Root reinforcement and extracellular products reduce streambank fluvial erosion

A detailed understanding of the factors that impact bank erodibility is necessary to effectively model changes in channel form. This study evaluated the combined contributions of roots and soil microorganisms to soil resistance against fluvial erosion. To do this, three flume walls were constructed to simulate unvegetated and rooted streambanks. Unamended and organic material (OM) amended soil treatments with either no-roots (bare soil), synthetic (inert) roots, or living roots (Panicum virgatum) were created and tested with the corresponding flume wall treatment. OM stimulated the production of extracellular polymeric substances (EPS) and appeared to increase the applied stress required to initiate soil erosion. Synthetic fibers alone provided a base reduction in soil erosion, regardless of the flow rate used. When used in combination, synthetic roots and OM-amendments reduced erosion rates by 86 % or more compared to bare soil; this reduction was identical to the live rooted treatments (95 % to 100 %). In summary, a synergistic relationship between roots and organic carbon inputs can significantly reduce soil erosion rates due to fiber reinforcement and EPS production. These results indicate that root-biochemical interactions, like root physical mechanisms, play an important role in influencing channel migration rates due to reductions in streambank erodibility.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Sarcopenia and systemic inflammation are associated with decreased survival after cytoreductive nephrectomy for metastatic renal cell carcinoma

BACKGROUND

This study was aimed at assessing the associations of sarcopenia, muscle density, adiposity, and inflammation with overall survival (OS) after cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma.

METHODS

In all, 158 patients undergoing CN from 2001 to 2014 had digitized preoperative imaging for tissue segmentation via Slice-O-Matic software (version 5.0) at the mid-L3 level. The skeletal muscle index was calculated with the skeletal muscle area (cm² ) normalized for height (m² ), and the skeletal muscle density (SMD) was calculated with average Hounsfield units. Adiposity was measured with the cross-sectional area (cm² ) of visceral, subcutaneous, and intramuscular adiposity compartments and was similarly normalized for height. The average fat density was obtained in Hounsfield units. OS was estimated with the Kaplan-Meier method. Associations between body composition, inflammation metrics, and relevant clinicopathology and OS were assessed with univariable and multivariate Cox analyses.

RESULTS

Seventy-six of the 158 patients (48%) were sarcopenic. Sarcopenia was associated with elevated neutrophil to lymphocyte ratios (NLRs; P = .02), increased age (P = .001), lower body mass indices (P = .009), greater modified Motzer scores (P = .019), and lower SMD (P = .006). The median OS was 15.0 and 29.4 months for sarcopenic and nonsarcopenic patients, respectively (P = .04). Elevated inflammation (NLR or C-reactive protein), in addition to sarcopenia, was independently associated with OS, with an elevated NLR ≥ 3.5 and sarcopenia associated with the poorest OS at 10.2 months. No associations were observed between measurements of muscle density or adiposity and OS.

CONCLUSIONS

Sarcopenia and measures of high systemic inflammation are additively associated with inferior OS after CN and may be of use in preoperative risk stratification.

LAY SUMMARY

Body composition and sarcopenia (a deficiency in skeletal musculature) have been shown to affect outcomes in cancer. We found that sarcopenic patients had poor survival in comparison with nonsarcopenic patients in the setting of metastatic renal cell carcinoma (mRCC). Patients with both elevated inflammation and sarcopenia had the poorest survival. Sarcopenia is an objective measure of nutrition that can assist in therapeutic counseling and decision-making for individualized treatment in mRCC.

Meta-regression Analysis of Study Heterogeneity for Systemic Outcomes after Periodontal Therapy

INTRODUCTION

The contribution of periodontal disease to adverse systemic consequences remains controversial. This analysis examined 2 well-investigated conditions independently and combined-adverse pregnancy outcomes and glycemic control for patients with diabetes-based on shared pathogenic mechanisms of periodontal infection and inflammation. It was proposed that inconsistencies in study design significantly contribute to outcome discrepancies found between periodontal intervention studies undergoing meta-analysis.

METHODS

Meta-analyses evaluating periodontal interventions on the rate of preterm birth and changes in glycated hemoglobin A1c in type 2 diabetes populations were conducted based on a systematic review of randomized controlled trials. Meta-regression covariates for exploring heterogeneity included sample size, level of medical management, and bias risk as moderator variables in a random-effects meta-regression.

RESULTS

Systematic review identified 17 studies of diabetes and 13 of pregnancy outcomes. Analyses of these studies identified 0.50% reduction in HbA1c and 0.78 odds ratio for preterm births. The heterogeneity associated with the models was high (I2 = 92.4 and I2 = 62.7%, respectively). The adjusted models evaluating each systemic condition separately accounted for 52.2% of the effect for diabetes and 81.4% for pregnancy outcome effects independently, and 63.5% collectively, across interventional studies.

CONCLUSION

This systematic review with meta-regression analysis of heterogeneity demonstrates that disparate results seen in randomized controlled trials of periodontal therapy affecting systemic outcomes may be explained in large part by study design, specifically stringency in consideration of medical management and sample size. The potential for confounding factors to influence outcomes remains a concern in understanding the implications of oral health on systemic conditions.

KNOWLEDGE TRANSFER STATEMENT

The findings of this study demonstrate that much of the benefits seen from periodontal therapy on adverse systemic outcomes for diabetes and pregnancy are due to limitations in study design.

Head and neck sarcoma: three-year data from a tertiary referral centre

INTRODUCTION

Sarcomas of the head and neck are neoplasms arising from the embryonic mesenchyme. They are rare and heterogeneous in nature and are associated with significant morbidity and mortality. This study evaluates patients referred to the Oxford Sarcoma Service, a tertiary referral centre.

METHODS

Patients discussed over a three-year period were included. Medical records were analysed using the electronic patient record database. Data were acquired on a range of domains, including: demographics, histopathology, treatment modality, recurrence, mortality, survival, etc.

RESULTS

Thirty-two eligible patients, 21 male and 11 female, were identified with a mean age of 58 years; 26 out of 32 patients had high-grade sarcomas. The commonest histological subtype was chondrosarcoma (8/32). Twenty-two underwent planned multidisciplinary team surgical resection after biopsy and staging: negative margins were noted in 9, with close and involved margins in 5 and 8, respectively. Local recurrence was noted in 13 and 6 had metastatic disease out of the 32 eligible patients. Mortality was noted in 10 out of 32 patients. Mean survival was 69.5 months. Five-year overall survival was 64%. Surgery demonstrated statistically significant improvement in survival (p=0.0095). There were no significant differences in survival, recurrence or marginal status between methods of adjuvant or neoadjuvant therapy.

CONCLUSION

Outcomes of head and neck sarcomas are inferior compared with other types of sarcoma. The nature of the complex surrounding anatomy presents unique challenges in surgical management. This in turn affects rates of local recurrence and prognosis. Therefore, it is critical that they are managed in tertiary, specialist centres with a multidisciplinary approach.

