Postconceptual Neonatal Dating by Transmastoid Ultrasound of Transcerebellar Diameter-Comparison to Crown Rump Length Measurement: A Proof of Concept Paper

OBJECTIVES

Transcerebellar diameter (TCD) has been utilized prenatally as a tool to estimate gestational age (GA) when fetal growth aberrations are suspected. Traditionally, first trimester ultrasound (1TUS) has been the gold standard of dating a pregnancy in spontaneous pregnancies. We sought to determine if neonatal TCD measurement was as accurate as 1TUS in the estimation of postconceptual gestational age (PCGA).

METHODS

A retrospective cohort from a registry of high-quality transmastoid views of consecutive patients from July 2019 to November 2020, delivered from 24 to 34 weeks GA, and with a 1TUS were included. The reference PCGA was the sum of the GA at delivery by 1TUS and day of life. The PCGA by TCD was calculated from Chang et al for GA by TCD. Reference and experimental values were compared by correlation, agreement within 7 days, and Bland-Altman analysis.

RESULTS

Of the 154 individual patients in the registry of high-quality transmastoid views during the study period, 62 met inclusion and exclusion criteria. PCGA by 1TUS and TCD were highly correlated (r = 0.86, P < .001; κ = 47% agreement within 7 days of PCGA). The bias of PCGA by TCD was 4.6 days earlier than the PCGA by 1TUS (95% confidence interval of agreement: -29.2, 20).

CONCLUSIONS

PCGA estimation by neonatal transmastoid TCD was highly correlated with that of 1TUS. It generally underestimates GA by 4.6 days. This relationship warrants further investigation to determine if this method of estimating PCGA in undated gestations is generalizable.

Efficacy and Safety of Anti-Tumor Necrosis Factor Alpha in Very Early Onset Inflammatory Bowel Disease

BACKGROUND

Very early onset inflammatory bowel disease (VEOIBD) is defined as disease onset in patients younger than 6 years. Challenges in treatment of VEOIBD include lack of approved therapies and increased incidence of monogenic immunodeficiencies. We report on patterns of anti-TNF use, efficacy, and safety in a large cohort of patients with VEOIBD.

METHODS

Very early onset inflammatory bowel disease patients receiving care at a single center were prospectively enrolled in a data registry and biorepository starting in 2012. Whole exome sequencing was available to all patients. Clinical data including IBD medication use and response were extracted from the medical record. We examined antitumor necrosis factor (anti-TNF) cumulative exposure and time to failure and evaluated the effect of covariates on anti-TNF failure using Cox proportional hazard regression.

RESULTS

In this cohort of 216 VEOIBD patients with median 5.8-year follow-up, 116 (53.7%) were TNF-exposed. Sixty-two TNF-exposed patients (53.4%) received their first dose at younger than 6 years. Cumulative exposure to anti-TNF was 23.6% at 1 year, 38.4% at 3 years, and 43.4% at 5 years after diagnosis. Cumulative exposure was greater in patients with Crohn's disease (P = .0004) and in those diagnosed in 2012 or later (P < .0001). Tumor necrosis factor failure occurred in 50.9% of those exposed. Features predictive of anti-TNF failure included ulcerative colitis/IBD-unclassified (hazard ratio, 1.94; P = .03), stricturing (hazard ratio, 2.20; P = .04), and younger age at diagnosis (hazard ratio, 1.25; P = .01). Adverse events occurred in 22.6% of infliximab-exposed and 14.3% of adalimumab-exposed.

CONCLUSIONS

Efficacy and safety of anti-TNFs in VEOIBD is comparable to what has previously been reported in older patients.

