A Case of Metastatic Choriocarcinoma-Related Paraneoplastic Thyroid Storm

Thyroid storm due to gestational trophoblastic disease (GTD) with metastatic choriocarcinoma is a rare but potentially life-threatening endocrine emergency. We report on a woman with molar pregnancy and metastatic choriocarcinoma who presented with thyroid storm (Burch-Wartofsky point scale of 45) a few weeks after the evacuation of GTD. She was initially managed with intravenous hydrocortisone, oral propylthiouracil (PTU), and esmolol infusion. After stabilization in the intensive care unit, 10 cycles of chemotherapy with etoposide, methotrexate, leucovorin, dactinomycin, and cyclophosphamide (EMA-CO) were initiated for stage 4 choriocarcinoma with brain and lung metastases. She underwent a hysterectomy soon after completing chemotherapy and received an additional 3 cycles of chemotherapy after the hysterectomy. As human chorionic gonadotropin (hCG) levels normalized, thyroid function reverted to normal as well. At the last follow-up, the patient was asymptomatic, euthyroid (without antithyroid medication), had a normal hCG titer of 1.7 mIU/mL (normal nonpregnant reference is < 5 mIU/mL), and the lung and brain lesions had resolved entirely. Management of thyroid storm in the presence of untreated metastatic choriocarcinoma requires a high index of suspicion and a multidisciplinary team approach to prevent complications and improve survival.

Diffuse Large B-cell Lymphoma of the Orbit With Intracranial Extension: A Rare Entity

Primary diffuse large B-cell lymphoma of the orbit is a rare diagnosis that accounts for less than 1% of all non-Hodgkin's lymphoma (NHL) cases. We present here the case of a middle-aged woman with a past medical history of intellectual delay and hypothyroidism who presented with a large diffusely infiltrating mass of the left orbit. A biopsy of the lesion during the patient's hospitalization confirmed a diagnosis of diffuse, large B-cell lymphoma. Due to extensive local invasion, she was deemed a poor surgical candidate. While inpatient, she was started on systemic chemotherapy and discharged with close follow-up planned with the oncologic and surgical teams.

Safety and efficacy of tenecteplase in patients with wake-up stroke assessed by non-contrast CT (TWIST): a multicentre, open-label, randomised controlled trial

BACKGROUND

Current evidence supports the use of intravenous thrombolysis with alteplase in patients with wake-up stroke selected with MRI or perfusion imaging and is recommended in clinical guidelines. However, access to advanced imaging techniques is often scarce. We aimed to determine whether thrombolytic treatment with intravenous tenecteplase given within 4·5 h of awakening improves functional outcome in patients with ischaemic wake-up stroke selected using non-contrast CT.

METHODS

TWIST was an investigator-initiated, multicentre, open-label, randomised controlled trial with blinded endpoint assessment, conducted at 77 hospitals in ten countries. We included patients aged 18 years or older with acute ischaemic stroke symptoms upon awakening, limb weakness, a National Institutes of Health Stroke Scale (NIHSS) score of 3 or higher or aphasia, a non-contrast CT examination of the head, and the ability to receive tenecteplase within 4·5 h of awakening. Patients were randomly assigned (1:1) to either a single intravenous bolus of tenecteplase 0·25 mg per kg of bodyweight (maximum 25 mg) or control (no thrombolysis) using a central, web-based, computer-generated randomisation schedule. Trained research personnel, who conducted telephone interviews at 90 days (follow-up), were masked to treatment allocation. Clinical assessments were performed on day 1 (at baseline) and day 7 of hospital admission (or at discharge, whichever occurred first). The primary outcome was functional outcome assessed by the modified Rankin Scale (mRS) at 90 days and analysed using ordinal logistic regression in the intention-to-treat population. This trial is registered with EudraCT (2014-000096-80), ClinicalTrials.gov (NCT03181360), and ISRCTN (10601890).

FINDINGS

From June 12, 2017, to Sept 30, 2021, 578 of the required 600 patients were enrolled (288 randomly assigned to the tenecteplase group and 290 to the control group [intention-to-treat population]). The median age of participants was 73·7 years (IQR 65·9-81·1). 332 (57%) of 578 participants were male and 246 (43%) were female. Treatment with tenecteplase was not associated with better functional outcome, according to mRS score at 90 days (adjusted OR 1·18, 95% CI 0·88-1·58; p=0·27). Mortality at 90 days did not significantly differ between treatment groups (28 [10%] patients in the tenecteplase group and 23 [8%] in the control group; adjusted HR 1·29, 95% CI 0·74-2·26; p=0·37). Symptomatic intracranial haemorrhage occurred in six (2%) patients in the tenecteplase group versus three (1%) in the control group (adjusted OR 2·17, 95% CI 0·53-8·87; p=0·28), whereas any intracranial haemorrhage occurred in 33 (11%) versus 30 (10%) patients (adjusted OR 1·14, 0·67-1·94; p=0·64).