Quantitative characterisation of ballistic cartridge cases from micro-CT

Evaluation of cartridge cases is essential within forensic ballistic analysis and is used in an attempt to establish a connection to the weapon used to fire it. This study consists of two experiments. The aims of Experiment 1 were to establish whether micro-CT is appropriate and repeatable for ballistic cartridge case analysis and if measurements can be extracted repeatably and reliably. Experiment 2 aimed to compare cartridge cases from two weapons to establish the magnitude of variation within and between weapons. A total of 48 cartridge cases fired by two distinct weapons were collected and micro-CT scanned to a high resolution. One randomly selected cartridge was scanned ten times under the same conditions to ensure repeatability of the scanning conditions in Experiment 1. Three novel measurements to quantitatively assess the firing pin impressions were proposed in Experiment 1 and comparatively analysed from two weapons in Experiment 2. Experiment 1 showed that micro-CT is an effective and highly repeatable and reliable method for 3-dimensional imaging and measurement of ballistic cartridge cases. Furthermore, high agreement for inter-rater reliability was found between five raters. Quantitative micro-CT analysis of the firing pin impression measurements in Experiment 2 showed a significant difference between the two studied weapons using Welch's t-test (p < 0.01). This study shows the advantage and reliability of utilising micro-CT for firing pin impression analysis. Quantitation of the firing pin impression allows distinction between the weapons studied. With expansion to further weapons, application of this methodology could complement current analysis techniques through classification models.

Segmentation and Linear Measurement for Body Composition Analysis using Slice-O-Matic and Horos

Body composition is associated with risk of disease progression and treatment complications in a variety of conditions. Therefore, quantification of skeletal muscle mass and adipose tissues on Computed Tomography (CT) and/or Magnetic Resonance Imaging (MRI) may inform surgery risk evaluation and disease prognosis. This article describes two quantification methods originally described by Mourtzakis et al. and Avrutin et al.: tissue segmentation and linear measurement of skeletal muscle. Patients' cross-sectional image at the midpoint of the third lumbar vertebra was obtained for both measurements. For segmentation, the images were imported into Slice-O-Matic and colored for skeletal muscle, intramuscular adipose tissue, visceral adipose tissue, and subcutaneous adipose tissue. Then, surface areas of each tissue type were calculated using the tag surface area function. For linear measurements, the height and width of bilateral psoas and paraspinal muscles at the level of the third lumbar vertebra are measured and the calculation using these four values yield the estimated skeletal muscle mass. Segmentation analysis provides quantitative, comprehensive information about the patients' body composition, which can then be correlated with disease progression. However, the process is more time-consuming and requires specialized training. Linear measurements are an efficient and clinic-friendly tool for quick preoperative evaluation. However, linear measurements do not provide information on adipose tissue composition. Nonetheless, these methods have wide applications in a variety of diseases to predict surgical outcomes, risk of disease progression and inform treatment options for patients.

Accurate prediction of saw blade thicknesses from false start measurements

BACKGROUND

False start analysis is the examination of incomplete saw marks created on bone in an effort to establish information on the saw that created them. The present study aims to use quantitative data from micro-CT cross-sections to predict the thickness of the saw blade used to create the mark. Random forest statistical models are utilised for prediction to present a methodology that is useful to both forensic researchers and practitioners.

METHOD

340 false starts were created on 32 fleshed cadaveric leg bones by 38 saws of various classes. False starts were micro-CT scanned and seven measurements taken digitally. A regression random forest model was produced from the measurement data of all saws to predict the saw blade thickness from false starts with an unknown class. A further model was created, consisting of three random forests, to predict the saw blade thickness when the class of the saw is known. The predictive capability of the models was tested using a second sample of data, consisting of measurements taken from a further 17 false starts created randomly selected saws from the 38 in the experiment.

RESULTS

Random forest models were able to accurately predict up to 100% of saw blade thicknesses for both samples of false starts.

CONCLUSION

This study demonstrates the applicability of random forest statistical regression models for reliable prediction of saw blade thicknesses from false start data. The methodology proposed enables prediction of saw blade thickness from empirical data and offers a significant step towards reduced subjectivity and database formation in false start analysis. Application of this methodology to false start analysis, with a more complete database, will allow complementary results to current analysis techniques to provide more information on the saw used in dismemberment casework.

Producing three-dimensional printed models of the hepatobiliary system from computed tomography imaging data

INTRODUCTION

Macroscopic anatomy has traditionally been taught using cadaveric material, lectures and a variety of additional resources including online modules and anatomical models. Traditional plastic models are effective educational tools yet they have significant drawbacks such as a lack of anatomical detail, a lack of texturisation and cost. Three-dimensional printed models stand to solve these problems and widen access to high-quality anatomical teaching. This paper outlines the use of three-dimensional multiplanar imaging (computed tomography) in the development of an accurate model of the hepatobiliary system.

MATERIALS AND METHODS

Computed tomography scans were used to construct a virtual three-dimensional model of the hepatobiliary system. This was printed locally as a full-size colour model. We give a complete account of the process and software used.

DISCUSSION

This study is among the first of a series in which we will document the newly formed Oxford Library of Anatomy. This series will provide the methodology for the production of three-dimensional models from computed tomography and magnetic resonance imaging scans, and the library will provide a complete collection of the most complex anatomical areas. We hope that these models will form an important adjunct in teaching anatomy to medical students and surgical trainees.

Prediction and Visualisation of Bony Impingement for Subject Specific Total Hip Arthroplasty

Bony impingement (BI) may contribute to restricted hip joint motion, and recurrent dislocation after total hip arthroplasty (THA), and therefore, should be avoided where possible. However, BI risk assessment is generally performed intra-operatively by surgeons, which is partially subjective and qualitative. Therefore, the aim of the study was to develop a method for identifying subject-specific BI, and subsequently, visualising BI area on native bone anatomy to highlight the amount of bone should be resected. Activity definitions and subject-specific bone geometries, constructed from CT scans, with planned implants were used as inputs for the method. For each activity, a conical clearance angle (CCA) was checked between femur and pelvis through simulation. Simultaneously, BI boundary and area were automatically calculated using ray intersection and region growing algorithm respectively. The potential use of the developed method was explained through a case study using an anonymised pre-THA patient data. Two pure (flexion, and extension) and two combined hip joint motions (internal and external rotation at flexion and extension respectively) were considered as activities. BI area were represented in two ways: (a) CCA specific where BI area for each activity with different CCAs was highlighted, (b) activity specific where BI area for all activities with a particular CCA was presented. Result showed that BI area between the femoral and pelvic parts was clearly identified so that the pre-operative surgical plan could be adjusted to minimise impingement. Therefore, this method could potentially be used to examine the effect of different preoperative plans and hip motion on BI, and to guide bony resection during THA surgery.

