Ashley Shepherd

Maternal docosahexaenoic acid supplementation during pregnancy and visual evoked potential development in term infants: a double blind, prospective, randomised trial

Aim: To test the hypothesis that maternal docosahexaenoic acid (DHA) supplementation during pregnancy enhances maturation of the visual evoked potential (VEP) in healthy term infants. Methods: One hundred women were supplemented with either fish oil capsules rich in DHA (n = 50) or placebo capsules (n = 50) from week 15 of pregnancy until delivery. Total fatty acids in red blood cells and plasma were measured at weeks 15, 28, and 40 of pregnancy and at delivery in umbilical cord blood. Infant visual pathway development was assessed using VEPs recorded to flash stimuli shortly after birth and to both flash and pattern-reversal stimuli at 50 and 66 weeks post-conceptional age (PCA). Results: Maternal supplementation did not significantly elevate the level of DHA in umbilical cord blood. Moreover, there were no significant differences in any of the VEP measures observed between supplementation groups. However, maturity of the pattern-reversal VEP at 50 and 66 weeks PCA was associated with DHA status of the infants at birth. Infants with higher DHA status, both as a concentration and as a percentage of total fatty acids, showed shorter P100 peak latencies of the pattern-reversal VEP than those with lower DHA status. Conclusions: Maternal DHA supplementation during pregnancy did not enhance VEP maturation in healthy term infants. However, these results show an association between the DHA status of infants at term and early postnatal development of the pattern-reversal VEP, suggesting that DHA status itself may influence maturation of the central visual pathways.

Emmetropisation following preterm birth

Background/aims: Even in the absence of retinopathy of prematurity (ROP), premature birth signals increased risk for abnormal refractive development. The present study examined the relation between clinical risk factors and refractive development among preterm infants without ROP. Methods: Cycloplegic refraction was measured at birth, term, 6, 12, and 48 months corrected age in a cohort of 59 preterm infants. Detailed perinatal history and cranial ultrasound data were collected. 40 full term (plus or minus 2 weeks) subjects were tested at birth, 6, and 12 months old. Results: Myopia and anisometropia were associated with prematurity (p<0.05). More variation in astigmatic axis was found among preterm infants (p<0.05) and a trend for more astigmatism (p<0.1). Emmetropisation occurred in the preterm infants so that at term age they did not differ from the fullterm group in astigmatism or anisometropia. However, preterm infants remained more myopic (less hyperopic) than the fullterm group at term (p<0.05) and those infants born <1500 g remained more anisometropic than their peers until 6 months (p<0.05). Infants with abnormal cranial ultrasound were at risk for higher hyperopia (p<0.05). Other clinical risk factors were not associated with differences in refractive development. At 4 years of age 19% of the preterm group had clinically significant refractive errors. Conclusion: Preterm infants without ROP had high rates of refractive error. The early emmetropisation process differed from that of the fullterm group but neither clinical risk factors nor measures of early refractive error were predictive of refractive outcome at 4 years.

Intrafamilial Genotyping of Helicobacter pylori from Faecal DNA.

Helicobacter pylori infection, often acquired in early childhood, is a global cause of undernutrition, gastritis, peptic ulcer disease and gastric carcinoma. This study tested the feasibility of using H. pylori shed in the faeces as a source of DNA for non-invasive epidemiological studies. H. pylori DNA was chemically recovered and isolated using a specific biotinylated oligonucleotide probe with magnetic capture from 28 H. pylori positive faecal samples obtained from children attending hospital for the investigation of suspected H. pylori infection, together with close family members. Random amplification of polymorphic DNA (RAPD) was subsequently used to discriminate each isolate. 93% of stool samples selected were typeable. Parent, child and sibling samples were compared and similarities determined. Phylogenetic analysis showed that H. pylori DNA obtained from the faeces can be used to genotype individual strains, offering a means of studying intrafamilial transfer of this microorganism.