A Systematic Review of Vitamin D and Fibroids: Pathophysiology, Prevention, and Treatment

Uterine fibroids are the most common tumor of reproductive-age women worldwide and cause significant morbidity in affected women. Vitamin D has emerged as a potential therapy for uterine fibroids based on experimental and epidemiologic evidence. The objective of this systematic review was to evaluate the role of vitamin D in the pathophysiology of uterine fibroids and its efficacy for prevention and treatment of fibroids. A comprehensive search was conducted of Cochrane Library, Embase, PubMed, Scopus, and Web of Science from inception to March 2022. English-language publications that evaluated vitamin D and uterine fibroids in humans, whether experimental or clinical, were considered. The search yielded 960 publications, and 89 publications met inclusion criteria: 23 preclinical studies, 25 clinical studies, and 41 review articles. Preclinical studies indicated that the vitamin D receptor was decreased in fibroid cells. Vitamin D treatment of fibroid cells decreased proliferation, extracellular matrix protein expression, and Wnt/β-catenin signaling. Fourteen clinical studies (n = 3535 participants) assessed serum vitamin D level in women with ultrasound-proven fibroids, and all found an inverse correlation between serum vitamin D level and presence of fibroids. Five clinical studies (n = 472 patients) evaluated treatment of fibroids with vitamin D. Four of five studies showed vitamin D significantly inhibited fibroid growth. One pilot study (n = 109 patients) of vitamin D for secondary prevention of fibroids demonstrated smaller recurrent fibroids in the treated group. These studies provide evidence for vitamin D as a therapy for uterine fibroids and underscore the need for well-designed, randomized, placebo-controlled clinical trials.

Racial disparities in commercial U.S. oocyte donors

e18501

Background: Patients undergoing cancer treatment are more likely to face infertility. Despite improvements in counseling and fertility preservation, some oncology patients will require the use of donor oocytes to complete their family. We investigated whether the current cohort of commercial oocyte donors reflects the racial profile of the U.S. population. We also evaluated whether there were differences in donors’ perception of pain and quality of informed consent by race to elucidate potential avenues to improve donor retention. Methods: Institutional Review Board approved, retrospective survey of commercial, U.S. oocyte donors was emailed to recent donors recruited through Donor Egg Bank USA prior to 2020. There were 246 respondents out of 503 opened emails (48.9%). Donors were recruited by twenty different clinics that are affiliated with the same donor egg bank. Results: Black and Hispanic donors were significantly underrepresented among commercial U.S. egg bank donors while Caucasian and mixed-race donors were overrepresented (Table - left). The perception of pain in donors, however, did not differ according to race (Table - right, p = 0.245). Over 80% of donors reported that they had received better than acceptable levels of preparation through the informed consent process. Respondents’ report of the quality of the informed consent process did not differ by race (p = 0.728). Conclusions: Our study represents one of the largest cohorts of recent U.S. oocyte donors. The racial composition of recruited donors overrepresents Caucasian and mixed-race donors while underrepresenting Hispanic and Black donors when compared to the racial identity self-reported in the 2020 US census. This may represent the demographics of the current recipient cohort; however, the lack of diversity is of particular concern for oncology patients seeking oocytes as their racial composition likely reflects the diversity represented in the U.S. population. Notably, there was no difference by race in the pain score of donors by race or the quality of their informed consent process suggesting that all donors were treated similarly regardless of racial identity. Donor egg banks should consider diversification of their donor profiles to provide equal access among oncology patient seeking donor oocytes.[Table: see text]

Spike protein multiorgan tropism suppressed by antibodies targeting SARS-CoV-2

While there is SARS-CoV-2 multiorgan tropism in severely infected COVID-19 patients, it's unclear if this occurs in healthy young individuals. In addition, for antibodies that target the spike protein (SP), it's unclear if these reduce SARS-CoV-2/SP multiorgan tropism equally. We used fluorescently labeled SP-NIRF to study viral behavior, using an in vivo dynamic imaging system and ex in vivo tissue analysis, in young mice. We found a SP body-wide biodistribution followed by a slow regional elimination, except for the liver, which showed an accumulation. SP uptake was highest for the lungs, and this was followed by kidney, heart and liver, but, unlike the choroid plexus, it was not detected in the brain parenchyma or CSF. Thus, the brain vascular barriers were effective in restricting the entry of SP into brain parenchyma in young healthy mice. While both anti-ACE2 and anti-SP antibodies suppressed SP biodistribution and organ uptake, anti-SP antibody was more effective. By extension, our data support the efficacy of these antibodies on SARS-CoV-2 multiorgan tropism, which could determine COVID-19 organ-specific outcomes.