Chronic HPA activity in mothers with preterm delivery: A pilot nested case-control study

BACKGROUND

Chronic hypothalamic-pituitary-adrenal (HPA) axis activity role in the pathogenesis of preterm birth (PTB) remains unclear due to inconsistent measures with limited ability to monitor long-term cortisol concentrations. We explored this relationship using the novel method of assessing cortisol in hair, which is a valid and reliable measure of chronic HPA axis activity.

METHODS

137 participants (40 PTB cases and 97 controls from a birth cohort of pregnant women in Peru) were interviewed and invited to provide a 9-cm hair sample from the posterior vertex position of the scalp (mean = 13 weeks gestation). Hair cortisol concentration (HCC) was determined using luminescence immunoassay and values were natural-log transformed. PTB cases were defined as women who delivered before 37 gestational weeks. Case-control differences were assessed using multivariable linear and logistic regressions.

RESULTS

Overall, combined pre-conception and first-trimester HCC was 13% lower among cases as compared with controls (p-value = 0.01). Compared with controls, maternal HCC among PTB cases were 14% (p = 0.11), 10% (p = 0.22) and 14% (p = 0.08) lower for 3-6 months pre-conception, 0-3 months pre-conception, and first trimester, respectively. After adjusting for putative confounders, a 1-unit increase in HCC was associated with 55% reduced odds of PTB (aOR = 0.45; 95% CI: 0.17-1.17). For a 1-unit increase in HCC in the scalp-intermediate and scalp-distal segments (representing HCC concentrations in 0-3 months pre-conception and first trimester), the corresponding odds for PTB were 0.53 (95% CI: 0.19-1.48) and 0.39 (95% CI: 0.13-1.13), respectively.

CONCLUSIONS

Women who deliver preterm, as compared with those who deliver at term, have lower preconception and first trimester HCC. Our findings suggest that HPA axis activation, integral to the adaptive stress-response system, may be chronically dysregulated in women at increased risk of PTB.

Epidemiology of Adult Uveitis in a Northern Ireland Tertiary Referral Centre

Uveitis is inflammation of the middle layer of the eye, called the uveal tract. It can be classified by anatomic location of the focus of inflammation inside the eye: intermediate, posterior or pan-uveitis. These types are less common than anterior uveitis (iritis), but more often have underlying aetiologies that require identification. Some aetiologies are infective, while others require systemic immunosuppression. Underlying aetiologies vary in different regions in the world, and so local data is important to guide clinicians. This study describes the aetiology of 255 cases of intermediate, posterior and pan-uveitis in adults. The most common non-infectious causes, after idiopathic, were sarcoid, Birdshot chorioretinopathy, demyelination-related and Behçet's, whereas toxoplasmosis and herpes simplex and zoster related retinitis were the common infectious causes. Neither age nor sex of the patient were related to aetiology.

Associations of Maternal Urinary Cadmium with Trimester-Specific Blood Pressure in Pregnancy: Role of Dietary Intake of Micronutrients

Previous studies revealed associations of urinary Cd (U-Cd), a chronic Cd exposure biomarker, with blood pressure (BP) in non-pregnant adults. However, the evidence regarding trimester-specific blood pressure in pregnancy and U-Cd and effect modification by dietary intake of micronutrients is scarce. We randomly selected 653 women from the Omega Study cohort. U-Cd was quantified by inductively coupled plasma mass spectrometry. Trimester-specific, systolic (SBP) and diastolic blood pressure (DBP) were determined employing standard protocols and mean arterial pressure (MAP) was also calculated. Associations of SBP, DBP, and MAP with U-Cd tertiles (≤0.21; 0.22-0.41; ≥0.42 μg/g Cr) were assessed using multivariable linear regression models. We also explored effect modification by pre-pregnancy BMI (≤25 or >25 kg/m²) or low/high micronutrients intake. After adjusting confounders in women with elevated (upper tertile) as compared with those with low (lowest tertile) U-Cd (≥0.42 vs. ≤0.21 μg/g Cr, respectively) had reduced third trimester MAP (-1.8; 95 % confidence interval (CI) = -3.1, -0.5 mmHg) and second trimester MAP (-1.1; 95 % CI = -2.3, -0.03 mmHg). A significant decrease in third-trimester MAP associated with increased U-Cd was observed only among normal/underweight women (BMI ≤ 25 kg/m²) and women with high dietary intake of micronutrients (calcium, magnesium, zinc, and selenium). Notably, U-Cd concentrations increased with the increased consumption of zinc and non-heme iron food sources. No significant differences in U-Cd concentrations were found in preeclamptic women compared with non-preeclamptic women. Our study provides evidence that dietary intake of micronutrients should be taken into account when assessing the health effects of Cd in pregnant women.

Supine sleep positioning in preterm and term infants after hospital discharge from 2000 to 2011

OBJECTIVE

Supine sleep positioning (SSP) has been shown to reduce the risk of sudden infant death syndrome (SIDS) and preterm infants are at higher risk for SIDS. Population-based estimates of SSP are lacking for the preterm population. The objectives of this study are: (1) compare the prevalence of SSP after hospital discharge for preterm and term infants in the United States; and (2) assess racial/ethnic disparities in SSP for preterm and term infants.

STUDY DESIGN

We analyzed the 2000 to 2011 data from the Pregnancy Risk Assessment Monitoring System of Centers for Disease Control and Prevention from 35 states. We measured prevalence of SSP by preterm and term gestational age (GA) categories. We calculated adjusted prevalence ratios (APR) to evaluate the likelihood of SSP for each GA category compared with term infants and the likelihood of SSP for non-Hispanic black (NHB) and Hispanic infants compared with non-Hispanic white (NHW) infants.

RESULTS

Prevalence of SSP varied by GA: ⩽27, 59.7%; 28 0/7 to 33 6/7, 63.7%; 34 0/7 to 36 6/7 (late preterm), 63.6%; and 37 0/7 to 42 6/7 (term) weeks, 66.8% (P<0.001). In the adjusted analyses, late preterm infants were slightly less likely to be placed in SSP compared with term infants (APR: 0.96, confidence interval: 0.95 to 0.98). There were racial/ethnic disparities in SSP for all GA categories when NHB and Hispanic infants were compared with NHW infants.

CONCLUSIONS

All infants had suboptimal adherence to SSP indicating a continued need to better engage families about SSP. Parents of late preterm infants and families of NHB and Hispanic infants will also require greater attention given their decreased likelihood of SSP.

Associations of socioeconomic position in childhood and young adulthood with cardiometabolic risk factors: the Jerusalem Perinatal Family Follow-Up Study

BACKGROUND

Several stages in the life course have been identified as important to the development of cardiovascular disease. This study aimed to assess the associations of childhood and adulthood socioeconomic position (SEP) and social mobility with cardiometabolic risk factors (CMRs) later in life.