Evaluation of Protocol Using Gene Capture and PCR for Detection of Helicobacter pylori DNA in Feces

ABSTRACT The route of transmission of Helicobacter pylori, which is usually acquired in childhood and is one of the most common bacterial infections in humans, remains undetermined. Mapping the distribution of H. pylori genotypes within families could help to determine the routes of transmission and risk factors. Here we describe a noninvasive method for obtaining H. pylori DNA isolates from the feces of children. Children presenting with gastrointestinal symptoms at the Royal Hospital for Sick Children were tested for gastric H. pylori colonization by using the 13C-urea breath test (UBT) and were asked to provide fecal samples, which were tested for H. pylori by using the HpSA fecal antigen test. DNA was purified from fecal samples by using a novel method of gene capture with subsequent H. pylori PCR analysis. Fifteen UBT-positive and 15 UBT-negative children participated in the study. The positive and negative predictive values for the assay were 80 and 100%, respectively. Fecal DNA purification followed by H. pylori PCR analysis is an effective tool for harvesting H. pylori DNA isolates from the feces of children. This technique may be developed to allow the diagnosis and noninvasive genotyping of H. pylori in children and their families.

Helicobacter pylori in children is strongly associated with poverty.

Background and Aims: To examine the association between prevalence of H. pylori colonisation and social deprivation in a sample of children investigated in hospital. Methods: A retrospective review of the hospital records of all children (n = 626) who underwent 13C-urea breath testing for suspected H. pylori infection at the Royal Hospital for Sick Children, Glasgow, Scotland between August 1995 to December 2002 was performed. Prevalence of H. pylori colonisation was measured by the 13C-urea breath test and socioeconomic status was measured by the Carstairs and Morris index of deprivation. Results: The overall prevalence of H. pylori was 26%. There was a highly significant positive association between H. pylori colonisation and poor socioeconomic status (p < 0.0001). The prevalence of colonisation was significantly higher in children from the most deprived areas (DepCat 6 and 7; 34%) compared to children from intermediate (DepCat 3 to 5; 22%) and the most affluent areas (DepCat 1 and 2; 16%) (p < 0.0001). Conclusions: Socioeconomic deprivation in childhood is associated with a high prevalence of H. pylori colonisation. While the incidence of H. pylori may be declining, it remains common in poor families. If the prevalence of H. pylori (26%) in this selected group reflects that of the population at large, then over gooo (5%) of Glasgows children are at risk of this preventable disease. In a city where the majority of adults are colonised with H. pylori, colonisation in early life adds to the burden of health risks to which deprived children are exposed.

Pattern-reversal visual evoked potentials in infants: gender differences during early visual maturation

This paper investigates gender differences in the peak latency and amplitude of the P1 component of the pattern‐reversal visual evoked potential (pattern‐reversal VEP) recorded in healthy term infants. Pattern‐reversal VEPs in response to a series of high contrast black and white checks (check widths 120′, 60′, 30′, 24′, 12′, 6′) were recorded in 50 infants (20 males, 30 females) at 50 weeks post‐conceptional age (PCA) and in 49 infants (22 males, 27 females) at 66 weeks PCA. Peak latency of the major component, P1, was considerably shorter in female compared with male infants. Differences in head circumference do not entirely account for the gender differences in peak latency reported here. A gender difference in P1 amplitude was not detected. These findings stress the importance of considering gender norms as well as age‐matched norms when utilizing the pattern‐reversal VEP in clinical investigations. Studies including a wider range of ages are clearly necessary in order to establish whether the earlier peak latencies in female infants represents a difference in the onset or rate of visual maturation.

A visual skills inventory for children with neurological impairments

Children with neurological impairments often have visual deficits that are difficult to quantify. We have compared visual skills evaluated by carers with results of a comprehensive visual assessment. Participants were 76 children with mild to profound intellectual and/or motor impairment (33 males, 43 females; age range 7mo–16y; mean age 5y 1mo [SD 4y 2mo]) who completed a visual skills inventory before attending a special vision clinic. The inventory included 16 questions about visual skills and responses to familiar situations. Responses were augmented by taking a structured clinical history, compared with visual evoked potential (VEP) and/or acuity card measures of visual acuity, and examined using exploratory factor analysis. Acuity ranged from normal to no light perception, and was positively associated with responses to individual questions. After excluding four uninformative questions, an association between the remaining questions and two significant independent factors was found. Factor 1 was associated with questions about visual recognition (e.g. ‘Does your child see a small silent toy?’) and these items were correlated with both the VEP and acuity card thresholds. Factor 2 was associated primarily with questions about visually mediated social interactions (e.g. ‘Does he/she return your silent smile?’). Evaluation of visual skills in children with neurological impairment can provide valid information about the quality of childrens vision. Questions with the highest validity for predicting vision are identified.