INTERPRETATION

In patients with wake-up stroke selected with non-contrast CT, treatment with tenecteplase was not associated with better functional outcome at 90 days. The number of symptomatic haemorrhages and any intracranial haemorrhages in both treatment groups was similar to findings from previous trials of wake-up stroke patients selected using advanced imaging. Current evidence does not support treatment with tenecteplase in patients selected with non-contrast CT.

FUNDING

Norwegian Clinical Research Therapy in the Specialist Health Services Programme, the Swiss Heart Foundation, the British Heart Foundation, and the Norwegian National Association for Public Health.

TECHNOLOGY-DRIVEN INTERGENERATIONAL PROGRAM IN THE PANDEMIC

Intergenerational programs increase interaction among groups allowing both generations to share their beliefs, talents, knowledge, and wisdom. The Senior Programming Intergenerational College Experience (SPICE) Project was designed to deliver an 11-week long intergenerational program with college-aged and older adult participants and was provided virtually during the pandemic. The purpose of this study was to describe the participation characteristics and attitudes towards aging and technology of older adults who completed the SPICE program. Older adult recruitment occurred through paper fliers posted at senior centers/housing, libraries, faith-based organizations in Genesee County, Michigan and through a large state-wide electronic study recruitment portal. Older adult participants were English speaking; aged 55+ years; able to participate in live Zoom sessions once/week; and were committed to complete >75% of the SPICE program. Online surveys were completed before/after SPICE to evaluate attitudes towards aging and technophilia. Results from 15 older adults who completed >75% of SPICE sessions indicated that they were able to cope with life as they got older (60%), viewed aging as a positive experience (85.7%), were not afraid to use new technology (68.6%) and believed technology was useful/fun (88.6%). Older adults were divided on willingness to try new technology and their ability to keep up with technological progress. These data indicate that for higher education institutions focused on designing age-inclusive online opportunities, older adults who possess a positive attitude toward aging and technology may be more likely to complete intergenerational programs.

Intersex human rights, sexual orientation, gender identity and the Yogyakarta Principles

Background

Intersex people are at risk of human rights abuses because their bodies do not fit medical and social norms for female or male bodies. The 2006 Yogyakarta Principles aim to promote good practices in protecting the rights of LGBT and intersex people by applying human rights law in relation to ‘sexual orientation' and ‘gender identity'. They were ineffective in protecting the rights of intersex people, including due to an inappropriate framing around sexual orientation and gender identity. In the same year, a group of clinicians published a ‘consensus statement' reframing intersex traits as ‘disorders of sex development', reinscribing medical authority over intersex bodies. In 2015 a first country (Malta) enacted protections of rights to bodily integrity and physical autonomy and freedom from discrimination, associated with a new attribute of ‘sex characteristics'.

Methods

In January 2017, the International Service for Human Rights and ARC International issued a call for submissions to supplement the Yogyakarta Principles, and brought together a drafting team. The Asia Pacific Forum of National Human Rights Institutions and United Nations Development Program also held a gender- and geopolitically-balanced conference to mark a decade of the original Principles and produce recommendations. An expert meeting was held in Geneva in September 2017 to agree the update.

Results

The ‘Yogyakarta Principles plus 10' elaborated a new attribute of sex characteristics and recognised rights to bodily integrity, truth and legal recognition. These directly respond to the human rights situation of intersex people, with relevance to intersex populations, healthcare workers, advocates, and policymakers.

Conclusions

Adoption of the new attribute and attention to the new Principles can help address the human rights of people with intersex variations within health, education, and other social policy settings.

The role of inflammation in the association between gestational diabetes and obstructive sleep apnea: A pilot study

Background

Obstructive sleep apnea is associated with pregnancy complications including gestational diabetes. Mechanisms underlying the association between obstructive sleep apnea and gestational diabetes remain to be elucidated.

Methods

Twenty-three participants with gestational diabetes underwent home sleep apnea testing. Obstructive sleep apnea was defined as an apnea hypopnea index > 5. Fasting morning blood samples were measured using multianalyte profiling (xMAP) multiplexed bead array immunoassay for Interleukin 6, tumor necrosis factor-alpha, and Interleukin 8.

Results

Age, body mass index, and gestational age at enrollment were 31 + 4.4 years, 35.7 + 7.4 kg/m², and 28 ± 4 weeks, respectively. Participants were 52% Caucasian and 16% had obstructive sleep apnea. We observed positive correlations between apnea hypopnea index and Interleukin 6 (r = 0.62, p = 0.005), Interleukin 8 (r = 0.56, p = .56), and tumor necrosis factor-alpha (r = .58, p = .009). Women with obstructive sleep apnea had higher levels of Interleukin 6 (F = 5.01, p = .037) and Interleukin 8 (F = 6.33, p = .021) vs. women without obstructive sleep apnea.

Conclusion

These preliminary results indicate that in women with gestational diabetes, apnea hypopnea index is associated with an elevated inflammatory profile.

