Young adult outcomes following premature birth: A Western Australian experience

BACKGROUND

Childhood outcomes following preterm birth are widely published, however long-term adult outcomes are less well described. We aimed to determine the quality of life and burden of co-morbidities experienced by preterm-born young adults in Western Australia.

METHODS

A retrospective observational study was conducted. Participants born at 23-33 weeks gestation cared for at King Edward Memorial Hospital during 1990 and 1991 were recruited from a historical birth cohort. Participants completed general, medical and reproductive health questionnaires. Results were compared with contemporaneous cohort data and/or population statistics.

RESULTS

Questionnaires were received from 73 young adults aged 28 to 30 years. The majority of respondents completed high school (94.5 %), were employed fulltime (74.0 %) and had close friends and family relationships. Almost all the participants considered their health to be good (94.0 %) and participated in light exercise (90.0 %). Increased hypertension, hypercholesterolaemia, asthma, neuropsychiatric conditions and visual impairment were reported. Depression Anxiety and Stress Scale (DASS-21) scoring identified increased mild anxiety. Increased consultation with healthcare workers and use of prescription medications were reported.

CONCLUSION

The group of preterm-born adults surveyed reported a good quality of life, supportive interpersonal relationships and they provided significant contributions to society. They did report increased medical and psychological conditions than the general population.

Functional Maturation of CD4+CD25+CTLA4+CD45RA+T Regulatory Cells in Human Neonatal T Cell Responses to Environmental Antigens/Allergens

A number of laboratories have reported cord blood T cell responses to ubiquitous environmental Ags, including allergens, by proliferation and cytokine secretion. Moreover, the magnitude of these responses has been linked with risk for subsequent expression of allergy. These findings have been widely interpreted as evidence for transplacental priming and the development of fetal T memory cells against Ags present in the maternal environment. However, we present findings below that suggest that neonatal T cell responses to allergens (and other Ags) differ markedly from those occurring in later life. Notably, in contrast to allergen-responsive adult CD4(+) T cell cultures, responding neonatal T cell cultures display high levels of apoptosis. Comparable responses were observed against a range of microbial Ags and against a parasite Ag absent from the local environment, but not against autoantigen. A notable finding was the appearance in these cultures of CD4(+)CD25(+)CTLA4(+) T cells that de novo develop MLR-suppressive activity. These cells moreover expressed CD45RA and CD38, hallmarks of recent thymic emigrants. CFSE-labeling studies indicate that the CD4(+)CD25(+) cells observed at the end of the culture period were present in the day 0 starting populations, but they were not suppressive in MLR responses. Collectively, these findings suggest that a significant component of the reactivity of human neonatal CD4(+) T cells toward nominal Ag (allergen) represents a default response by recent thymic emigrants, providing an initial burst of short-lived cellular immunity in the absence of conventional T cell memory, which is limited in intensity and duration via the parallel activation of regulatory T cells.

Mycobacterial adenitis: role of Mycobacterium bovis, non-tuberculous mycobacteria, HIV infection, and risk factors in Arusha, Tanzania

OBJECTIVE

To assess risk factors and mycobacterial agents in mycobacterial adenitis.

DESIGN

Cross sectional involving comparison analysis of high-risk groups.

SETTING

Seven hospitals in rural and semi-rural districts of Arusha.

SUBJECTS

The study comprised of 457 patients of clinically diagnosed mycobacterial adenitis.

INTERVENTIONS

Biopsy materials were cultured and identification of mycobacterial isolates, and HIV infection testing were performed using standard methods. A questionnaire was used to establish information for assessing risk factors.

MAIN OUTCOME MEASURES

Proportions of mycobacterial isolates, risk factors and odds ratios.

RESULTS

Of the 457 specimens, 65(14.2%) were culture positive. Isolates identified were M. bovis, 7(10.8%) M. tuberculosis, 27(41.5%) and non-tuberculous mycobacteria 31(47.7%). HIV infection and ingestion of raw milk were linked with increased risk of M. bovis infection by OR of 13.6 (95% CI, 1.7 - 109.9) and 15.28 (3.26 - 71.7), respectively. On multivariate analysis, an OR of 16.2 (1.3 - 201.3) for having M. bovis adenitis was linked to HIV infection, raw milk and houses with poor ventilation. An OR of 5.2 (1.2 - 20.6) for non-tuberculous mycobacterial adenitis was linked to history of TB in the family, HIV infection, raw milk, raw animal products and poor knowledge on transmission of tuberculosis.

