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There is increasing concern that adults with a past history of incarceration are at particular disadvantage in exiting homelessness. Supported housing with case management has emerged as the leading service model for assisting homeless adults; however there has been limited examination of the success of adults with past history of incarceration in obtaining housing within this paradigm. Data were examined on 14,557 veterans who entered a national supported housing program for homeless veterans, the Housing and Urban Development-Veterans Affairs Supportive Housing program (HUD-VASH) during 2008 and 2009, to identify characteristics associated with a history of incarceration and to evaluate whether those with a history of incarceration are less likely to obtain housing and/or more likely to experience delays in the housing attainment process. Veterans who reported no past incarceration were compared with veterans with short incarceration histories (≤ 1 year) and those with long incarceration histories (>1 year). A majority of participants reported history of incarceration; 43 % reported short incarceration histories and 22 % reported long incarceration histories. After adjusting for baseline characteristics and site, history of incarceration did not appear to impede therapeutic alliance, progression through the housing process or obtaining housing. Within a national supported housing program, veterans with a history of incarceration were just as successful at obtaining housing in similar time frames when compared to veterans without any past incarceration. Supported housing programs, like HUD-VASH, appear to be able to overcome impediments faced by formerly incarcerated homeless veterans and therefore should be considered a a good model for housing assistance programs.

Hypertension in pregnancy includes a group of distinct disorders that require special consideration in both prevention and pharmacological treatment. In recent years, there have been few advances regarding the pathophysiology and prevention of pre-eclampsia, however there have been some promising studies regarding possible modes of screening women for preeclampsia before clinical signs and symptoms are apparent. The recommendations for first-line drug therapy for the hypertensive complications of pre-eclampsia, and the recommendations for pharmacological treatment of women with chronic hypertension antedating pregnancy, have changed little primarily because first-line medications have the advantage of having had more extensive research experience. Recent clinical trials have demonstrated the efficacy and safety of various second-line drugs for the hypertensive disorders of pregnancy; whether these therapies can eventually replace the standard recommended medications will require more extensive long-term investigation.

Hypertension in pregnancy includes a group of distinct disorders that require special consideration in both prevention and pharmacologic treatment. In recent years, there have been few advances regarding the pathophysiology and prevention of preeclampsia, or in recommendations for first-line drug therapy of the hypertensive complications of preeclampsia. Similarly, the recommendations for pharmacologic treatment of women with chronic hypertension antedating pregnancy have changed little, primarily because first-line medications have the advantage of having been the subjects of extensive research experience. Recent clinical trials have demonstrated the efficacy and safety of various second-line drugs for treating hypertensive disorders of pregnancy; whether these therapies can eventually replace the standard recommended medications will require more extensive long-term investigation.

Enolase is a dimeric cytoplasmic enzyme whose double gamma isoenzyme, neuron-specific enolase, is predominantly found in neuronal and neuroendocrine tissues. Cell injury causes its release into the blood and cerebrospinal fluid (CSF). Neuron-specific enolase has been measured in the serum and CSF of adults and full-term asphyxiated neonates as a marker of neurological injury. We recently observed an elevation of neuron-specific enolase in the amniotic fluid of women whose neonates subsequently developed intraventricular hemorrhage or periventricular leukomalacia. The purpose of our study was to establish reference values of neuron-specific enolase in the amniotic fluid as a function of gestational age.A total of 110 amniotic fluid samples, obtained primarily for genetic studies (16-20 weeks, n = 22), for evaluation of preterm labor (21-35 weeks, n = 66) and for fetal lung maturity studies (36-40 weeks, n = 22), were analyzed for neuron-specific enolase. Samples were from women who subsequently delivered term neonates with normal neurological examinations or who delivered preterm neonates with normal neurosonograms up to the 7th day of life. Descriptive statistics and non-parametric correlations were used for analysis.There was no correlation between gestational age and concentration of neuron-specific enolase (Spearman's r = 0.059, p = 0.63). The overall mean neuron-specific enolase value was 2.5 +/- 1.39 microg/l. The highest value obtained was 6 microgl. Of the 110 women, 105 (95.5%) had neuron-specific enolase values of less than 5 microg/l, while five (4.5%) had values ranging from 5 to 6 microg/l.The amniotic fluid level of neuron-specific enolase does not change as a function of gestational age. These stable levels may have utility in the evaluation of cases with fetal neurological injury.