Nuclear shapes: Quest for triaxiality in 86Ge and the shape of 98Zr

The region of neutron-rich nuclei above the N = 50 magic neutron shell closure encompasses a rich variety of nuclear structure, especially shapeevolutionary phenomena. This can be attributed to the complexity of sub-shell closures, their appearance and disappearance in the region, such as the N = 56 sub shell or Z = 40 for protons. Structural effects reach from a shape phase transition in the Zr isotopes, over shape coexistence between spherical, prolate, and oblate shapes, to possibly rigid triaxial deformation. Recent experiments in this region and their main physics viewpoints are summarized.

Milestone assessment of minimally invasive surgery in Pediatric Urology fellowship programs

INTRODUCTION

Minimally invasive surgery has become an important aspect of Pediatric Urology fellowship training. In 2014, the Accreditation Council for Graduate Medical Education published the Pediatric Urology Milestone Project as a metric of fellow proficiency in multiple facets of training, including laparoscopic/robotic procedures.

OBJECTIVE

The present study assessed trends in minimally invasive surgery training and utilization of the Milestones among recent Pediatric Urology fellows.

STUDY DESIGN

Using an electronic survey instrument, Pediatric Urology fellowship program directors and fellows who completed their clinical year in 2015 were surveyed. Participants were queried regarding familiarity with the Milestone Project, utilization of the Milestones, robotic/laparoscopic case volume and training experience, and perceived competency with robotic/laparoscopic surgery at the start and end of the fellowship clinical year according to Milestone criteria. Responses were accepted between August and November 2015.

RESULTS

Surveys were distributed via e-mail to 35 fellows and 30 program directors. Sixteen fellows (46%) and 14 (47%) program directors responded. All fellows reported some robotic experience prior to fellowship, and 69% performed >50 robotic/laparoscopic surgeries during residency. Fellow robotic/laparoscopic case volume varied: three had 1-10 cases (19%), four had 11-20 cases (25%), and nine had >20 cases (56%). Supplementary or robotic training modalities included simulation (9), animal models (6), surgical videos (7), and courses (2). Comparison of beginning and end of fellowship robotic/laparoscopic Milestone assessment (Summary Fig.) revealed scores of <3 in (10) 62% of fellow self-assessments and 10 (75%) of program director assessments. End of training Milestone scores >4 were seen in 12 (75%) of fellow self-assessment and eight (57%) of program director assessments.

DISCUSSION

An improvement in robotic/laparoscopic Milestone scores by both fellow self-assessment and program director assessment was observed during the course of training; however, 43% of program directors rated their fellow below the graduation target of a Milestone score of 4.

CONCLUSION

The best ways to teach minimally invasive surgery in fellowship training must be critically considered.

Adolescent Substance Use Following a Deadly U.S. Tornado Outbreak: A Population-Based Study of 2,000 Families

Despite conceptual links between disaster exposure and substance use, few studies have examined prevalence and risk factors for adolescent substance use and abuse in large, population-based samples affected by a recent natural disaster. We addressed this gap using a novel address-based sampling methodology to interview adolescents and parents who were affected by the 4th deadliest tornado outbreak in U.S.

HISTORY

Postdisaster interviews were conducted with 2,000 adolescent-parent dyads living within a 5-mile radius of the spring 2011 U.S. tornadoes. In addition to descriptive analyses to estimate prevalence, hierarchical linear and logistic regression analyses were used to examine a range of protective and risk factors for substance use and abuse. Approximately 3% reported substance abuse since the tornado. Greater number of prior traumatic events and older age emerged as consistent risk factors across tobacco and alcohol use and substance abuse since the tornado. Tornado incident characteristics, namely, greater loss of services and resources after the tornado and posttraumatic stress disorder since the tornado, were associated with greater alcohol consumption. Service loss increased risk for binge drinking, whereas, for substance abuse, posttraumatic stress disorder increased risk and parent presence during the tornado decreased risk. Greater family tornado exposure was associated with a greater number of cigarettes smoked in female but not male teen participants. Both trauma and non-trauma-related factors are relevant to postdisaster substance abuse among adolescents. Future research should examine the role of broader ecological systems in heightening or curtailing substance use risk for adolescents following disaster exposure.

Does physician continuity within a clinical trial increase retention and compliance among adolescent smokers?

BACKGROUND

Retention and compliance are hurdles in many clinical trials designed for adolescents. Factors that may improve these issues in a challenging population may lead to increased data and power in much needed adolescent substance abuse research.

METHODS

Within a large-scale smoking cessation study for adolescents, physician continuity (PC) was examined to determine its effect on retention, compliance, and cessation.

RESULTS

In an analysis of 98 participants, participants with physician continuity throughout the study were more likely to attend more treatment visits and be medication compliant. It was also found that PC had no effect on participant smoking cessation.

CONCLUSIONS

It appears that PC may be one way to increase retention and compliance within an adolescent clinical trial, without interfering with the specific aim of the research study (in this case, smoking cessation).

High molecular mass multimer complexes and vascular expression contribute to high adiponectin in the fetus

CONTEXT

High plasma adiponectin concentrations in human fetuses and neonates are unique features of early developmental stages. Yet, the origins of the high adiponectin concentrations in the perinatal period remain elusive.

OBJECTIVE

This study was undertaken to identify the sources and functional properties of adiponectin in utero.

