugesia tigrina was investigated in two British eutrophic lakes: Colemere, England, harbours an asexually reproducing population and Llyn Coron, North Wales, a population that reproduces both sexually and asexually. Monthly samples of triclads were taken from the undersides of stones in both lakes, and from ceramic tiles and plastic trays in Colemere and Llyn Coron, respectively, over two years. In both populations, body size-structure decreased slightly over winter, with an absence of very large and very small animals. Individual growth occurred in spring, and over summer the proportion of large and small individuals declined and increased, respectively. During September to November, size-structure was fairly stable. Increases in the size structure of the populations were associated with higher temperatures and an increased food supply; stability in size structure during the autumnal post-reproductive period, when temperatures were favourable for growth, to the occurrence of intraspecific competition for food; and decreases in size structure to lower temperatures during the winter. In both populations the density of triclads increased in summer to a peak in autumn, thereafter declining to a nadir in spring. The numerical peak in autumn was due to recruitment from reproduction, and the subsequent decline to deaths following the occurrence of intraspecific competition for food in late autumn, some invertebrate predation and winter mortality. Asexual reproduction (fission) started in June and finished during August in both populations. Laboratory experiments indicated that the occurrence and rate of fission is influenced by temperature and the amount of available food. The critical temperature for the initiation and cessation of fission lay between 14 and 16 °C in laboratory studies, and in the field fissioning started as temperatures approached 15 °C. In Llyn Coron, cocoon deposition commenced in June, peaked in July with only a very few produced in August. Triclads collected from the field outside these months could not be induced to lay cocoons in the laboratory. Laboratory experiments showed that cocoons were deposited at temperatures of 17.5, 20, and 25 °C, but not at 12.5 °C. Thus, in the field, cocoon production started when temperatures approached 15 °C in June, but had ceased whilst temperatures were still in excess of 15 °C in late August. Termination of cocoon dsposition is associated with the disappearance of large triclads in excess of 20 mm2, below which animals are not sexually mature; disappearance of large animals was due to fissioning, death after sexual reproduction, and probably shrinkage due to severe intraspecific competition for food. Laboratory experiments indicated that the Colemere population had, potentially, greater fission production than the Llyn Coron population. Despite this, the numerical size of the Colemere and Llyn Coron populations increased seven-fold and eleven-fold, respectively, over the reproductive period. Whether or not this difference in reproductive potential between the populations will continue is speculative; the introduction of D. tigrina to Llyn Coron is relatively recent and the population may still be expanding to reach the carrying capacity of the habitat. Its high reproductive output must have helped its successful invasion of the lake.