To evaluate the association between relative growth restriction and preterm birth.Pregnant women referred for sonographic fetal weight assessments between 24 and 34 weeks of gestation were studied for gestational age at delivery. If a patient underwent more than one study, only the last one was considered. Patients with delivery induced iatrogenically or with abnormal growth patterns due to known pathology, such as maternal diabetes or fetal congenital anomaly, were excluded. A gestational age of 37 weeks or less was considered preterm and a gestational age of more than 37 weeks at delivery was considered term. Fetal weight estimation was obtained by Hadlock's formula based on biparietal diameter, femur length, and head and abdominal circumferences. The estimated fetal weight percentile was computed according to William's tables. Mean gestational age and incidence of preterm delivery for each fetal weight percentile between 1 and 100, at increments of 10, were calculated. The mean estimated fetal weight percentile, biparietal diameter, femur length, head circumferences and abdominal circumferences of preterm and term patients were compared.Among the 419 patients who met the inclusion criteria, duration of gestation was significantly shorter in fetuses with low estimated fetal weight percentile. The risk of preterm birth was 49% in fetuses of less than the 40th birth-weight percentile compared with a risk of 20% in fetuses of more than the 40th birth-weight percentile, representing a relative risk of 2.3. Individual fetal measurements indicate a head-sparing effect in the preterm group.Sonographically estimated fetal weight percentile measured between 24 and 34 weeks' gestation may be used as an additional and individually pertinent predictor of preterm birth.

Confidence intervals contain a wealth of clinically relevant information that is not available in the P value and usual significance testing. Numerous articles discuss the hazards of interpreting study results based solely on the P value, raising both practical and philosophical concerns. The general recommendation is that clinical research should not just test hypotheses, but also describe magnitudes of clinical effect. To this end, the confidence interval is a crucial tool in interpreting clinical studies. In this report, we show how one may use confidence intervals to gain further insight into clinical research. For example, by using confidence intervals, one can identify statistically significant results that are clinically imprecise, or conversely, statistically nonsignificant results that are quite precise. In addition, confidence intervals, like the P value, are influenced by sample size. We show how sample sizes that are sufficiently large to test hypotheses may be too small to generate precise estimates of the magnitude of effect. The application and interpretation of confidence intervals are demonstrated through the use of several examples.

Our purpose was to measure intra-amniotic pressure before and after decompression amniocentesis in twin-twin transfusion syndrome.Intra-amniotic pressures were measured during decompression amniocentesis on 18 occasions in 5 pregnancies complicated by twin-twin transfusion syndrome. The intra-amniotic pressure was determined with a water manometer before and after removal of amniotic fluid. For comparison, intra-amniotic pressure was determined in 10 uncomplicated gestations.Initial intra-amniotic pressures in twin-twin transfusion gestations (mean, 17.2 +/- 5.2 cm H2O; range, 5.5 to 33.0 cm H2O) were higher than those of the uncomplicated gestations (mean, 8.4 +/- 3.3 cm H2O; range, 3.5 to 13.5 cm H2O; p0.002). Intra-amniotic pressures following therapeutic amniocentesis (mean, 10.9 +/- 5.1 cm H2O; range, 3.5 to 23.0 cm H2O) were not different from those of the uncomplicated gestations (p = 0.16).The intra-amniotic pressure in twin-twin transfusion gestations is higher than that of the uncomplicated gestation. Decompression amniocentesis reduces intra-amniotic pressure to that of the uncomplicated gestation.