DESIGN AND METHODS

Tissue specimens were obtained at autopsy from 21- to 39-wk-old stillborn human fetuses. Adipose tissue and placenta were obtained at term elective cesarean section. Adiponectin complexes and expression were measured by immunodetection and real-time PCR.

RESULTS

Adiponectin mRNA transcripts were detected in fetal sc and omental adipose depots at lower concentrations than in maternal adipose tissue. Immunoreactive adiponectin was also observed in vascular endothelial cells of fetal organs, including skeletal muscle, kidney, and brain. The absence of adiponectin in all placental cell types and lack of correlation between maternal and umbilical adiponectin indicate that umbilical adiponectin reflects its exclusive production by fetal tissues. The most prominent forms of adiponectin in fetal plasma were high and low molecular mass (HMW and LMW) multimers of 340 and 160 kDa, respectively. The proportion of the HMW complexes was 5-fold (P < 0.001) higher in umbilical plasma than in adult. The high HMW and total adiponectin levels were associated with lower insulin concentration and lower homeostasis model of assessment of insulin resistance indices in umbilical plasma, reflecting higher insulin sensitivity of the fetus compared with adult.

CONCLUSIONS

The abundance of HMW adiponectin and its vascular expression are characteristics of human fetal adiponectin. Combined with high insulin sensitivity, fetal adiponectin may be a critical determinant of in utero growth.

Virtual pulmonary arterioscopy in pulmonary embolic disease

16 slice multidetector CT provides virtual endoscopic views of the inside of arteries, or any other hollow structures. This is performed non-invasively using post-processing of three-dimensional isotropic image data sets, acquired during standard CT examinations. These virtual endoscopic views are simultaneously correlated with the standard multiplanar reconstructions, with the ability to navigate a virtual camera through the hollow structure under study. Normal and abnormal volume rendered images of the pulmonary arteries are presented in correlation with the multiplanar reformats. The abnormal images show the volume rendered appearances of acute and chronic pulmonary embolic disease. It is also postulated that this technique has a problem solving role in the differential diagnosis of chronic mural emboli from extravascular structures such as adjacent lymph nodes or bronchiolar impaction. This technique may also have a role in medical education, providing clinicians and medical students with interactive three-dimensional representations of disease processes.

Inhalation delivery of manganese superoxide dismutase-plasmid/liposomes protects the murine lung from irradiation damage

Intratracheal injection of manganese superoxide dismutase-plasmid/liposome (MnSOD-PL) complexes has been demonstrated to delay the onset and reduce the extent of ionizing irradiation-induced murine pulmonary organizing alveolitis/fibrosis. To facilitate translation of this modality to clinical fractionated radiotherapy, inhalation delivery of MnSOD-PL was developed using an ultrasonic nebulizer. Transgene product was quantitated by immunohistochemical quantitation and pulmonary tissue levels of MnSOD biochemical activity. C57BL/6NHsd female mice demonstrated a plasmid dose-dependent increased expression of MnSOD transgene product over the range of 250 microg-2.5 mg of MnSOD-PL administered over a constant 5 min interval. Delivery of a constant concentration of 500 microg of MnSOD-PL with varying times of administration ranging from 0.5 to 10 min demonstrated optimal MnSOD expression at 5 min. Mice pretreated by inhalation delivery of MnSOD-PL demonstrated significantly improved survival after 20 Gy single fraction irradiation to both lungs compared to LacZ-PL inhalation-treated or irradiated control mice. Mice receiving 10 fractions of 3.5 cGy demonstrated increased pulmonary MnSOD transgene product activity by a protocol of every Monday-Wednesday or daily inhalation of MnSOD-PL. Thus, inhalation radioprotective gene therapy using MnSOD-PL provides a practical and effective method for delivery of lung-specific radioprotection during fractionated radiotherapy protocols in a mouse model.

Intraoral manganese superoxide dismutase-plasmid/liposome (MnSOD-PL) radioprotective gene therapy decreases ionizing irradiation-induced murine mucosal cell cycling and apoptosis

BACKGROUND

Single or multiple intraoral administrations of manganese superoxide dismutase-plasmid/liposomes (MnSOD-PL) to C3H/HeNHsd mice receiving single fraction or fractionated ionizing irradiation to the head and neck region have been shown to significantly decrease mucosal ulceration, weight loss and to improve survival.

MATERIALS AND METHODS

To elucidate the mechanism of irradiation protection by MnSOD-PL and explore possible additive or synergistic protective effects with Amifostine (WR2721), mice received a single fraction of 19, 22.5, 25 or 30 Gy, or 24 fractions of 3 Gy irradiation to the oral cavity and oropharynx. Multiple parameters of irradiation-induced toxicity were quantitated in subgroups of each irradiated group of mice treated with single or multiple administrations of intraoral MnSOD-PL and/or intravenous WR2721.