METHODS

We conducted follow-up examinations of 1132 offspring, aged 32, within a population-based cohort of all births in Jerusalem from 1974 to 1976. SEP was indicated by parents' occupation and education, and adulthood SEP was based on offspring's occupation and education recorded at age 32. Linear regression models were used to investigate the associations of SEP and social mobility with CMRs.

RESULTS

Childhood-occupational SEP was negatively associated with body mass index (BMI; β=-0.29, p=0.031), fat percentage (fat%; β=-0.58, p=0.005), insulin (β=-0.01, p=0.031), triglycerides (β=-0.02, p=0.024) and low-density lipoprotein cholesterol (LDL-C; β=-1.91, p=0.015), independent of adulthood SEP. Adulthood-occupational SEP was negatively associated with waist-to-hip ratio (WHR; β=-0.01, p=0.002), and positively with high-density lipoprotein cholesterol (HDL-C; β=0.87, p=0.030). Results remained similar after adjustment for smoking and inactivity. Childhood-educational SEP was associated with decreased WHR and LDL-C level (p=0.0002), and adulthood-educational SEP was inversely associated with BMI (p=0.001), waist circumference (p=0.008), WHR (p=0.001) and fat% (p=0.0002) and positively associated with HDL-C (p=0.030). Additionally, social mobility (mainly upward) was shown to have adverse cardiometabolic outcomes.

CONCLUSIONS

Both childhood and adulthood SEP contribute independently to CMR. The match-mismatch hypothesis may explain the elevated CMRs among participants experiencing social mobility. Identification of life-course SEP-related aspects that translate into social inequality in cardiovascular risk may facilitate efforts for improving health and for reducing disparities in cardiovascular disease.

Clinical Regression and Remission of Primary Refractory Angiocentric Lymphoma Following Autologous Tumour Peptide Antigen-charged Dendritic Cells After High-dose Chemotherapy and Autologous Stem Cell Rescue

We report on the case of a 34-year old man with a previously refractory high-grade non-Hodgkin's Lymphoma which regressed following dendritic cell based immunotherapy after high-dose chemotherapy. Antigen presenting cells known as dendritic cells were cultured from harvested autologous peripheral blood progenitor cells. The dendritic cells were then exposed to unfractionated tumour peptides derived from a skin biopsy section inflitrated with lymphoma. These charged dendritic cells infused into the patient together with autologous T-lymphocytes after high-dose chemotherapy with peripheral blood stem cell rescue. Although the lymphoma relapsed after the high-dose chemotherapy it regressed again following the dendritic cell infusion. The patient's T-lymphocytes demonstrated in vitro reactivity to tumour peptides whereas the lymphocytes of controls did not. We propose that the lymphoma regression occurred because of a T cell mediated response against the tumour induced by the charged dendritic cells.

Utility of CSF Pressure Monitoring to Identify Idiopathic Intracranial Hypertension without Papilledema in Patients with Chronic Daily Headache

The aim of the present study was to report on the utility of continuous Pcsf monitoring in establishing the diagnosis of idiopathic intracranial hypertension without papilledema (IIHWOP) in chronic daily headache (CDH) patients. We report a series of patients ( n = 10) with refractory headaches and suspected IIHWOP referred to us for continuous Pcsf monitoring between 1991 and 2000. Pcsf was measured via a lumbar catheter and analysed for mean, peak, highest pulse amplitude and abnormal waveforms. A 1-2 day trial of continuous controlled CSF drainage (10 cc/h) followed Pcsf monitoring. Response to CSF drainage was defined as improvement in headache symptoms. Patients with abnormal waveforms underwent a ventriculoperitoneal (VPS) or lumboperitoneal (LPS) shunt insertion. All patients had normal resting Pcsf (8 ± 1 mmHg) defined as ICP < 15 mmHg. During sleep, all patients had B-waves and 90% had plateau waves or near plateau waves. All patients underwent either a VPS or LPS procedure. All reported improvement of their headache after surgery. Demonstration of pathological Pcsf patterns by continuous Pcsf monitoring was essential in confirming the diagnosis of IIHWOP, and provided objective evidence to support the decision for shunt surgery. Increased Pcsf was seen mostly during sleep and was intermittent, suggesting that Pcsf elevation may be missed by a single spot-check LP measurement. The similarity between IIHWOP and CDH suggests that continuous Pcsf monitoring in CDH patients may have an important diagnostic role that should be further investigated.

Prevalence and Correlates of Migraine Among Women Attending a Prenatal Care Clinic in Lima, Peru

Migraine headaches are among the leading causes of disability in the world. The burden of migraines is highest in women of reproductive age. This cross-sectional study characterized the prevalence, symptoms and correlates of migrainous headaches in 154 pregnant women attending a prenatal care clinic in Lima, Peru. Lifetime prevalence of migraine defined by modified IHS criteria was 9.1± (95± CI 4.6–13.6). When probable migraines were included, the lifetime prevalence of migraine in this population was 29.2± (95± CI 22.0–36.4). Migraine headaches were associated with a maternal history of headache, childhood carsickness, a diagnosis of allergies, and a high frequency of fatigue. Although headache-related disability was low in terms of missed work and recreation, high rates of headache pain and medicinal use reflect the true impact on this population.

Associations between paternal urinary phthalate metabolite concentrations and reproductive outcomes among couples seeking fertility treatment

INTRODUCTION

Limited evidence suggests that male exposure to ubiquitous environmental phthalates may result in poor reproductive outcomes among female partners.

METHODS

This analysis included male-female couples undergoing in vitro fertilization (IVF) and/or intrauterine insemination (IUI). We evaluated associations between the geometric mean of paternal specific gravity-adjusted urinary phthalate concentrations prior to the female partners' cycle and fertilization, embryo quality, implantation, and live birth using generalized linear mixed models.

RESULTS

Two-hundred eighteen couples underwent 211 IVF and 195 IUI cycles. Trends were observed between paternal urinary mono-3-carboxypropyl phthalate (MCPP; P=0.01) and mono(carboxyoctyl) phthalate (MCOP; P=0.01) and decreased odds of implantation. MCPP and MCOP were also associated with decreased odds of live birth following IVF (P=0.01 and P=0.04, respectively), and monobutyl phthalate above the first quartile was significantly associated with decreased odds of live birth following IUI (P=0.04). However, most urinary phthalate metabolites were not associated with these reproductive outcomes.

CONCLUSION

Selected phthalates were associated with decreased odds of implantation and live birth.

Managing Injuries of the Neck Trial (MINT): a randomised controlled trial of treatments for whiplash injuries

OBJECTIVES

To examine the clinical effectiveness of a stepped care approach over a 12-month period after an acute whiplash injury; to estimate the costs and cost-effectiveness of each strategy including treatments and subsequent health-care costs; and to gain participants' perspective on experiencing whiplash injury, NHS treatment, and recovery within the context of the Managing Injuries of the Neck Trial (MINT).