To identify sensitive epidemiologic predictors of a positive hepatitis C virus antibody test in asymptomatic persons, and to compare the cost of testing only persons with an epidemiologic predictor to that of universal screening.Seventeen hundred consecutive pregnant women were tested by enzyme-linked immunosorbent assay for antibody to hepatitis C virus. Seventy-five subjects tested positive and were compared with 257 pregnant women who tested negative. Cohort and control patients were interviewed and their medical records were reviewed to identify those with chosen predictors of a positive hepatitis C virus antibody test.Seventy-four of 75 cohort patients and 108 of 257 controls had one or more predictors of a positive antibody test. Cohort patients were significantly more likely (P.001) to have the following: human immunodeficiency virus infection, a sex partner with a risk factor for hepatitis, age greater than 30 years, and a history of drug use, blood transfusion, sexually transmitted disease, hepatitis, or incarceration. The sensitivity and specificity of a single predictor in identifying a person with a positive test were 99 and 58%, respectively. The cost of finding a single individual with a positive antibody test by universal screening was $674, compared to $303 by selectively screening persons with one or more predictors of a positive antibody test.Most individuals with positive hepatitis C virus antibody tests can be identified on the basis of epidemiologic predictors, reducing the cost of testing by 55%. These patients may receive appropriate medical therapy, and their children may be evaluated for possible infection by vertical transmission of hepatitis C virus.

Objective: Because our previous studies in several vascular preparations suggest that posthypoxic reoxygenation elicits tone responses by generation of hydrogen peroxide we compared the actions of reoxygenation and hydrogen peroxide on isolated human placental arteries and veins. Study Design: Endothelium-intact and denuded arteries and veins (1 to 2 mm diameter, from normal term deliveries), incubated under 95% oxygen/5% carbon dioxide or 5% oxygen/5% carbon dioxide (balance nitrogen) and precontracted with 1 to 10 nmol/L U46619, were exposed to hypoxia (95% nitrogen/5% carbon dioxide, Po2 8 to 10 torr) followed by reoxygenation and to 1 to 100 µmol/L hydrogen peroxide in the presence and absence of the inhibitor of prostaglandin biosynthesis, 10 µ-mol/L indomethacin. Results: In both arteries and veins posthypoxic reoxygenation or exposure to hydrogen peroxide produced vascular contraction that was eliminated or reversed to a modest relaxation by indomethacin, consistent with mediation by prostaglandins. Hypoxia after incubation with 5% oxygen, but not 95% oxygen, caused a modest prostaglandin-independent relaxation. Removal of the endothelium did not alter any of these responses. Conclusion: Placental arteries and veins show a similar prostaglandin-mediated contraction to hydrogen peroxide and posthypoxic reoxygenation, consistent with a possible involvement of hydrogen peroxide in the response to reoxygenation.

T-lymphocyte subpopulations were evaluated longitudinally in 62 primigravidas. Beginning early in the second trimester, women who later developed preeclampsia showed a significantly lower proportion of T-helper cells compared with those who remained normotensive (27.0 +/- 7.1 versus 34.7 +/- 7.9%; P less than or equal to .001). The decrease in the T-helper cell count occurred several weeks before the development of preeclampsia and reverted to normal 6-10 weeks postpartum.

Cardiac events in 30 patients in preterm labor on ritodrine therapy were examined continuously on a Holter monitor. Unsuspected events, such as persistent severe tachycardia, premature ventricular contractions, and supraventricular premature contractions, were observed. These events did not occur more frequently in patients with cardiac symptoms. None of these changes were observed by standard monitoring methods. Continued beta-mimetic stimulation in the presence of these events may lead to the serious cardiopulmonary complications that have been reported during ritodrine infusion.

High dietary protein intake is known to increase glomerular filtration rate in the nonpregnant state. The effects of dietary protein on renal function in human pregnancy are not well known. We studied 392 patients with singleton uncomplicated pregnancies at gestational ages of 7-40 weeks. Creatinine clearance was correlated with protein intake estimated from 24-hour dietary recall during the same period. Creatinine clearances were significantly higher when dietary protein was more than 50 g than when it was less than 50 g (P less than .005). The short- or long-term significance of this finding is unclear.

Fetal monitoring data in 200 consecutive cases was evaluated in the second hour prior to delivery to determine how neonatal outcome could be most accurately predicted. It was found that the correlation between ominous fetal heart rate-uterine contraction (FHR-UC) patterns and a depressed Apgar score at 1 minute was, at best, 37%. However, where the last fetal scalp blood pH (FSB-pH) was less than or equal to 7.2, neonatal depression occurred in 88% of cases. FSB-pH, therefore, provided a more reliable means of diagnosing fetal distress.