Cerebrospinal fluid drainage kinetics across the cribriform plate are reduced with aging

Background

Continuous circulation and drainage of cerebrospinal fluid (CSF) are essential for the elimination of CSF-borne metabolic products and neuronal function. While multiple CSF drainage pathways have been identified, the significance of each to normal drainage and whether there are differential changes at CSF outflow regions in the aging brain are unclear.

Methods

Dynamic in vivo imaging of near infrared fluorescently-labeled albumin was used to simultaneously visualize the flow of CSF at outflow regions on the dorsal side (transcranial and -spinal) of the central nervous system. This was followed by kinetic analysis, which included the elimination rate constants for these regions. In addition, tracer distribution in ex vivo tissues were assessed, including the nasal/cribriform region, dorsal and ventral surfaces of the brain, spinal cord, cranial dura, skull base, optic and trigeminal nerves and cervical lymph nodes.

Results

Based on the in vivo data, there was evidence of CSF elimination, as determined by the rate of clearance, from the nasal route across the cribriform plate and spinal subarachnoid space, but not from the dorsal dural regions. Using ex vivo tissue samples, the presence of tracer was confirmed in the cribriform area and olfactory regions, around pial blood vessels, spinal subarachnoid space, spinal cord and cervical lymph nodes but not for the dorsal dura, skull base or the other cranial nerves. Also, ex vivo tissues showed retention of tracer along brain fissures and regions associated with cisterns on the brain surfaces, but not in the brain parenchyma. Aging reduced CSF elimination across the cribriform plate but not that from the spinal SAS nor retention on the brain surfaces.

Conclusions

Collectively, these data show that the main CSF outflow sites were the nasal region across the cribriform plate and from the spinal regions in mice. In young adult mice, the contribution of the nasal and cribriform route to outflow was much higher than from the spinal regions. In older mice, the contribution of the nasal route to CSF outflow was reduced significantly but not for the spinal routes. This kinetic approach may have significance in determining early changes in CSF drainage in neurological disorder, age-related cognitive decline and brain diseases.

A delicate subject: The impact of cultural factors on neonatal and perinatal decision making

The neonatal intensive care unit (NICU) is a high-stress environment for both families and health care providers that can sometimes make appropriate medical decisions challenging. We present a review article of non-medical barriers to effective decision making in the NICU, including: miscommunication, mixed messages, denial, comparative social and cultural influences, and the possible influence of perceived legal issues and family reliance on information from the Internet. As examples of these barriers, we describe and discuss two cases that occurred simultaneously in the same NICU where decisions were influenced by social and cultural differences that were misunderstood by both medical staff and patients' families. The resulting stress and emotional discomfort created an environment with sub-optimal relationships between patients' families and health care providers. We provide background on the sources of conflict in these particular cases. We also offer suggestions for possible amelioration of similar conflicts with the twin goals of facilitating compassionate decision making in NICU settings and promoting enhanced well-being of both families and providers.

Measurement of the refractive index of highly turbid media: reply to comment

Peiponen et al. [Opt. Lett.35, 4108 (2010)] have expressed concern that a theoretical model we proposed in Calhoun et al. [Opt. Lett.35, 1224 (2010)] for total internal reflection from a turbid medium may be inconsistent with the experimental data, in the sense that the model fails to take into account unexplained oscillations in our data. We show that their concern arises from misinterpretation of our data and theory, and is, therefore, unfounded. NOTE: Optics Letters apologizes to the authors for the delay in the publication of this Reply.

Measurement of the refractive index of highly turbid media

We demonstrate a first simultaneous measurement of the real and imaginary parts of the refractive index of a highly turbid medium by observing the real-time reflectance profile of a divergent laser beam made incident on the surface of the turbid medium. We find that the reflectance data are well described by Fresnel theory that correctly includes the effect on total internal reflection of angle-dependent penetration into the turbid medium.