DESIGN

Two linked, pragmatic, randomised controlled trials. In Step 1, emergency departments (EDs) were cluster randomised to usual care advice (UCA) or The Whiplash Book advice (WBA)/active management advice. In Step 2, participants were individually randomised to either a single session of advice from a physiotherapist or a physiotherapy package of up to six sessions. An economic evaluation and qualitative study were run in parallel with the trial.

SETTING

Twelve NHS trusts in England comprising 15 EDs.

PARTICIPANTS

People who attended EDs with an acute whiplash injury of whiplash-associated disorder grades I-III were eligible for Step 1. People who had attended EDs with whiplash injuries and had persistent symptoms 3 weeks after ED attendance were eligible for Step 2.

INTERVENTIONS

In Step 1, the control intervention was UCA and the experimental intervention was a psycho-educational intervention (WBA/active management advice). In Step 2 the control treatment was reinforcement of the advice provided in Step 1 and the experimental intervention was a package of up to six physiotherapy treatments.

MAIN OUTCOME

The primary outcome was the Neck Disability Index (NDI), which measures severity and frequency of pain and symptoms, and a range of activities including self-care, driving, reading, sleeping and recreation. Secondary outcomes included the mental and physical health-related quality-of-life (HRQoL) subscales of the Short Form questionnaire-12 items (SF-12) and the number of work days lost.

RESULTS

A total of 3851 patients were recruited to Step 1 of the trial. 1598 patients attending EDs were randomised to UCA, and 2253 were randomised to WBA/active management. Outcome data were obtained at 12 months for 70% and 80% of participants at Step 1 and Step 2, respectively. The majority of people recovered from the injury. Eighteen per cent of the Step 1 cohort had late whiplash syndrome. There was no statistically or clinically significant difference observed in any of the outcomes for participants attending EDs randomised to UCA or active management advice [difference in NDI 0.5, 95% confidence interval (CI) -1.8 to 2.8]. In Step 2 the physiotherapy package resulted in improvements in neck disability at 4 months compared with a single advice session, but these effects were small at the population level (difference in NDI -3.2, 95% CI -5.8 to -0.7). The physiotherapy package was accompanied by a significant reduction in the number of work days lost at 4-month follow-up (difference -40.2, 95% CI -44.3 to -35.8).

CONCLUSIONS

MINT suggests that enhanced psycho-educational interventions in EDs are no more effective than UCA in reducing the burden of acute whiplash injuries. A physiotherapy package provided to people who have persisting symptoms within the first 6 weeks of injury produced additional short-term benefits in neck disability compared with a single physiotherapy advice session. However, from a health-care perspective, the physiotherapy package was not cost-effective at current levels of willingness to pay. Both experimental treatments were associated with increased cost with no discernible gain in health-related quality of life. However, an important benefit of the physiotherapy package was a reduction in work days lost; consequently, the intervention may prove cost-effective at the societal level.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN33302125.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 49. See the HTA programme website for further project information.

Impact of Chronic Oral H2-Antagonist Therapy on Left Ventricular Systolic Function and Exercise Capacity

It has been suggested that H2-antagonists may adversely affect left ventricular systolic function. To assess the effects of cimetidine, famotidine, and ranitidine on exercise capacity and left ventricular systolic function, the authors conducted a randomized, double-blind, four-way crossover study in 15 healthy male volunteers with placebo control. Each subject underwent a maximal upright treadmill exercise test, aerobic metabolic assessment, and two-dimensional stress echocardiography on six separate occasions. The initial two treadmill exercise tests with aerobic metabolic assessment and stress echocardiography were performed to minimize the learning effect. In the final four evaluations, subjects were randomized to receive 7 days of oral treatment with cimetidine 400 mg twice daily, famotidine 40 mg daily, ranitidine 150 mg twice daily, and placebo. A comparison of exercise tests, aerobic metabolic assessment, and stress echocardiography results found no significant differences between any of the H2-antagonists and placebo. In addition, there were no significant differences in test results between cimetidine, famotidine, and ranitidine. Specifically, exercise treadmill time, maximal oxygen consumption, respiratory quotient, maximal exercise systolic and diastolic blood pressure, maximal exercise heart rate, left ventricular end-diastolic dimension, left ventricular end-systolic dimension, and ejection fraction were not different between treatments. The authors conclude that 7 days of oral treatment with cimetidine, famotidine, or ranitidine has no deleterious effect on exercise capacity or left ventricular systolic function in healthy subjects.

Hematological parameters and metabolic syndrome: findings from an occupational cohort in Ethiopia

AIMS

To examine associations between hematological parameters (i.e., hemoglobin, hematocrit, platelet counts, red blood cell (RBC), and white blood cell (WBC) counts) and components of metabolic syndrome (MetS) among working adults in Addis Ababa, Ethiopia.

MATERIALS AND METHODS

Participants were 1868 (1131 men and 737 women) working Ethiopian adults. MetS was classified according to the International Diabetes Federation criterion. Odds ratios (ORs) and 95% confidence intervals (95% CIs) of MetS were calculated using logistic regression procedures.

RESULTS

Hematologic parameters (hemoglobin, hematocrit, and RBC) were positively associated with MetS components (P(trend)<0.05). In both men and women, white blood cell (WBC) counts were positively associated with BMI and waist circumference (P<0.05). RBC counts were associated with diastolic blood pressure in men (P<0.05) and women (P<0.001). Men in the third quartile of hemoglobin concentrations had 2-fold increased odds (OR=1.99; 95% CI) of MetS compared with the lowest reference quartile (P(trend)=0.031) while women in the fourth hemoglobin quartile had 2.37-fold increased odds of having MetS compared with the reference group (P(trend)=0.003). Both men and women in the fourth quartiles of RBC counts had 2.26-fold and 3.44-fold increased odds of MetS (P=0.002 in men, P<0.001 in women). Among women, those in the fourth quartiles of hematocrit and platelet counts had 2.53-fold and 2.01-fold increased odds of MetS as compared with those in the reference group (P(trend)=0.004 and 0.065 respectively).

CONCLUSION

Our study findings provide evidence in support of using hematological markers for early detection of individuals at risk for cardiovascular disease.

Establishing a range of motion boundary for total hip arthroplasty

Range of motion of the hip joint is a major contributor to dislocation post total hip replacement. Impingement is often treated as a surrogate for dislocation and occurs – prosthetically – when the neck of the femoral component contacts with the rim of the pelvic acetabular cup. This impingement is caused by movement of the leg during activities of daily living. This article analyses hip joint range of motion and its implication for impingement. A systematic literature review was undertaken with the purpose of establishing a range of motion benchmark for total hip replacement. This paper proposes a method by which a three-dimensional range of motion boundary established from the literature can be presented. The nominal boundary is also validated experimentally using a number of configurations of a neutral hip joint coordinate frame.