RESULTS

In 19 Gy single fraction irradiated mice, MnSOD-PL treatment the day before irradiation alone or in combination with intravenous WR2721 significantly decreased the irradiation induction of mucosal cell cycling as measured by 5-bromo-2-deoxyuridine (BuDR) uptake in oral cavity mucosal cells at 48 hours and decreased ulceration of the tongue at nine days after irradiation compared to control, irradiated or irradiated, WR2721-treated mice. Mice treated in single fractions of 22.5, 25 or 30 Gy showed MnSOD-PL protection against irradiation-induced oral mucosal apoptosis and xerostomia measured in decreased saliva output. In fractionated irradiated mice, twice weekly hemagglutinin (HA) epitope-tagged MnSOD uptake in oral cavity and tongue mucosal cells was not detectably altered by daily WR2721 intravenous administration. Mice treated with both radioprotective agents (MnSOD-PL and WR2721) demonstrated a significant decrease in irradiation-induced xerostomia (measured as reduced salivary gland output volume), mucosal ulceration and improved survival.

CONCLUSION

Enhanced salivary gland function in WR2721-treated mice in the absence of detectable mucosal protection, coupled with relatively low uptake of HA-MnSOD in the salivary glands of intraorally-treated mice, suggests that a combination of both radioprotective agents may prove optimally effective for the prevention of the acute and late normal tissue toxicities of fractionated radiotherapy for head and neck cancer.

Molecular analysis of collagen XVIII reveals novel mutations, presence of a third isoform, and possible genetic heterogeneity in Knobloch syndrome

Knobloch syndrome (KS) is a rare disease characterized by severe ocular alterations, including vitreoretinal degeneration associated with retinal detachment and occipital scalp defect. The responsible gene, COL18A1, has been mapped to 21q22.3, and, on the basis of the analysis of one family, we have demonstrated that a mutation affecting only one of the three COL18A1 isoforms causes this phenotype. We report here the results of the screening of both the entire coding region and the exon-intron boundaries of the COL18A1 gene (which includes 43 exons), in eight unrelated patients with KS. Besides 20 polymorphic changes, we identified 6 different pathogenic changes in both alleles of five unrelated patients with KS (three compound heterozygotes and two homozygotes). All are truncating mutations leading to deficiency of one or all collagen XVIII isoforms and endostatin. We have verified that, in exon 41, the deletion c3514-3515delCT, found in three unrelated alleles, is embedded in different haplotypes, suggesting that this mutation has occurred more than once. In addition, our results provide evidence of nonallelic genetic heterogeneity in KS. We also show that the longest human isoform (NC11-728) is expressed in several tissues (including the human eye) and that lack of either the short variant or all of the collagen XVIII isoforms causes similar phenotypes but that those patients who lack all forms present more-severe ocular alterations. Despite the small sample size, we found low endostatin plasma levels in those patients with mutations leading to deficiency of all isoforms; in addition, it seems that absence of all collagen XVIII isoforms causes predisposition to epilepsy.

A planned randomized clinical trial of treatment for mild gestational diabetes mellitus

OBJECTIVE

A planned study is described which will determine whether a benefit exists for the treatment of mild carbohydrate intolerance during pregnancy.

METHODS

A randomized clinical trial of women with mild gestational diabetes will compare perinatal outcomes in those receiving diet therapy and insulin as required versus those randomized to no specific treatment.

RESULTS

The primary outcome of this study will be a composite of neonatal morbidity in the treatment and control groups.

CONCLUSIONS

A randomized treatment trial of mild gestational diabetes mellitus will clarify whether identification and treatment of mild gestational diabetes mellitus reduces perinatal morbidity. This information will aid in selecting appropriate thresholds for the treatment of gestational diabetes mellitus.

Understanding of others' intentions in children with autism

Many studies have shown that children with autism have difficulty understanding the thoughts and beliefs of other people. However, little research has been conducted on what these children understand about simpler mental states such as intentions. The current study tested the understanding of others' intentions in 2 1/2- to 5-year-old children with autism and a control group of children with other developmental delays. We used Meltzoff's (1995) test of understanding of others' unfulfilled intentions in an imitation context, with an additional "End State" condition. We found no significant between-group differences on any measure involving the understanding of others' intentions. Although within-group patterns suggested that children with autism may have a slightly less complex understanding of others' intentions than do other children, it was clear that any deficits these children showed in this area were not as marked as those they typically show on traditional theory of mind tasks.

Why we should eliminate the due date: a truth in jest

We currently use flawed calculations to set a woman's due date based on menstrual periods to determine gestational age. We use the estimated gestational age to make management decisions based on our patients' individual needs. This principle is in contrast to our patients' use of dating to set an estimated date of confinement. This date is seen as a very specific point in time. Patients and their families plan on that date and become distressed when the expected date is not met. Given that many patients are induced electively, that many will have their delivery dates changed, and that many will have delivery dates adjusted for medical reasons, and most importantly given that dating is inaccurate and unreliable, we propose eliminating the due date. We propose giving patients a calculated assigned week of delivery at 32 weeks. An assigned week of delivery allows for individualization of obstetric care based on the needs of our patients, their support systems, and hospital staffing. We believe an assigned week of delivery will improve obstetric practice and patient satisfaction.

