Summary In a study to evaluate the reproducibility and accuracy of the sonar technique of measurement of the in vivo fetal crown‐rump length (Robinson, 1973), a series of in vivo and in vitro experiments was performed in which the random and systematic errors inherent in the technique were assessed. The potential sources of random error were those of operator judgement, movement of the fetus and mother, machine sensitivity settings and measurement from the photograph; while the sources of systematic error were those of oscilloscope scale factor, and velocity calibration inaccuracies, and the effect of beam width. The overall effect of the random errors, that is, the reproducibility of the technique, was assessed in an in vivo blind trial in which three independent measurements were made of the fetus. In a series of 30 experiments the average standard deviation of the three readings was found to be 1.2 mm. Evaluation of the systematic errors by in vivo experimentation, on the other hand, showed that the basic sonar measurements were in error by an overestimate of 1 mm for the beam width effect and 3.7 per cent for the scale factor and velocity calibration errors. A weighted non‐linear regression analysis of 334 measurements was performed in order to obtain a “curve of best fit” for the period covering 6 to 14 weeks of menstrual age. The values obtained were corrected for the systematic errors and compared with widely quoted anatomical figures. In the second part of this investigation the original data was further analyzed to determine on a statistical basis the accuracy of the technique as a method of estimating maturity. It was shown that such an estimate could be made to within 4.7 days with a 95 per cent probability on the basis of a single measurement, and to within 2.7 days if three independent measurements were made.

Excessive daytime sleepiness is common even in patients with PD who are independent and do not have dementia. Sudden-onset sleep without warning is infrequent. The Epworth score has adequate sensitivity for predicting prior episodes of falling asleep while driving and its specificity can be increased by use of the Inappropriate Sleep Composite Score. It is unknown if routinely performing these assessments could be more effective in predicting future risk for these rare sleep attacks. Patients should be warned not to drive if they doze in unusual circumstances.

Sic We read with great interest the commentary by Rennie and Cardozo (Vol 105, December 1998)'. Massive haemorrhage is a serious and challenging condition that is often difficult to manage. The article does well in highlighting the variety of treatments of this problem and its lessons should be. learnt by the seasoned pelvic surgeon as well as those who are in training. We fully endorse the comments made by the authors regarding the difficulty in keeping pace with coagulation deficit in the face of intractable haemorrhage. The implications of this catastrophe are even more pronounced in the more frequently encountered obstetrical haemorrhage. We had similar h o m t j h g experiences twice in the last six months during elective caesarean sections. The two cases were performed due to previous caesarean section and associated placenta praevia and both culminated in caesarean hysterectomy due to massive intrapartum blood loss. In our second case a consultant haema-tologist was involved at an early stage, and cryoprecipitate, fresh frozen plasma and platelets were given appropriately. Despite trans-fusing 41 units of blood there was no haematological evidence of a coagulation deficit, yet massive haemorrhage continued necessitating packing the abdomen as a temporary measure to stop the bleeding. It was removed forty-eight hours later uneventfully. Bleeding caused by coagulation disorders is at microvascular level and all the blood components used in replacement therapy cannot plug up holes in larger arteries and veins. The difficulty with haemorrhage in the pelvis stems from lacerations of deep pelvic veins, and can vary in magnitude from trivial to life threatening. Pelvic veins may be fragile, tortuous, hidden from view, and distended. Moreover gynaecological surgeons do not have the luxury of using tourniquets to control bleeding. Another moral to the story is that whenever extensive pelvic dis-section is anticipated or encountered intraoperatively, the help given by a haematologist at an early stage may have a considerable impact on the outcome. Additionally, a member of the operating or anaesthetic teams should be dedicated to monitor blood loss and replacement. In the excitement of the moment it is very possible to lose count of the number of units of blood, blood components, crystal-loids and other fluids that have been given as well as the amount of blood loss. One strength of the article is the surgeons' realistic appraisal of their limitations; it is a wise individual who knows when to seek assistance. The attitude of the surgeon may be the deciding factor in the outcome of the situation, a point worth stressing in the training of junior surgeons. Reference 1 Aberdeen Endometria1 Ablation Trials Group. A randomised trial of endometrial ablation versus hysterectomy for the treatment of dys-functional uterine bleeding: outcome at four years. Br J Obstet Gynaecoll999; 106 360-366. 0 RCOG 1999 Br J Obstet Gynaecol 106,874-876