Prevalence of Metabolic Syndrome among Working Adults in Ethiopia

Objective. To evaluate the prevalence of metabolic syndrome (MetS) according to the International Diabetes Federation (IDF) and Adult Treatment Panel (ATP) III criteria among working East African adults. Design. This cross-sectional study of 1,935 individuals (1,171 men and 764 women) was conducted among working adults in Addis Ababa, Ethiopia. The study was conducted in accordance with the STEPwise approach of the World Health Organization. Results. According to ATP III and IDF definitions, the overall prevalence of MetS was 12.5% and 17.9%, respectively. Using ATP III criteria, the prevalence of MetS was 10.0% in men and 16.2% in women. Application of the IDF criteria resulted in a MetS prevalence of 14.0% in men and 24.0% in women. The most common MetS components among women were reduced high-density lipoprotein-cholesterol (HDL-C) (23.2%) and abdominal obesity (19.6%); whilst reduced HDL-C concentrations (23.4%) and high blood pressure (21.8%) were most common among men. Conclusion. MetS and its individual components are prevalent among an apparently healthy working population in Ethiopia. These findings indicate the need for evidence-based health promotion and disease prevention programs; and more robust efforts directed towards the screening, diagnosis and management of MetS and its components among Ethiopian adults.

Laboratory reference values of complete blood count for apparently healthy adults in Ethiopia

BACKGROUND

The objective of this study was to evaluate reference intervals for complete blood cell count parameters among apparently healthy 1,807 adults from Addis Ababa, Ethiopia.

METHODS

Blood specimens were collected from each participant using standard procedures. The collected aliquots were processed according to standard operating procedures to determine participants' complete blood counts. Non-parametric methods were employed to calculate the reference intervals and 90% confidence intervals for complete blood counts.

RESULTS

Overall the results show that reference ranges for women are lower than men. The white blood cell count, neutrophil, lymphocyte, monocyte, eosinophil, and basophil reference values appear to be lower than values reported elsewhere.

CONCLUSIONS

Our study is the first comprehensive study on reference intervals of complete blood count among apparently healthy adults in Ethiopia. Future studies that assess other hematological parameters and studies that assess reference values for African pediatric populations are warranted.

Methylenetetrahydrofolate reductase677 C→T polymorphism and plasma folate in relation to pre-eclampsia risk among Peruvian women

OBJECTIVES

Pre-eclampsia is an important cause of maternal and fetal morbidity and mortality worldwide. Hyperhomocyst(e)inemia in pregnancy is associated with an increased risk of pre-eclampsia in most studies. Nutritional and genetic factors regulate homocyst(e)ine levels. A missense mutation 677 C-->T in the gene for methylenetetrahydrofolate reductase (MTHFR) has been associated with an increased pre-eclampsia risk in some, although not most, previously studied populations.

METHODS

To further understand the role of this polymorphism in the etiology of pre-eclampsia, we genotyped a total of 125 pre-eclamptics and 179 normotensive pregnant Peruvian women.

RESULTS

The wild-type allele frequency among cases and controls was 54% and 58%, respectively. Twenty percent of cases and 17% of controls were homozygous for the 677 C-->T MTHFR genotype (T/T). After adjustment for confounding by covariates including maternal age, nulliparity, pre-pregnancy body mass index and use of prenatal vitamins, women homozygous for the 677 C-->T MTHFR genotype (T/T) experienced a modest, statistically non-significant increased risk of pre-eclampsia (adjusted OR 1.6, 95% CI 0.7, 3.8). Maternal folate deficiency was associated with a statistically non-significant doubling in risk of pre-eclampsia in this population (adjusted OR 2.0, 95% CI 0.9, 4.3).

CONCLUSIONS

There was no evidence to suggest that pre-eclampsia risk is positively associated with the T/T genotype overall, or in the context of folate deficiency.

Evidence of placental haemorrhage and preterm delivery

OBJECTIVE

To evaluate evidence of placental haemorrhage (PH) obtained through maternal interviews, patient charts and placental pathology examinations as potential indicators of a 'bleeding pathway' to preterm delivery (PTD).

DESIGN

Prospective cohort.

SETTING

Fifty-two clinics in five communities in Michigan, USA (1998-2004).

POPULATION

A subset (n = 996) of cohort participants with complete placental pathology data.

METHODS

First-trimester bleeding and placental abruption were ascertained by mid-trimester interviews and chart review, respectively. Disc-impacting blood clot was defined as a gross placental examination finding of a blood clot impacting adjacent tissue. Microscopic haemorrhage was defined as 'high' (top quintile) scores on an aggregate measure of placental pathology findings suggestive of atypical maternal vessel haemorrhage. These four PH indicators were compared with one another and with risk of PTD assessed by logistic regression analyses.

MAIN OUTCOME MEASURES

Preterm delivery and PTD subtypes (i.e. <35 weeks, 35-36 weeks; spontaneous, medically indicated) compared with term deliveries.

RESULTS

Placental abruption cases had 2.3-fold to 5.5-fold increased odds of the other three PH indicators. Disc-impacting blood clots and microscopic haemorrhage were associated with one another (odds ratio [OR] = 4.6), but not with first-trimester bleeding. In a multivariable model that included all four PH indicators and confounders, risk of PTD < 35 weeks was elevated with first-trimester bleeding (OR = 1.9 [1.0, 3.4]), placental abruption (OR = 5.2 [1.7, 16.2]), disc-impacting blood clots (OR = 2.3 [1.0, 5.0]) and microscopic haemorrhage (OR = 2.4 [1.4, 4.2]).

CONCLUSIONS

Multiple clinical and subclinical PH indicators are associated with PTD, particularly early PTD.

Retinal drusen: harbingers of age, safe havens for trouble

Drusen are small focal extracellular deposits underneath the retina, visible ophthalmoscopically as yellow dots. The more hard drusen there are, the greater the risk of developing soft drusen and retinal pigmentary changes, which in turn increase the risk of developing advanced age-related macular degeneration. Much remains to be discovered about drusen. For the patient with drusen, basic advice on diet and smoking and maintenance of a high level of vigilance for visual changes is appropriate management.

Prevalence of metabolic syndrome and its relationship with leisure time physical activity among Peruvian adults

BACKGROUND

Metabolic syndrome (MetS) is an important risk factor of cardiovascular disease (CVD) and type 2 diabetes. Previous studies have suggested an inverse relationship between physical activity and MetS. However, these findings were inconsistent, and few investigators have examined these associations among South Americans. We estimated the prevalence of MetS and its association with leisure time physical activity (LTPA) among Peruvian adults.

MATERIALS AND METHODS

This cross-sectional study of 1675 individuals (619 men and 1056 women) was conducted among residents in Lima and Callao, Peru. Information about LTPA, socio-demographical and other lifestyle characteristics was collected by interview. The presence of MetS was defined using the Adult Treatment Panel III criteria.