Screening guidelines for retinopathy of prematurity: the need for revision in extremely low birth weight infants

OBJECTIVE

To determine whether significant retinopathy of prematurity (ROP) can be detected before 31 to 33 weeks' postmenstrual age (PMA) in extremely low birth weight (ELBW) infants.

METHODS

Medical records of all ELBW infants (<1000 g at birth) admitted to our regional perinatal center between April 1995 and January 1999 were reviewed retrospectively. Screening examinations for ROP were routinely performed at 4 to 6 weeks' chronological age (CA) from birth and followed at least every other week. Data were collected for infants who developed ROP. We determined the PMA at which the first screening eye examination demonstrated prethreshold disease and the subsequent examination that showed threshold disease (if it occurred). The percentages of infants who developed prethreshold ROP diagnosed at </=31 weeks' PMA and of those who progressed to threshold ROP before 34 weeks' PMA were determined.

RESULTS

All 258 ELBW infants were screened for ROP. Seventy-eight infants (30%) were diagnosed with prethreshold ROP. Twenty-seven of these infants (35%) progressed to threshold ROP. Ten infants who progressed to threshold ROP were <34 weeks' PMA at the time of this diagnosis. Of these 10 infants, 3 were diagnosed at 31 weeks' PMA, 4 at 32 weeks', and 3 at 33 weeks'.

CONCLUSION

More than 80% of ELBW infants who developed prethreshold disease in this cohort were </=33 weeks' PMA. The joint statement screening option of independently using 31 to 33 weeks' PMA for the first eye examination would have led to a diagnosis of threshold ROP on first examination in as many as 13% (10/78) of our patients. Early identification of prethreshold ROP is important for providing timely intervention in this rapidly progressive disease. Therefore, ELBW infants should receive initial ROP screening using the CA guideline of 4 to 6 weeks rather than the 31- to 33-week postconceptional age guideline.

Characterization of heat-inducible expression and cloning of HtpG (Hsp90 homologue) of Porphyromonas gingivalis

Porphyromonas gingivalis is implicated in the etiology of periodontal disease. Associations between microbial virulence and stress protein expression have been identified in other infections. For example, Hsp90 homologues in several microbial species have been shown to contribute to virulence. We previously reported that P. gingivalis possessed an Hsp90 homologue (HtpG) which cross-reacts with human Hsp90. In addition, we found that elevated levels of serum antibody to Hsp90 stress protein in individuals colonized with this microorganism were associated with periodontal health. However, the role of HtpG in P. gingivalis has not been explored. Therefore, we cloned the htpG gene and investigated the characteristics of HtpG localization and expression in P. gingivalis. htpG exists as a single gene of 2,052 bp from which a single message encoding a mature protein of approximately 68 kDa is transcribed. Western blot analysis revealed that the 68-kDa polypeptide was stress inducible and that a major band at 44 kDa and a minor band at 40 kDa were present at constitutive levels. Cellular localization studies revealed that the 44- and 40-kDa species were associated with membrane and vesicle fractions, while the 68-kDa polypeptide was localized to the cytosolic fractions.

Cellular localization of a Hsp90 homologue in Porphyromonas gingivalis

We previously reported an association between elevated serum antibody titers to the 90-kDa human heat shock protein (Hsp90), periodontal health and colonization by Porphyromonas gingivalis. In this study, we examined the cellular localization of the Hsp90 homologue of P. gingivalis. Cultures of P. gingivalis were heat-stressed (45 degrees C) and examined for localization of the Hsp90 homologue. Heat stress induced a 4-5-fold increase in anti-Hsp90 antibody reactivity over that of the unstressed controls. Western blot analysis revealed two bands (44 and 68 kDa) that reacted with anti-Hsp90 antibodies. The 68-kDa band was heat-inducible, while the 44-kDa band was not. Immunogold staining revealed that the Hsp90 homologue localized principally to the membrane and extracellular vesicles. Subcellular fractionation confirmed that the Hsp90 homologue was primarily membrane-associated.

Librarians' use of HealthWeb for reference and instruction

HealthWeb is a selective Internet resource that links users to annotated, evaluated Internet resources in the health sciences. A collaborative effort of librarians from more than twenty academic institutions, it is a valuable tool for librarians at the Reference Desk and during instruction sessions. Contents of the Reference Resources section are highlighted, as well as an example of use of the Nursing page during a typical class.