Mortality experience among employees at a hydrometallurgical nickel refinery and fertiliser complex in Fort Saskatchewan, Alberta (1954-95)

OBJECTIVE

To study the mortality experience of workers at a hydrometallurgical nickel refinery and fertiliser complex in Fort Saskatchewan, Alberta, Canada.

METHODS

A total of 1649 male employees of Sherritt International who worked for at least 12 continuous months during the years 1954 to 1978 at the Fort Saskatchewan, Alberta hydrometallurgical nickel refinery and fertiliser complex were followed up for an additional 17 years. Mortality was ascertained from the Canadian mortality data base maintained by Statistics Canada and covered the years 1954-95. Statistics were analysed with Monson's computer program.

RESULTS

Total mortality, when compared with the Canadian population, was significantly below expectation. Fewer deaths were found for circulatory disease, ischaemic heart disease, respiratory disease, neoplasms, digestive cancer, and accidents, poisonings, and violence. Among the 718 men in the group exposed to nickel, there were no deaths due to nasal cavity or paranasal sinus cancer. Fewer deaths were found for all causes, circulatory disease, ischaemic heart disease, neoplasms and digestive cancer. Lower death rates were observed than expected for respiratory malignancies and cancer of the bronchus and lung.

CONCLUSION

No association was found in this study between exposure to nickel concentrate or metallic nickel in the hydrometallurgical refining process and the subsequent development of respiratory cancer.

Possible neuronal refractory or recovery artifacts associated with recording the mismatch negativity response

The mismatch negativity (MMN) is an event-related potential that involves a negative voltage shift of baseline electroencephalographic (EEG) activity in the approximate latency window of the N1 and P2 cortical potentials in response to new or novel sounds. The MMN is present at birth and has been hypothesized to serve as an automatic preconscious detector of changes in the auditory environment. Research paradigms used to extract the MMN response from EEG activity have a potential problem related to neuronal refractoriness or recovery. Both N1 and P2 are known to increase in amplitude with longer interstimulus intervals (ISIs). The MMN extraction procedures involve mathematical subtraction of waveforms elicited by standard sounds (with short ISIs) from those recorded to rare deviant sounds (with longer ISIs). Any ISI-dependent amplitude changes in N1 and/or P2 could therefore alter the morphology of the resulting difference wave and lead to misinterpretation of the nature of the underlying MMN generators. We tested 12 young females and found that the MMN can be influenced by ISI-dependent refractory effects that may modify the waveform morphology. This has important clinical implications since the MMN is being investigated as an assessment tool.

Comparing viewer and array mental rotations in different planes

Participants imagined rotating either themselves or an array of objects that surrounded them. Their task was to report on the egocentric position of an item in the array following the imagined rotation. The dependent measures were response latency and number of errors committed. Past research has shown that self-rotation is easier than array rotation. However, we found that imagined egocentric rotations were as difficult to imagine as rotations of the environment when people performed imagined rotations in the midsagittal or coronal plane. The advantages of imagined self-rotations are specific to mental rotations performed in the transverse plane.

Electrophysiologic correlates of attention versus stimulus competition in young male and female listeners

The effects of attention and stimulus competition on the late auditory-evoked potential (LAEP) were compared in 10 young males and 10 young females. Listeners attended to discriminably different oddball tonal sequences presented binaurally or monaurally. Peak amplitudes in response to the frequent tones were measured for N1, P2, and early and late N2 (N2e and N21) components of the LAEP Whereas N1 amplitudes increased, the amplitudes of P2 decreased when listeners attended to, rather than ignored, the tones. Competition effects for both N1 and P2 resulted in reduced amplitudes in the presence of contralateral competition. Although findings with N2e and N21 suggested possible attention and competition effects, as well as gender differences, the data were inconsistent and will need further experimental verification. The present findings with the N1 and P2 components provide evidence that different neural processes underlie the attention and competition effects in the human brain.

Fibrinogen, other putative markers of inflammation, and weight gain in middle-aged adults--the ARIC study. Atherosclerosis Risk in Communities

PURPOSE

Weight gain is an important risk factor for the development of the metabolic syndrome, and inflammatory mediators are strongly associated with this syndrome. Our aim was to investigate whether inflammation predicts the development of weight gain in populations.

RESEARCH METHODS AND PROCEDURES

We investigated selected markers of inflammation in the prediction of weight gain over an approximately 3-year period in a biethnic cohort of 13,017 men and women, 45 to 64 years of age, using multiple linear and logistic regression modeling.

RESULTS

In adjusted models, those in the highest quartile of fibrinogen gained, during the first 3 years of follow-up, an estimated 0.23 kg/year more than those in the lowest quartile (p < 0.001). Adjusted odds of a large (greater than the 90th percentile) weight gain for those in the highest quartile of fibrinogen were 1.65 (95% confidence interval [CI], 1.38 to 1.97) times those in the lowest quartile. Similarly adjusted odds ratios for a large weight gain for those with high levels of white blood cell count, factor VIII, and von Willebrand factor were 1.38 (1.14 to 1.67), 1.28 (1.08 to 1.53), and 1.28 (1.08 to 1.51), respectively.