We wished to determine the specificity of smooth-pursuit eye tracking dysfunction to schizophrenia and the prevalences of dysfunction among functionally psychotic and normal individuals. Therefore, we investigated pursuit tracking in a large sample of psychotic patients, normal subjects, and first-degree relatives (N = 482). Patients were recruited as part of an epidemiological study of first-episode psychosis that used a broadly based referral network to identify all cases in a major metropolitan area over a 2'/2-year period. Patients received diagnoses of schizophrenia, schizophreniform disorder, psychotic mood disorder, and paranoid or other psychotic disorder based on the third edition of the Diagnostic and Statistical Manual of 'Mental Disorders (American Psychiatric Association, 1980). The distribution of tracking performance was bimodal for the schizophrenic patients and their relatives, perhaps reflecting major gene action. Moreover, poor tracking ran in families. Pursuit tracking dysfunction was relatively specific to schizophrenic patients and their relatives and occurred infrequently in other psychotic patients and normal subjects.In many independent investigations an association between smooth-pursuit eye tracking impairment and schizophrenia has been documented (for recent reviews, see lacono, 1988). First-degree relatives of schizophrenic individuals, including their twins, are also likely to show oculomotor dysfunction (Holzman et al, 1988;Matthysse, Holzman, & Lange, 1986). Some have speculated that deviant pursuit oculomotion is a psychophysiological marker of genetic predisposition to schizophrenia, and a genetic model has been advanced to account for some family data (Holzman et al., 1988). Holzman et al. (1988) and Matthysse et al. (1986) have posited that almost all cases of schizophrenia can be accounted for by a latent trait governed by a dominant gene. The expression of the gene is hypothesized to be pleiotropic, with carriers manifesting schizophrenia, dysfunctional pursuit tracking, or both traits.

Seventy-five patients meeting international diagnostic criteria for narcolepsy enrolled in a 6-week, three-period, randomized, crossover, placebo-controlled trial. Patients received placebo, modafinil 200 mg, or modafinil 400 mg in divided doses (morning and noon). Evaluations occurred at baseline and at the end of each 2-week period. Compared with placebo, modafinil 200 and 400 mg significantly increased the mean sleep latency on the Maintenance of Wakefulness Test by 40% and 54%, with no significant difference between the two doses. Modafinil, 200 and 400 mg, also reduced the combined number of daytime sleep episodes and periods of severe sleepiness noted in sleep logs. The likelihood of falling asleep as measured by the Epworth Sleepiness Scale was equally reduced by both modafinil dose levels. There were no effects on nocturnal sleep initiation, maintenance, or architecture, nor were there any effects on sleep apnea or periodic leg movements. Neither dose interfered with the patients' ability to nap voluntarily during the day nor with their quantity or quality of nocturnal sleep. Modafinil produced no changes in blood pressure or heart rate in either normotensive or hypertensive patients. The only significant adverse effects were seen at the 400-mg dose, which was associated with more nausea and more nervousness than either placebo or the 200-mg dose. As little as a 200-mg daily dose of modafinil is therefore an effective and well-tolerated treatment of excessive daytime somnolence in narcoleptic persons.

No abstract

In a randomized, placebo-controlled, double-blind study, glatiramer acetate (Copaxone) reduced the relapse rate and slowed accumulation of disability for patients with relapsing - remitting multiple sclerosis. Of the original 251 patients randomized to receive glatiramer acetate or placebo, 208 chose to continue in an open-label study with all patients receiving active drug. The majority of the original double-blind cohort continues to receive glatiramer acetate by daily subcutaneous injection and are evaluated at 6-month intervals and during suspected relapse. The data reported here are from approximately 6 years of organized evaluation, including the double-blind phase of up to 35 months and the open-label phase of over 36 months. Daily subcutaneous injections of 20 mg glatiramer acetate were well tolerated. The mean annual relapse rate of the patients who received glatiramer acetate since randomization and continued into the open-label study was 0.42 (95% confidence interval (CI), CI=0.34 - 0.51). The rate per year has continued to drop and for the sixth year is 0.23. Of the group who have received glatiramer acetate without interruption for 5 or more years, 69.3% were neurologically unchanged or have improved from baseline by at least one step on the Expanded Disability Status Scale (EDSS). Patients who left the open-label phase were surveyed by questionnaire. The majority responded, providing information about their current status and reasons for dropping out. This study demonstrates the sustained efficacy of glatiramer acetate in reducing the relapse rate and in slowing the accumulation of disability in patients with relapsing forms of multiple sclerosis. Multiple Sclerosis (2000) 6 255 - 266

SynopsisFour measures of mental health – Panic, Depression, Somatization and Well-Being – have been developed for use in a population of Southeast Asian refugees. The scales, a product of work with 1348 refugees, demonstrate conceptual significance, good reliability, concurrent validity and stability of structure across samples. They are culturally sensitive, enabling intra-cultural study as well as screening for clinical purposes. The measures also permit comparisons, for research purposes, with non-Asians.