Consciousness as a self-organizing process: an ecological perspective

The evolution of consciousness is seen in the context of energy-driven evolution in general, where energy and information are understood as two sides of the same coin. From this perspective consciousness is viewed as an ecological system in which streams of cognitive, perceptual, and emotional information form a rich complex of interactions, analogous to the interactive metabolism of a living cell. The result is an organic, self-generating, or 'autopoietic', system, continuously in the act of creating itself. Evidence suggests that this process is chaotic, or at least chaotic-like, and capable of assuming a number of distinct states best understood as chaotic attractors.

Periurethral collagen injection for the treatment of urinary incontinence in children

PURPOSE

We assessed the efficacy and safety of periurethral collagen injection for urinary incontinence in children with neurogenic bladder dysfunction.

MATERIALS AND METHODS

We treated 11 children (mean age 10.6 years) who had incontinence and neurogenic bladder dysfunction with periurethral injections of glutaraldehyde cross-linked collagen. All patients were on anticholinergics and all but 1 were on clean intermittent catheterization preoperatively. Four patients had previously undergone augmentation cystoplasty. All patients were assessed before and after injection with a subjective continence scale and multichannel urodynamics. Followup ranged from 4 to 20 months from the last injection.

RESULTS

Mean group Valsalva leak point pressure was 34.5 cm. water. Four of the 11 patients had an identifiable detrusor leak point pressure. Overall success rate was 55% with 4 patients dry and 2 improved. Success correlated with a minimum increase in Valsalva leak point pressure of 20 to 25 cm. water to greater than 60 cm. water. Three patients had no demonstrable Valsalva leak point pressure after injection. All 5 patients in whom treatment failed had no change in Valsalva leak point pressure, including 2 with small capacity, poorly compliant bladders preoperatively. Because they had a component of sphincteric insufficiency, they underwent injection in the hope of increasing capacity with increased continence. In 3 patients Valsalva leak point pressure was greater than 50 cm. water. Detrusor leak point pressure developed in 3 patients postoperatively, including 1 with significantly increased Valsalva leak point pressure. One patient with significantly increased Valsalva leak point pressure had urethral hypermobility postoperatively. Of the 3 patients who subsequently underwent augmentation cystoplasty 1 is now dry, 1 is wet and 1 died of complications unrelated to urological disease. Patients underwent 1 to 4 procedures (mean 2.5).

CONCLUSIONS

Periurethral collagen injection may be effective for urinary incontinence in patients who have adequate capacity with good compliance and low Valsalva leak point pressure. When there is no response to repeat injections or a transient response, one should consider the possibility of bladder decompensation.

Comparative urodynamic findings after primary valve ablation, vesicostomy or proximal diversion

PURPOSE

There is little known about the effect of urinary diversion on the bladder of children with posterior urethral valves. There is a fear that diversion may result in contracted noncompliant bladders. We wished to compare urodynamic parameters in patients who underwent primary ablation of posterior urethral valves and in those who underwent diversion in the form of vesicostomy or pyelostomy.

MATERIALS AND METHODS

Urodynamics were done in 32 boys with a history of posterior urethral valves divided into 3 groups based on initial treatment: 1) transurethral valve ablation; 2) cutaneous vesicostomy, subsequent closure and valve ablation, and 3) proximal cutaneous pyelostomy, subsequent reconstitution and valve ablation.

RESULTS

Patients who underwent initial diversion with vesicostomy or pyelostomy had bladders with larger functional capacity, better compliance and less instability. Chronic renal failure developed in 25% of the patients who underwent primary valve ablation and 33% of those who underwent diversion. Average period of diversion in vesicostomy and pyelostomy patients was 25 months.

CONCLUSIONS

Based on our findings temporary diversion does not seem to damage bladders. On the contrary, placing a damaged bladder at rest may help to improve bladder function. Bladder function following reconstitution correlated poorly with ultimate outcome and progression to renal failure. While we do not recommend temporary diversion as the treatment of choice for patients with posterior urethral valves, we believe that when chosen as treatment, it can be safely performed with little risk of further damage to the bladder.