CONCLUSIONS

M. bovis caused one out of ten cases of culture positive mycobacterial adenitis. Non-tuberculous mycobacteria were more common than M. tuberculosis (50% and 40% of the cases, respectively). HIV infection and raw animal products are among the risk factors identified for M. bovis and non-tuberculous mycobacterial adenitis.

Fracture and fortified breast milk in an extremely preterm infant

Metabolic bone disease (MBD) in the newborn predominantly affects preterm infants. The risk of MBD is inversely proportional to gestational age and birthweight, and directly related to postnatal complications. Poor bone mineralization has been shown in 55% of infants born at less than 1000 g. Optimal nutrition for very preterm infants is thought to be mother's own milk but supplementation is required to meet dietary requirements. However, there is insufficient evidence to determine that supplementation of human milk with commercial fortifiers has an effect on bone mineral content. We report a case of severe MBD with fractures in an extremely preterm infant who was fed with fortified mother's milk.

Specific patterns of responsiveness to microbial antigens staphylococcal enterotoxin B and purified protein derivative by cord blood mononuclear cells are predictive of risk for development of atopic dermatitis

BACKGROUND

Mononuclear cells from children with active atopic dermatitis (AD) have been reported to be hyper-responsive to certain microbial stimuli, in particular staphylococcal enterotoxin B (SEB). However, it is not known whether this responsiveness is acquired during disease development, or is inherent. We investigated this question in a cohort of children at high risk of atopy followed prospectively from birth to age 3 years. We asked whether their cord blood mononuclear cell (CBMC) cytokine responses to SEB, to an unrelated microbial stimulus purified protein derivative (PPD), or to common allergens, were predictive of risk for subsequent AD development during infancy.

METHODS

Children at high risk of developing atopy were randomly selected from an ongoing prospective cohort. Cord blood was collected at birth. The children were seen at 6 months, 1, 2 and 3 years and examined for the development of AD. IFN-gamma, IL-5, IL-10 and IL-13 production by CBMC cultured in the presence of SEB, PPD, PHA, house dust mite (HDM) allergen, ovalbumin (OVA) and cat allergen was determined.

RESULTS

SEB-induced IL-5 production by CBMC was elevated in children who developed AD at 6 months (P = 0.01) and 2 years (P = 0.009). PPD-induced IL-5 responses were also elevated in CBMC from children who developed AD at 6 months, 2 years and 3 years (P = 0.05, P = 0.06 and P = 0.06, respectively), as were PPD-induced IL-10 responses (P = 0.05 at 1 years, P = 0.007 at 2 years, P = 0.003 at 3 years) and corresponding IFN-gamma responses (P = 0.05 at 6 months, P = 0.003 at 2 years, P = 0.0004 at 3 years). Increased IL-10 responses to HDM allergen were also observed throughout the observation period in CBMC from children who developed AD.

CONCLUSION

Children who develop infantile AD appear to have a predisposition to respond to SEB in a Th2-dominant manner involving selective stimulation of IL-5 production. The increased IL-10 and IFN-gamma induced in response to PPD by children with AD may point to additional intrinsic differences in responses to microbial stimuli between those at high vs. those at low risk for AD, which merit more detailed investigations.