The purple line as a measure of labourprogress: a longitudinal study

BackgroundVaginal examination (VE) and assessment of the cervix is currently considered to be the gold standard for assessment of labour progress. It is however inherently imprecise with studies indicating an overall accuracy for determining the diameter of the cervix at between 48-56%. Furthermore, VEs can be unpleasant, intrusive and embarrassing for women, and are associated with the risk of introducing infection. In light of increasing concern world wide about the use of routine interventions in labour it may be time to consider alternative, less intrusive means of assessing progress in labour. The presence of a purple line during labour, seen to rise from the anal margin and extend between the buttocks as labour progresses has been reported. The study described in this paper aimed to assess in what percentage of women in labour a purple line was present, clear and measurable and to determine if any relationship existed between the length of the purple line and cervical dilatation and/or station of the fetal head.MethodsThis longitudinal study observed 144 women either in spontaneous labour (n = 112) or for induction of labour (n = 32) from admission through to final VE. Women were examined in the lateral position and midwives recorded the presence or absence of the line throughout labour immediately before each VE. Where present, the length of the line was measured using a disposable tape measure. Within subjects correlation, chi-squared test for independence, and independent samples t-test were used to analyse the data.ResultsThe purple line was seen at some point in labour for 109 women (76%). There was a medium positive correlation between length of the purple line and cervical dilatation (r = +0.36, n = 66, P = 0.0001) and station of the fetal head (r = +0.42, n = 56, P < 0.0001).ConclusionsThe purple line does exist and there is a medium positive correlation between its length and both cervical dilatation and station of the fetal head. Where the line is present, it may provide a useful guide for clinicians of labour progress along side other measures. Further research is required to assess whether measurement of the line is acceptable to women in labour and also clinicians.

Do the Institute of Medicine’s (IOM’s) dimensions of quality capture the current meaning of quality in health care? – An integrative review

Aims: The aim of this study was to determine whether the widely adopted Institute of Medicine’s dimensions of quality capture the current meaning of quality in health care literature. Design: An integrative review was utilised as there has been a multitude of published papers defining quality in relation to health care, therefore collective analysis may provide new insight and understanding. Method: Papers offering a definition or conceptual understanding of quality in relation to health care were identified by searching relevant databases. Papers were excluded according to predefined criteria. An integrative review was conducted and the Institute of Medicine’s dimensions were used as a framework for data extraction and analysis. Findings: The review identified two important additional dimensions of quality; namely caring and navigating the health care system and argues that they require recognition as dimensions in their own right. Conclusion: In the current climate of constrained finances there is a risk that the allocation of resources is directed to current explicit dimensions to the detriment of others. The result may be a reduction in health care quality, rather than improvement.

The frequency and reasons for vaginal examinations in labour

OBJECTIVE Vaginal examinations (VEs) in labour are a routine part of intrapartum care. Current U.K. guidelines recommend that VEs are offered to women at regular intervals of not less than 4h and only performed when justifiably necessary. However, justification may be interpreted differently by different midwives. This study aimed to investigate (i) the number of VEs performed in relation to length of labour and (ii) the reasons given by midwives for performing the VE. METHODS This study recruited a group of women (n=144) admitted in either spontaneous labour or for induction of labour from one NHS hospital in Scotland. The number of VEs performed, the reason provided by the midwife for its need and the length of labour were all recorded. FINDINGS The number of VEs carried out (mean 2.9, SD 1.5, range 1-7) increased as length of time in labour in hospital increased. Approximately half the sample (52%) had 3 or more VEs during labour. Almost 70% of women had more VEs than expected when the criteria of 4 hourly VEs was applied. The most common reason given by midwives for performing a VE was to assess labour progress and to assess the commencement of labour. CONCLUSIONS Despite maternity care policy to limit interventions in normal labour, we found that a substantial number of women received more VEs than was consistent with adherence to guidelines. However, until further research is conducted to validate other measures of labour progress, the number of VEs undertaken during labour is unlikely to decrease.