A chaotic systems analysis of the nasal cycle

The nasal cycle is a chaotic ultradian rhythm with a period ranging from about 75 to 200 minutes. It has been shown to correlate highly with EEG amplitude in the contralateral hemisphere at virtually all frequencies, suggesting a connection between this rhythm and laterality of brain function. During a three-week period, five participants estimated airflow from both nostrils every 30 minutes during waking hours. Estimates were recorded on Likert scales and analyzed in three distinct phases: (1) reconstructing two-dimensional attractors by lagging and embedding; (2) computing Fourier frequency analyses; and (3) estimating fractal dimensions. Attractor reconstructions demonstrate noticeable order when compared to Monte Carlo reconstructions of the same data sets, and dimension estimates are in the fractal range. The attractor reconstructions, in combination with the frequency analyses, show distinct individual differences in the structure of the nasal cycle. The advantages of chaotic systems analyses over traditional behavioral statistics are discussed.

Light does not induce an increase in cyclic-GMP content of squid or Limulus photoreceptors

Both slices of squid (Loligo) retinas and Limulus ventral photoreceptors, with or without prior stimulation by flashes of bright light, were rapidly frozen and analysed for cyclic-GMP content by radioimmunoassay. Measurement of the freezing process indicated that freezing occurred at about 100 msec after the light flash. No significant changes in cyclic-GMP content were induced by light in either tissue. These data do not confirm previous reports that cyclic-GMP content of invertebrate photoreceptors is markedly increased by illumination.

Light-induced GTPase activity and GTP[gamma S] binding in squid retinal photoreceptors

Illumination greatly increases the GTPase activity in homogenates of squid (Loligo) whole retinas or rhabdomeric membranes. Adenylylimidodiphosphate inhibits the light-insensitive (but not the light-sensitive) GTPase activity in these homogenates. Illumination also greatly increases the binding of GTP[gamma S] to the rhabdomeric membranes. This binding at saturating illuminations indicates that there are approximately 10-100 times more rhodopsin molecules than G-protein molecules in squid photoreceptors. Each light-activated rhodopsin molecule activates about 10 G-protein molecules which might provide amplification for the first stage of the phototransduction cascade.

Pharmacokinetics of caffeine in breast milk and plasma after single oral administration of caffeine to lactating mothers

Six healthy lactating women ranging in age from 28 to 35 years were selected to participate in the study. The women had been nursing their infants from 3 1/2 weeks up to 17 weeks. On the morning of the study each participant received 100 mg dose of caffeine. The oral dose of caffeine was taken with a glass of water on an empty stomach. Blood samples were collected from zero time to 24 h after caffeine administration. Each subject aseptically collected breast milk from the right and left breasts by manual expression or using a mechanical breast pump, from zero time to 24 h after caffeine administration. Caffeine in plasma and breast milk was determined by gas liquid chromatography using nitrogen phosphorous detection. Caffeine was rapidly absorbed producing plasma time to peaks ranging from 0.50 to 1.00 h, with values for peak concentrations between 3.60 and 6.15 micrograms ml-1 in plasma. In breast milk, time to peak ranged from 0.75 to 2.00 h and concentration values between 1.98 and 4.30 micrograms ml-1. No significant differences were found between attainment of the time of the peak in plasma and breast milk, p greater than 0.05. In addition, peak concentration for the right and left breast were not statistically different, p greater than 0.05. However, significant differences, p less than 0.05, between plasma and both breasts in regards to the peak concentrations were found. The overall breast milk/plasma ratio obtained from the respective area under the curves were 0.815 +/- 0.0521 and 0.809 +/- 0.202 for the right and left breast, respectively, and no statistical differences were observed between the right and left breasts, p greater than 0.05. In summary, caffeine is rapidly transferred to breast milk. Multiple dose studies are needed to provide more information about caffeine concentration in breast milk of women who receive multiple doses of caffeine or who chronically consume caffeine.