RESULTS

Overall, the prevalence of MetS was 26.9% and was more common among women (29.9%) than men (21.6%). Habitual participation in LTPA was associated with a 23% reduced risk of MetS (OR = 0.77; 95% CI: 0.60-1.03). There was an inverse trend of MetS risk with amount of LTPA (P = 0.016). Compared with non-exercisers, those who exercised <150 min/week had a 21% reduced risk of MetS (AOR = 0.79; 95% CI 0.60-1.04). Individuals who exercised > or = 150 min/week, compared with non-exercisers, had a 42% reduced risk of MetS (AOR = 0.58; 95% CI: 0.36-0.93). Associations of similar magnitudes were observed when men and women were studied separately.

CONCLUSION

These data document a high prevalence of MetS and suggest an association with LTPA among urban dwelling Peruvians. Further prospective studies are needed to confirm these observations and to examine interventions that may promote increased physical activity in this population.

Relationship of maternal plasma leptin and risk of pre-eclampsia: a prospective study

OBJECTIVE

We measured maternal plasma leptin concentrations in 55 women with pre-eclampsia and 487 normotensive women to determine whether elevated leptin concentrations were associated with the occurrence of pre-eclampsia.

METHODS

Maternal blood samples were collected at 13 weeks' gestation, on average. Plasma leptin concentrations were determined using immunoassay. Logistic regression procedures were used to calculate odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

Leptin concentrations were 78% higher in cases than control subjects (median 34.6 vs. 19.5 ng/ml; p < 0.001). Relative to women with leptin concentrations of < 27.4 ng/ml, those with elevated leptin concentrations (> or = 27.4 ng/ml) experienced a 2.3-fold increased risk of pre-eclampsia (OR 2.3; 95% CI 1.1-4.6). We observed evidence of a strong linear component of trend in risk of pre-eclampsia with increasing maternal plasma leptin concentration. Each 10-ng/ml increase in leptin concentration was associated with a 30% increase in pre-eclampsia risk (OR 1.3; 95% CI 1.1-1.5). Overweight women with elevated leptin concentrations experienced the highest risk of pre-eclampsia (OR 6.4; 95% CI 3.1-13.2) as compared with lean women with no leptin elevations.

CONCLUSION

Elevated plasma leptin concentration and maternal overweight status appear to be independently associated with an increased risk of pre-eclampsia.

Risk factors for preeclampsia-eclampsia among Zimbabwean women: recurrence risk and familial tendency towards hypertension

We sought to estimate the risk of recurrence of preeclampsia-eclampsia among Zimbabwean women. Additionally, we sought to assess the extent to which family history of pregnancy-induced or chronic hypertension was predicative of the risk of developing preeclampsia-eclampsia. This hospital based case-control study was conducted at Harare Maternity Hospital, Harare Zimbabwe during the period June 1995 to April 1996. Study participants were 200 women with preeclampsia or eclampsia and 200 normotensive pregnant women serving as controls. Logistic regression procedures were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Among multiparous women, a history of any pregnancy-induced hypertension was associated with a 10.5-fold increase in risk of preeclampsia-eclampsia in a subsequent pregnancy (95% CI 4.7-23.5). Women who reported that their mother or sisters experienced pregnancy-induced hypertension were found to be at an increased risk of preeclampsia-eclampsia (OR = 2.3 and 2.6, respectively). A 2.3-fold excess risk of preeclampsia-eclampsia was associated with paturients' maternal history of chronic hypertension (95% CI 1.3-3.6). The corresponding relative risk of preeclampsia-eclampsia for women reporting to have a sister with chronic hypertension was 2.6 (95% CI 1.2-5.3). Zimbabwean women, like North American and European women, are at increased risk for the recurrence of preeclampsia-eclampsia. Findings from our study and those of others suggest a possible genetic component involved in the multifactorial aetiology of preeclampsia-eclampsia. The information provided here should be useful to clinicians involved in the management of patients with a prior history or family history of hypertension.

Normal pressure hydrocephalus: long-term outcome after shunt surgery

BACKGROUND/OBJECTIVE

Little is known about the long-term clinical course and management of patients with normal pressure hydrocephalus (NPH) treated by cerebrospinal fluid (CSF) shunting.

METHODS

We retrospectively reviewed records of 55 patients diagnosed with idiopathic NPH (INPH) and treated with CSF shunts, all of whom were followed for more than 3 years after the original shunt surgery. At each annual follow-up visit, the patient was assessed by Folstein Mini Mental State Examination, detailed clinical evaluation of gait and assessment of headache, cognition, gait or urination, as assessed by the patient and relatives.

RESULTS

The mean duration of follow-up was 5.9+/-2.5 years. There was an overall sustained improvement among all symptoms. Gait showed the highest maintenance of improvement over baseline (83% at 3 years and 87% at the last analysed follow-up of 7 years), cognition showed intermediary improvement (84% and 86%, respectively), and urinary incontinence showed the least improvement (84% and 80%, respectively). Fifty-three percent of patients required shunt revisions. Indications for revision included shunt malfunction (87%), infection (10%) and change of shunt configuration (3%). Overall, 74% revisions resulted in clinical improvement.

CONCLUSIONS

Clinical improvement of patients with NPH can be sustained for 5-7 years in some patients with NPH, even if shunt revision surgery is needed multiple times. With earlier diagnosis and treatment of NPH and the increasing lifespan of the ageing population, the need for long-term follow-up after shunt surgery for NPH may be greater than it was in the past. Monitoring, identification and treatment of shunt obstruction is a key management principle.

Lysophosphatidic acid is detectable in human bronchoalveolar lavage fluids at baseline and increased after segmental allergen challenge

BACKGROUND

Lysophosphatidic acid (LPA) is a biologically active lysophospholipid and a component of normal plasma. LPA binds to receptors expressed on circulating and structural lung cells and affects cell growth and activation. Whether LPA is present in the lung has not been previously reported.

OBJECTIVE

To develop an assay to measure LPA in bronchoalveolar lavage (BAL) fluids, and to study the association between LPA and allergic airway inflammation.

METHODS

Seventeen allergic subjects underwent bronchoscopy and segmental allergen challenge, followed 18 h later by BAL. Supernatants were analysed for LPA content using liquid chromatography and mass spectroscopy. Expression of LPA receptors on primary bronchial epithelial cells was analysed by immunolabelling, and the effects of LPA on epithelial cell barrier function was investigated by measuring transepithelial resistance.

RESULTS

LPA was detectable in BAL from control lung segments, and significantly increased 18 h after allergen challenge. Polyunsaturated species of LPA were especially increased following segmental allergen challenge. LPA levels did not strongly correlate with the number or percentages of eosinophils, neutrophils of lymphocytes, whereas MIP-3alpha (CCL20) levels correlated significantly with the allergen-driven influx of lymphocytes. The levels of LPA from control sites correlated inversely with BAL protein content, suggesting that LPA promoted epithelial barrier integrity at baseline. Experiments using primary human bronchial epithelial cells confirmed that LPA tightened the epithelial cell barrier.

