For many obstetricians and midwives continuous electronic fetal heart rate monitoring during labour has replaced the traditional method of intermittent auscultation. Of the eight prospective randomised controlled trials designed to assess its value in obstetric care, four were concerned with mothers defined as being at high-risk, three with normal or low-risk patients, and the eighth with the total population of a maternity hospital over several months. None suggested any major advantage of continuous fetal heart rate monitoring over intermittent surveillance in terms of neonatal mortality, morbidity, cord blood pH values, or the five minute Apgar score. The rates of caesarean section and forceps delivery were higher in the continuously monitored group. For low-risk mothers there is a good case for a return to the traditional method of intermittent auscultation with its lower false-positive rate, lesser incidence of intervention, and opportunity for greater contact between the maternity care staff and the mother.

The best management of fetal hydronephrosis is controversial. Despite the lack of experimental evidence that prenatal drainage of the obstructed urinary tract substantially improves ultimate renal function, various forms of percutaneous intervention on the fetal bladder and kidney have been used. To evaluate the efficacy of intervention for suspected fetal obstructive uropathy, all published reports of drainage of the fetal urinary tract up to December, 1985, were reviewed. In the 57 reported cases, the most common type of intervention was placement of a vesicoamniotic shunt (37%). Complications occurred in 25 cases (44%), including inadequate shunt drainage or migration (19%), onset of premature labour within 48 h (12%), urinary ascites (7%), and chorioamnionitis (5%). Of 28 fetuses with associated oligohydramnios, only 6 (21%) survived. 2 of these survivors had vesicoamniotic shunts, 2 single or multiple bladder aspirations, 1 an external renal drainage catheter, and 1 in-utero vesicostomy. Because of the high complication rate and lack of evidence of improved survival from in-utero drainage procedures, a prospective, randomised trial is needed to compare survival with and without vesicoamniotic shunt placement.

Current experience with the safety and efficacy of vaccines in infected children and adults is reviewed to examine the basis for decisions about routine immunisations of children infected with the human immunodeficiency virus (HIV). No adverse reactions to inactivated vaccines have been noted, but complications with live vaccines have been recorded with both BCG and smallpox. Limited experience with live poliomyelitis and measles vaccines in HIV-infected children has not yet shown any severe complications from these vaccines. Theoretical concerns that immunisation might accelerate the course of HIV infection are not supported by available data. Serological response to most inactivated and live vaccines is reduced in HIV-infected persons, and is related to the degree of immunosuppression present. Preliminary evidence suggests that the severity of some vaccine-preventable diseases is increased in HIV-infected children. This review finds general support for recommendations on immunisation of HIV-infected children that have been developed by the World Health Organisation.

Diseases with disappearing intrahepatic bile ducts may be developmental, immunological, infective, vascular, or chemical in origin. The immunological group includes primary biliary cirrhosis, graft-versus-host disease, and sarcoidosis. HLA class 2 antigens are displayed on the bileducts and recognition of biliary antigens by cytotoxic T-cells leads to destruction of interlobular ducts. Primary sclerosing cholangitis is associated with immunological features, but the hepatic histology is not that of immunological duct disease. The association with immunodeficiency syndromes, and the finding that secondary sclerosing cholangitis may occur in patients with the acquired immunodeficiency syndrome who are infected with cytomegalovirus, suggest that primary sclerosing cholangitis might be infective in origin. In bacterial cholangitis there is contiguity between the biliary system and the intestinal tract and usually, but not necessarily, partial biliary obstruction. Interference with the hepatic arterial supply to the bileducts leads to vascular cholangitis. Chemical cholangitis follows injection of scolicidal agents into the biliary tree. Diseases with disappearing bileducts have a long natural history and hepatocellular failure occurs late. In the late stages hepatic transplantation gives good results.

The collection of genes known as the major histocompatibility gene complex (MHC) appears to subserve three functions. Firstly, its class I genes, coding for antigens on all nucleated cells, assist clones of cytotoxic T cells to kill virus-infected cells quickly, without being muffled by the myriad numbers of free virus particles. Secondly, the absence of autoimmunity to both class I and class II MHC antigens shows that they impose unbreakable tolerances on the immune repertoire. The class II antigens, which are confined to B lymphocytes (if their apparent occurrence on other dividing cells is a cross-reaction), may have the sole function of tolerance induction, supplementing this activity of the class I antigens. Both sets of MHC antigens serve to diversify immunity-repertoire gaps among individuals of a population, thus hampering epidemic spread of infection and providing a diversity of immunoreactivity that favours survival of at least some members of a population in the face of pestilence. Thirdly, the permanence of the MHC tolerance inductions affords a powerful, adaptable mechanism for curtailment of reproductively disadvantageous autoimmune disease liable to arise through somatic mutations in lymphocytes multiplying under drive from a microbial antigenic stimulus.

The best therapy for children with acute lymphoblastic leukaemia (ALL) who have an initial bone marrow relapse and subsequently achieve second remission is controversial. Some findings suggest that bone marrow transplantation (BMT) is better than chemotherapy whereas others do not. An analysis of 871 children treated by BMT or chemotherapy showed that outcome was correlated with risk factors at diagnosis and with length of first remission. BMT seemed superior in patients who relapsed within 18 months of first remission while on maintenance chemotherapy. BMT was not demonstrably superior in patients who relapsed more than 18 months after first remission. The choice of treatment in childhood ALL must be based on prognostic variables at diagnosis and on the circumstances of the relapse.

Parasomnias are due to a combination of familial, developmental, and environmental factors. The clinical features are well known, but reports by patients do not always match the typical descriptions. Parasomnias are not due to mental ill-health but are occasionally associated with brain disease. Their recognition is important, but treatment is rarely necessary. Occasionally, life-threatening injuries result from sleep-walking and night terrors.