DISCUSSION

Fibrinogen and other putative markers of inflammation predict weight gain in middle-aged adults. Given the known links between the inflammatory response and intermediary metabolism and the methodological strengths of the Atherosclerosis Risk in Communities (ARIC) cohort, these findings, though without immediate clinical applicability, suggest that inflammatory processes play a role in the development of the metabolic syndrome and cardiovascular disease in part through stimulation of weight gain.

Electrophysiologic signs of auditory competition in the human brain

The present project investigated the electrophysiologic effects of auditory competition on components of the late auditory evoked potential (LAEP). A group of 12 young female listeners attended to deviant tones interspersed among frequent tones in one ear while trains of deviant and frequent tones of a different frequency were either present or absent at the opposite ear. Comparison of event-related potential (ERP) waveforms with competition- and attention-related difference waves revealed evidence that the neural effects of competition were not simply a moderation of the effects of selective attention (i.e. the processing negativity). The two difference waves exhibited amplitude peaks that were not mirror-images with respect to polarity. This suggests the existence of a unique underlying neural process that is responsible for the effects of competition on the LAEP.

Pneumotonometry versus Goldmann tonometry after laser in situ keratomileusis for myopia

PURPOSE

To assess the reliability of intraocular pressure (IOP) measurement by Goldmann applanation tonometry (GAT) versus pneumotonometry in patients after laser in situ keratomileusis (LASIK) for myopia.

SETTING

Shiley Eye Center, University of California San Diego, La Jolla, California, USA.

METHODS

In this prospective study, 31 eyes of 17 patients were evaluated before and 1 month after having LASIK for myopia. A masked observer measured preoperative and postoperative IOP by GAT centrally and by pneumotonometry at the center and the periphery of the cornea. Central corneal thickness and curvature were evaluated.

RESULTS

Preoperative IOP showed a good correlation between GAT and pneumotonometry values (r = 0.82). Mean postoperative IOP by GAT was lower by 3.8 mm Hg +/- 2.2 (SD) (26.3% +/- 15.2%) than by pneumotonometry: 2.3 +/- 2.8 mm Hg (15.4% +/- 10.7%) (P = .01). There were no statistically significant differences in central IOP versus peripheral IOP measured by pneumotonometry (P = .4). Regression analysis showed no statistically significant differences in IOP as a function of change in corneal thickness or change in corneal curvature with either device.

CONCLUSION

Postoperatively, there was a decrease in IOP measured by central GAT that was statstically significant. Differences in pneumotonometry were less substantial, with greater reliability of pneumotonometry than GAT after LASIK.

Unilateral auditory temporal resolution deficit: a case study

An adult with a unilateral precipitous severe high-frequency hearing loss displayed a selective auditory temporal resolution deficit in the poorer ear, despite excellent word recognition ability in quiet bilaterally. Word recognition performance was inferior in interrupted noise, reverberation, and time-compression conditions when stimuli were presented to the hearing-impaired ear and compared with performance for stimuli presented to the normal-hearing ear or that of normal-hearing listeners. It was suggested that a restricted listening bandwidth was responsible for the performance decrement on the tasks involving temporal resolution. This case illustrates the importance of employing temporal resolution tasks in an audiologic test battery. Such assessment tools may reveal deficits that otherwise may go unnoticed in light of excellent word recognition in quiet.

The effects of venting on in-the-ear, in-the-canal, and completely-in-the-canal hearing aid shell frequency responses: real-ear measures

The acoustic effects of 1-, 2-, and 3-mm vents were investigated with in-the-ear, in-the-canal, and completely-in-the-canal hearing aid shells. Real-ear sound pressure level measures were obtained from unvented and vented shells with 12 adults. In general, with increasing vent size, a statistically significant (p < .05) increase in the amount of low-frequency reduction, an upward shift in vent cutoff frequencies, and an upward shift in vent-associated resonances occurred for all hearing aid shell styles. There was no significant change in the slope of the low-frequency reduction across all hearing aid shell styles (p > .05), albeit the frequency response curves were shifted upward in frequency with increasing vent diameters. Only with the in-the-ear and completely-in-the-canal hearing aid shells were statistically significant (p < .05) differences found with the magnitude of vent-associated resonance as a function of vent diameter, and these differences were not consistent across the different styles. These findings suggest that venting may be used effectively to tune low-frequency responses in custom in-the-ear hearing instruments.

Intraocular pressure measurement in patients with instrastromal corneal ring segments

PURPOSE

To study the measurement of intraocular pressure after implantation of Intacs (ICRS) intrastromal corneal ring segment, a device that is positioned circumferentially in the peripheral corneal stroma to correct myopia. The device changes the corneal curvature by shortening arc length. Since the ring segments are made of polymethylmethacrylate, this may cause localized changes in corneal elasticity so intraocular pressure measurement may be affected.