CONCLUSION

Lysophosphatidic acid is detectable in human BAL fluids at baseline and its expression increases during allergic inflammation. LPA does not appear to be a dominant chemoattractant for eosinophils or lymphocytes during allergic airway inflammation. In the absence of ongoing inflammation, LPA may promote epithelial barrier integrity.

Association of gestational diabetes mellitus and low-density lipoprotein (LDL) particle size

A predominance of small, dense low-density lipoproteins (LDL) is characteristic of the dyslipidemic state seen in type 2 diabetes. However, no study has investigated the association in gestational diabetes mellitus (GDM), which is pathophysiologically similar to type 2 diabetes. We hypothesized that LDL particle size is reduced in GDM cases compared with controls. Gradient gel electrophoresis was used to characterize LDL subclass phenotypes in non-fasting intrapartum plasma from 105 GDM cases and 96 controls. All participants were free of pre-existing diabetes or hypertension. The authors used logistic regression to estimate odds ratios (OR) and 95 % confidence intervals (CI) adjusted for confounders. Women with this phenotype had a significant 4.9-fold (95 % CI: 1.1-23.2) increased risk of GDM compared with those with the large, buoyant phenotype. The magnitude of this association was attenuated when plasma triglyceride and other confounders were included in the model (OR=4.2, 95 % CI: 0.5-39.5). Mean LDL particle size in GDM cases was smaller compared with controls (270.1 vs. 272.7A, p=0.003). The OR of GDM risk was 1.8 (95 % CI: 0.9-3.3) for every 10-A reduction in LDL particle size. Large prospective studies are needed to evaluate the association between smaller LDL particle size in early pregnancy with subsequent GDM risk.

Ankyloblepharon filiforme adnatum

Two cases of a rare congenital eyelid abnormality, ankyloblepharon filiforme adnatum, are presented, and novel aspects of treatment, associations and classification are discussed.

Cardiovascular monkey telemetry: Sensitivity to detect QT interval prolongation

INTRODUCTION

Preclinical evaluation of delayed ventricular repolarization manifests electrocardiographically as QT interval prolongation and is routinely used as an indicator of potential risk for pro-arrhythmia (potential to cause Torsades de Pointes) of novel human pharmaceuticals. In accordance with ICH S7A and S7B guidelines we evaluated the sensitivity and validity of the monkey telemetry model as a preclinical predictor of QT interval prolongation in humans.

METHODS

Cardiovascular monitoring was conducted for 2 h pre-dose and 24 h post-dosing with Moxifloxacin (MOX), with a toxicokinetic (TK) evaluation in a separate group of monkeys. In both studies, MOX was administered orally by gavage in 0.5% methylcellulose at 0, 10, 30, 100, 175 mg/kg. Each monkey received all 5 doses using a dose-escalation paradigm. Inherent variability of the model was assessed with administration of vehicle alone for 4 days in all 4 monkeys (0.5% methylcellulose in deionized water).

RESULTS

MOX had no significant effect on mean arterial pressure, heart rate, PR or QRS intervals. MOX produced significant dose-related increases in QTc at doses of 30 (Cmax=5.5+/-0.6 microM), 100 (Cmax=16.5+/-1.6 microM), and 175 (Cmax=17.3+/-0.7 microM) mg/kg with peak increases of 22 (8%), 27 (10%), and 47 (18%) ms, respectively (p<or=0.05; compared to vehicle).

DISCUSSION

In conclusion, we have developed a reproducible, sensitive and reliable primate telemetry model in rhesus monkeys, which exhibits low inherent intra-animal variability and high sensitivity to detect small but significant increases in QT/QTc interval (approximately 4%) with MOX in the same range of therapeutic plasma concentrations attained in humans. Therefore, the primate telemetry model should be considered an important preclinical predictor of QT prolongation of novel human pharmaceuticals.

Neurologic prognosis and withdrawal of life support after resuscitation from cardiac arrest

OBJECTIVE

To study the impact of neurologic prognostication on the decision to withdraw life-sustaining therapies (LST) in comatose patients resuscitated after cardiac arrest.

METHODS

The authors prospectively studied a consecutive series of post-resuscitation comatose patients referred for neurologic prognostication at a single center for 4 years. For most patients, neurologic prognostication was not sought due to early death or rapid return to consciousness. Prognostication was based on Glasgow Coma Score (GCS) and Brainstem Reflex Score (BRS), with EEG and cortical evoked potentials (CEP), which were graded as benign, uncertain, and malignant. The outcomes were as follows: survivors (Group S), brain or cardiac death (Group D), and death from withdrawal of life sustaining therapy (Group W). In Group W, the time interval to withdrawal of LST was analyzed by EEG and CEP grades.

RESULTS

Of 58 patients studied, 10 were in Group S, 8 in Group D, and 40 in Group W. Initial median GCS and BRS was similar for all groups with significant improvement noted in Group S, but not in Group D or Group W. In Group W, CEP grade correlated with the median duration of continued therapy before a decision to withdraw LST: 7 days for benign CEP, 2 days for uncertain CEP, and 1 day for malignant CEP, p = 0.0004.

CONCLUSION

In patients with poor neurologic recovery early after resuscitation from cardiac arrest, physicians appear to use the cortical evoked potential grade to estimate prognosis. Cortical evoked potential grade correlated with the waiting time until life sustaining therapies were withdrawn after no improvement in neurologic examination was seen.

Functional variants of the lipoprotein lipase gene and the risk of preeclampsia among non-Hispanic Caucasian women

Hypertriglyceridemia is an important pathophysiologic feature of preeclampsia, a common vascular disorder of pregnancy. Three well-documented functional variants (N291S, S447X, and D9N) of the lipoprotein lipase gene were related to hypertriglyceridemia. Results from the only two studies concerning the relationship between these variants and preeclampsia risk have been inconsistent. We investigated this relationship in a case-control study including 144 preeclamptic and 290 normotensive pregnant women (all non-Hispanic Caucasians). We estimated odds ratios (OR) and 95% confidence intervals (CI) adjusted for maternal age, pre-pregnancy body mass index, and parity. After adjusting for covariates, women with the 291 N/S or S/S genotype had significantly increased risk of preeclampsia (OR 6.9, 95% CI 1.9-25.4) compared with women with the common 291N/N genotype. The 447 S/X or X/X genotype was not significantly associated with preeclampsia risk. The frequency of the 9N variant allele was 1.8% in controls, while this allele was not observed among cases. Haplotype 9D/291S/447S was strongly associated with higher risk of preeclampsia as compared with the most common haplotype 9D/291N/447S (adjusted OR 6.6, 95% CI 1.7-25.0). Results from our study support the thesis that abnormal lipid metabolism is important in the pathogenesis of preeclampsia.