Development of interleukin-12-producing capacity throughout childhood

Increasing evidence indicates that the capacity to induce protective Th1 immune responses is impaired in early childhood, an observation that can be partially attributed to deficiencies in antigen-presenting-cell function. Synthesis of interleukin 12 (IL-12), a key Th1-trophic cytokine, is markedly reduced in the neonatal period, though there is a paucity of knowledge concerning the ontogeny of IL-12-synthetic capacity throughout the childhood years. Hence, we examined the production of bioactive IL-12 p70 by circulating mononuclear cells in a population of healthy individuals. As expected, the capacity to synthesize IL-12 p70 in response to either lipopolysaccharide or heat-killed Staphylococcus aureus was markedly impaired at birth, even after priming of cells with gamma interferon. Surprisingly however, IL-12 p70 synthesis by peripheral blood mononuclear cells from both 5- and 12-year-old children was still substantially below that seen in adults, and this did not appear to be related to excessive production of IL-10. In contrast, dendritic cells from adults and neonates, derived from monocytes with granulocyte-macrophage colony-stimulating factor and IL-4, synthesized equivalent amounts of IL-12 p70 in response to microbial stimulation. This indicates that the impaired capacity for IL-12 synthesis in childhood is not an intrinsic property of circulating mononuclear cells but rather can be readily overcome in response to appropriate maturational stimuli. Because IL-12 arose predominantly from circulating HLA-DR(+) cells that lacked B-cell- and monocyte-specific markers, we propose that the slow maturation of IL-12-synthetic capacity in the childhood years can be attributed to deficiencies in the number and/or function of dendritic cells.

Microbial life beneath a high arctic glacier

The debris-rich basal ice layers of a high Arctic glacier were shown to contain metabolically diverse microbes that could be cultured oligotrophically at low temperatures (0.3 to 4 degrees C). These organisms included aerobic chemoheterotrophs and anaerobic nitrate reducers, sulfate reducers, and methanogens. Colonies purified from subglacial samples at 4 degrees C appeared to be predominantly psychrophilic. Aerobic chemoheterotrophs were metabolically active in unfrozen basal sediments when they were cultured at 0.3 degrees C in the dark (to simulate nearly in situ conditions), producing (14)CO(2) from radiolabeled sodium acetate with minimal organic amendment (> or =38 microM C). In contrast, no activity was observed when samples were cultured at subfreezing temperatures (< or =-1.8 degrees C) for 66 days. Electron microscopy of thawed basal ice samples revealed various cell morphologies, including dividing cells. This suggests that the subglacial environment beneath a polythermal glacier provides a viable habitat for life and that microbes may be widespread where the basal ice is temperate and water is present at the base of the glacier and where organic carbon from glacially overridden soils is present. Our observations raise the possibility that in situ microbial production of CO(2) and CH(4) beneath ice masses (e.g., the Northern Hemisphere ice sheets) is an important factor in carbon cycling during glacial periods. Moreover, this terrestrial environment may provide a model for viable habitats for life on Mars, since similar conditions may exist or may have existed in the basal sediments beneath the Martian north polar ice cap.

Efficient construction of 6-azasteroids: dual inhibitors of steroidal 5 alpha-reductase

A new route to 17 beta-substituted-6-azaandrost-4-en-3-ones, potent dual inhibitors of type 1 and 2 steroidal 5 alpha-reductase, is described.

Self-process in comorbid mental illness and drug abuse

A theory of social influence is proposed as a framework within which to examine the psychosocial processes that underlie substance abuse among persons with severe mental illness. The theory's potential to account for some of the empirical findings in the mental health and substance abuse literatures is discussed, and implications for research are offered.

The physician survey on the post-concussion and whiplash syndromes

BACKGROUND

The post-concussion syndrome (PCS) and whiplash syndrome (WS) have been controversial topics among physicians for many decades. There is little information available on the opinions and practices of physicians.

METHODS

In June of 1992, we performed a national survey by mail of the four physician groups most commonly treating these problems. The number of respondents and response rates were as follows: family physicians, 118, 16%; neurologists, 100, 21%; neurosurgeons, 97, 23%; orthopedists, 82, 13%. The survey instrument contained items on demographics, definitions, causation, prognosis, medico-legal aspects, testing, and treatment.

RESULTS

Only a minority of respondents believe that PCS and WS are clearly defined syndromes. A substantial minority report that psychogenic and litigation factors are most responsible for the conditions. Most of the physicians believe that PCS and WS have a 3-6 month recovery time. A significant minority concur that symptoms of the two syndromes resolve when litigation is settled. Most of the physicians order tests to rule out pathology although a minority order tests to reassure patients or because of litigation concerns. Only a minority of respondents believe that effective treatments are available. Not surprisingly, a multitude of conventional and unconventional treatments are sometimes recommended.