METHODS

We measured the intraocular pressure of 12 eyes in which the ICRS had been in place longer than 6 months. We used Goldmann applanation and Tono-Pen tonometers over the central corneal and the paracentral corneal areas. We also measured the intraocular pressure with the Tono-Pen applanated directly over the intrastromal corneal ring segments.

RESULTS

The resulting intraocular pressure measurements were similar for the Tono-Pen tonometer readings over the central cornea, paracentral cornea, and the Goldmann applanation tonometer readings over the central cornea (P < .01). Our measurements using the Goldmann applanation tonometer on the paracentral corneal area showed artificially elevated intraocular pressure in the 40 to 60 mmHg range. We were not able to obtain consistent results when we measured the intraocular pressure using the Tono-Pen on the corneal area directly overlying the intrastromal corneal ring segment implants.

CONCLUSION

Consistent intraocular pressure measurements on eyes with the ICRS can be obtained with the Goldmann applanation tonometer over the central corneal area or with the Tono-Pen tonometer over the central or paracentral corneal areas.

Surveillance of potential associations between occupations and causes of death in Canada, 1965-91

OBJECTIVE

To detect unsuspected associations between workplace situations and specific causes of death in Canada.

METHODS

An occupational surveillance system was established consisting of a cohort of 457,224 men and 242,196 women employed between 1965 and 1971, constituting about 10% of the labour force in Canada at that time. Mortality between 1965 and 1991 has been determined by computerised record linkage with the Canadian mortality database. Through regression analysis, associations between 670 occupations and 70 specific causes of death were measured.

RESULTS

There were almost 116,000 deaths among men and over 26,800 deaths among women. About 28,000 comparisons were made between occupations and specific causes of death. With various reporting criteria, several potential associations were highlighted, including: infectious disease mortality among barbers and hairdressers; laryngeal cancer among male metal fitters and assemblers; lung cancer among female waiters; breast cancer among female metal fitters and assemblers; brain cancer among female nursing assistants and male painters; and ischaemic heart disease among female inspectors and foremen and among male taxi drivers and chauffeurs.

CONCLUSIONS

When excess risk of mortality is apparent, the intention of this occupational surveillance system is to spark further studies to gain aetiological knowledge.

Physical activity and incident hypertension in black and white adults: the Atherosclerosis Risk in Communities Study

BACKGROUND

The epidemiologic observation that physical activity reduces the risk for hypertension has only been made for white men who self-reported hypertension. This study examined physical activity and clinically determined incident hypertension in black and white men and women of the Atherosclerosis Risk in Communities (ARIC) Study.

METHODS

ARIC is a population-based prospective study with four U.S. clinic centers. The present analyses included 7,459 black and white adults 45-65 years of age. Hypertension (systolic/diastolic blood pressure >/= 140/90 mm Hg) was defined by blood pressure measured by a random-zero device or medication use. Physical activity was assessed with the Baecke questionnaire.

RESULTS

After adjustment for age, baseline blood pressure, ARIC center, education, body mass index, waist-hip ratio, parental history of hypertension, cigarette smoking, alcohol consumption, and diet, white men in the highest quartile of leisure activity (primarily cycling and walking) had a 34% lower odds of developing hypertension over 6 years compared to the least active (OR = 0.66, 95% CI = 0.47-0.94; P for quartile trend = 0.01). Baseline activity was not associated with incident hypertension in white women or blacks.

CONCLUSIONS

Leisure-time physical activity reduces the odds of hypertension in middle-aged white men. Additional studies in women and blacks are needed.

Social cognition, joint attention, and communicative competence from 9 to 15 months of age

At around 1 year of age, human infants display a number of new behaviors that seem to indicate a newly emerging understanding of other persons as intentional beings whose attention to outside objects may be shared, followed into, and directed in various ways. These behaviors have mostly been studied separately. In the current study, we investigated the most important of these behaviors together as they emerged in a single group of 24 infants between 9 and 15 months of age. At each of seven monthly visits, we measured joint attentional engagement, gaze and point following, imitation of two different kinds of actions on objects, imperative and declarative gestures, and comprehension and production of language. We also measured several nonsocial-cognitive skills as a point of comparison. We report two studies. The focus of the first study was the initial emergence of infants' social-cognitive skills and how these skills are related to one another developmentally. We found a reliable pattern of emergence: Infants progressed from sharing to following to directing others' attention and behavior. The nonsocial skills did not emerge predictably in this developmental sequence. Furthermore, correlational analyses showed that the ages of emergence of all pairs of the social-cognitive skills or their components were inter-related. The focus of the second study was the social interaction of infants and their mothers, especially with regard to their skills of joint attentional engagement (including mothers' use of language to follow into or direct infants' attention) and how these skills related to infants' early communicative competence. Our measures of communicative competence included not only language production, as in previous studies, but also language comprehension and gesture production. It was found that two measures--the amount of time infants spent in joint engagement with their mothers and the degree to which mothers used language that followed into their infant's focus of attention--predicted infants' earliest skills of gestural and linguistic communication. Results of the two studies are discussed in terms of their implications for theories of social-cognitive development, for theories of language development, and for theories of the process by means of which human children become fully participating members of the cultural activities and processes into which they are born.