Ninety-two consecutive cases of breech presentation with birth weights less than or equal to 2,000 g were examined for early periventricular/intraventricular hemorrhage (PV/IVH) and neonatal demise. The total group and subgroups, based on birth weight and gestational age, showed significantly less early PV/IVH and perinatal mortality if delivered by cesarean section. There is a need for a prospective, randomized, multicentric study of this subject.

Nipple stimulation was found to be a safe alternative to oxytocin in the management of the third stage of labor.

Nipple stimulation with an electric breast pump was compared with oxytocin infusion as a means of labor induction. The time from stimulation to the onset of regular uterine activity and to 200 Montevideo units of uterine activity and the time until entrance into the active phase of labor were significantly shorter in the nipple stimulation group. Once the women were in active labor, there was no difference between the groups in the length of labor or mode of delivery.

Four patients with severe Rh isoimmunization are presented in whom sinusoidal fetal heart rate patterns were recorded. In 2 cases in which the pattern was seen intermittently in the postintrauterine transfusion period, the perinatal outcome was good. In the 2 cases in which the pattern was seen spontaneously and continuously, the outcome was poor, confirming the ominous and possibly agonal significance of the latter pattern.

This study presents 3 cases of severe soft-tissue malformations of the fetus. Prenatal diagnosis was established early in the second trimester, and the accuracy of the diagnosis was confirmed by pathological examination in each instance. A clinically oriented work-up plan for early prenatal diagnosis is proposed.

Experience with the management of 4 pairs of locked twins is described and analyzed. In view of the high morbidity figures a proposed preemptive management is suggested.

Hypertensive disorders of pregnancy contribute significantly to perinatal mortality. Successful application of modern tests of antepartum fetal status and appropriately timed delivery, with monitored labor and liberal use of cesarean section led to significantly improved fetal and neonatal salvage in 242 patients with hypertensive disorders of pregnancy between 1973 and 1975. The reduction in perinatal mortality to a corrected rate of 12/1000 in the years 1973-1975, compared to a previous rate of 75/1000 between 1970 and 1972, justifies the modern aggressive management of hypertensive disorders in pregnancy.

Maternal serum prolactin (PRL) levels were evaluated in patients having contraction stress tests (CST) by nipple stimulation. Of 79 CSTs, 14 failed and 65 were successful. Poststimulation PRL levels in failed cases were significantly lower than those in gestational age-matched successful cases, despite longer duration of nipple stimulation in the failed cases.

Neonatal mortality, idiopathic respiratory distress syndrome, and early periventricular/intraventricular hemorrhage in the neonate weighing 2000 g or less were correlated with umbilical artery acid-base status. Neonatal mortality and, to a lesser extent, idiopathic respiratory distress syndrome correlated with umbilical artery acidosis. Early periventricular/intraventricular hemorrhage was associated with low Apgar scores, but showed no correlation with umbilical artery acid-base status.

On routine fontanelle scanning of neonates weighing less than or equal to 2000 g within the first 24 hours of life, 21% had abnormal findings related to peri/intraventricular hemorrhage. These findings occurred almost exclusively in patients who were in labor, with one exception, and were not observed without labor. Once labor ensued, the performance of cesarean section did not prevent periventricular and intraventricular hemorrhage. Other obstetric factors including fetal heart rate monitoring and umbilical artery pH values were not related to early periventricular and intraventricular hemorrhage. The practical significance of these findings is discussed.

Two hundred eighty patients with vertex presentation who were in spontaneous labor and delivered neonates weighing 2 kg or less were examined for early ultrasound evidence of periventricular/intraventricular hemorrhage. This was correlated retrospectively with delivery route (cesarean section versus vaginal delivery) and delivery method (low forceps delivery versus normal spontaneous delivery) in the group born vaginally. No correlation was evident between early periventricular/intraventricular hemorrhage and delivery route or method.

Twenty children who had been exposed to ritodrine in the management of preterm labor between 24 and 34 weeks' gestational age were examined at seven to nine years of life and compared with matched control subjects. No significant differences were detected in factors of growth, neurologic findings, and psychometric testing.