CONCLUSIONS

Many aspects of PCS and WS are controversial among treating physicians. This controversy can have a profound impact on the quality and cost of patient care. Ongoing research is required to discover more effective treatments for mild brain injury and chronic pain.

Pumiliotoxin alkaloids: a new class of sodium channel agents

Pumiliotoxin B (PTX-B) and a variety of congeneric alkaloids and synthetic analogs stimulated sodium flux and phosphoinositide breakdown in guinea pig cerebral cortical synaptoneurosomes. The effects of PTX-B and active congeners and analogs on sodium flux in synaptoneurosomes were potentiated markedly by scorpion venom (Leiurus quinquestriatus). In neuroblastoma cells, PTX-B and active congeners had no effect on sodium flux unless synergized by alpha-scorpion toxin or scorpion venom. Certain inactive congeners, lacking hydroxyl groups in the 6-alkylidene side chain, inhibited sodium flux elicited by PTX-B, scorpion venom, or the sodium channel activator batrachotoxin. Such inhibition appeared different from inhibition by local anesthetics, since pumiliotoxins, unlike local anesthetics, had little or no effect on binding of [3H]batrachotoxinin A benzoate to sodium channels. Thus, it appears likely that some "inactive" congeners bind to the PTX-B binding site, but do not activate sodium channels. In the absence of scorpion venom the stimulation of phosphoinositide breakdown in synaptoneurosomes was consonant with the stimulatory effects of these compounds on sodium flux through voltage-dependent sodium channels.

Sonographic detection of portal venous gas in infants with necrotizing enterocolitis

A characteristic pattern of hepatic parenchymal and portal venous abnormalities was seen with sonography in 12 infants with necrotizing enterocolitis (NEC). In five cases these changes were seen before any radiographic abnormalities were observed. Sonography of 232 infants without NEC did not show these changes. The sonographic abnormalities are believed to be caused by small amounts of gas within the portal venous system and hepatic parenchyma. Because of the simplicity of the sonographic examination and the sensitivity and specificity of the findings, abdominal sonography may be of great value in the early evaluation of infants suspected of having NEC.

Choline incorporation into lecithin in response to insulin or dexamethasone in homogeneous cell cultures of rat lung epithelial cells and fibroblasts

Labeled choline incorporation into adult rat lung alveolar epithelial cells and adult rat lung fibroblasts in monolayer culture was determined after incubation with insulin (Ins) 10 micrograms/ml, Dexamethasone (Dex) 10(-6)M, or no drug (ND). Incubation periods were 1, 3, 4, and 5 hours. The lecithin (phosphatidyl choline - PC) recovered was separated inot disaturated phosphatidyl choline (DSPC) and unsaturated phosphatidyl choline (USPC). Results expressed as specific activity per hour (see Table) indicate that the incorporation of choline into PC and USPC was greater in fibroblasts (F) than in epithelial cells (E) whether ND, Dex or Ins was present. For incorporation into DSPC, there was no difference between E and F whether ND, Dex or Ins was present. There was significant increase in choline incorporation into PC or USPC for both cell types when Ins was present, whereas there was no difference for either cell type when Dex was present. Insulin significantly increased choline incorporation into DSPC in E cells only. Dex was no different from ND in DSPC incorporation in either cell type. We attribute the greater lecithin synthesis of the F cells to a more rapid increase in cellular structural lipids in the fibroblast cell. Dex had no effect on either cell type possibly from the short-term exposure or possibly because the effect of dexamethasone on alveolar epithelial cells is mediated by product(s) from other lung cells, and thus requires a mixed cell culture to have its effect. We suggest that further study of isolated homogeneous cell lines will not be fruitful in the evaluation of mechanisms of acceleration of lung maturation.

Rapid detection of neonatal intracranial hemorrhage by transillumination

Using transillumination and a sensitive cadmium sulfide light meter, 145 newborns were screened for the presence of intracranial hemorrhage. Intracranial hemorrhage (ICH) was suspected when the light meter could not detect any light passing through the anterior fontanel when the light beam was directed through the frontal eminence. ICH was confirmed by branial computed tomography or postmortem examination in all 17 infants not transmitting light. Spectrophotometry was performed on samples of cerebrospinal fluid (CSF) to demonstrate the mechanism through which blood in the CSF blocks light transmission.