Third and Fourth Vaccine Doses Broaden and Prolong Immunity to SARS-CoV-2 in Adult Patients with Immune-Mediated Inflammatory Diseases

Previous studies have reported impaired humoral responses after SARS-CoV-2 mRNA vaccination in patients with immune-mediated inflammatory diseases (IMIDs), particularly those treated with anti-TNF biologics. We previously reported that IMID patients diagnosed with inflammatory bowel disease, psoriasis, psoriatic arthritis, ankylosing spondylitis, or rheumatoid arthritis exhibited greater waning of Ab and T cell responses than healthy control subjects after SARS-CoV-2 vaccine dose 2. Fewer data are available on the effects of third and fourth doses. This observational cohort study collected plasma and PBMCs from healthy control subjects and untreated or treated patients with IMIDs prevaccination and after one to four doses of SARS-CoV-2 mRNA vaccine (BNT162b2 or mRNA-1273). SARS-CoV-2-specific Ab levels, neutralization, and T cell cytokine release were measured against wild-type and Omicron BA.1 and BA.5 variants of concern. Third vaccine doses substantially restored and prolonged Ab and T cell responses in patients with IMIDs and broadened responses against variants of concern. Fourth-dose effects were subtle but also prolonged Ab responses. However, patients with IMIDs treated with anti-TNF, especially patients with inflammatory bowel disease, exhibited lower Ab responses even after the fourth dose. Although T cell IFN-γ responses were maximal after one dose, IL-2 and IL-4 production increased with successive doses, and early production of these cytokines was predictive of neutralization responses at 3-4 mo postvaccination. Our study demonstrates that third and fourth doses of the SARS-CoV-2 mRNA vaccines sustain and broaden immune responses to SARS-CoV-2, supporting the recommendation for three- and four-dose vaccination regimens in patients with IMIDs.

Patients with fulminant myocarditis supported with veno-arterial extracorporeal membrane oxygenation: a systematic review and meta-analysis of short-term mortality and impact of risk factors

Fulminant myocarditis (FM) may lead to cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Results of effectiveness studies of VA-ECMO have been contradictory. We evaluated the aggregate short-term mortality after VA-ECMO and predictive factors in patients with FM. We systematically searched in electronic databases (February 2022) to identify studies evaluating short-term mortality (defined as mortality at 30 days or in-hospital) after VA-ECMO support for FM. We included studies with 5 or more patients published after 2009. We assessed the quality of the evidence using the QUIPS and GRADE tools. Mortality was pooled using random effect models. We performed meta-regression to explore heterogeneity based on a priori defined factors. We included 54 observational studies encompassing 2388 FM patients supported with VA-ECMO. Median age was 41 years (25th to 75th percentile 37-47), and 50% were female. The pooled short-term mortality was 35% (95% CI 29-40%, I² = 69%; moderate certainty). By meta-regression, studies with younger populations showed lower mortality. Female sex, receiving a biopsy, cardiac arrest, left ventricular unloading, and earlier recruitment time frame, did not explain heterogeneity. These results remained consistent regardless of continent and the risk of bias category. In individual studies, low pH value, high lactate, absence of functional cardiac recovery on ECMO, increased burden of malignant arrhythmia, high peak coronary markers, and IVIG use were identified as independent predictors of mortality. When conventional therapies have failed, especially in younger patients, cardiopulmonary support with VA-ECMO should be considered in the treatment of severe FM.

Incidental finding of juvenile angiofibroma from pre-orthodontic radiographs: two case reports and a literature review

This case series presents two asymptomatic cases of juvenile angiofibroma which were initially incidentally identified in pre-orthodontic radiographs. Juvenile angiofibroma is an uncommon, locally aggressive benign, vascular neoplasm with invasive growth patterns. Due to the hypervascularity of these tumours, there are biopsy associated risks and multi-slice computed tomography, magnetic resonance imaging and angiography are usually employed for diagnosis. Early pre-symptomatic identification of this lesion facilitates early management and limiting potential life-threatening complications. This highlights the importance of thorough interpretation of dental radiographs, including the evaluation of structures which are not in the primary region of interest. © 2022 Australian Dental Association.

Accelerated waning of immunity to SARS-CoV-2 mRNA vaccines in patients with immune-mediated inflammatory diseases

BACKGROUNDLimited information is available on the impact of immunosuppressants on COVID-19 vaccination in patients with immune-mediated inflammatory diseases (IMID).METHODSThis observational cohort study examined the immunogenicity of SARS-CoV-2 mRNA vaccines in adult patients with inflammatory bowel disease, rheumatoid arthritis, ankylosing spondylitis, or psoriatic disease, with or without maintenance immunosuppressive therapies. Ab and T cell responses to SARS-CoV-2, including neutralization against SARS-CoV-2 variants, were determined before and after 1 and 2 vaccine doses.RESULTSWe prospectively followed 150 subjects, 26 healthy controls, 9 patients with IMID on no treatment, 44 on anti-TNF, 16 on anti-TNF with methotrexate/azathioprine (MTX/AZA), 10 on anti-IL-23, 28 on anti-IL-12/23, 9 on anti-IL-17, and 8 on MTX/AZA. Ab and T cell responses to SARS-CoV-2 were detected in all participants, increasing from dose 1 to dose 2 and declining 3 months later, with greater attrition in patients with IMID compared with healthy controls. Ab levels and neutralization efficacy against variants of concern were substantially lower in anti-TNF-treated patients than in healthy controls and were undetectable against Omicron by 3 months after dose 2.CONCLUSIONSOur findings support the need for a third dose of the mRNA vaccine and for continued monitoring of immunity in these patient groups.FUNDINGFunded by a donation from Juan and Stefania Speck and by Canadian Institutes of Health (CIHR)/COVID-Immunity Task Force (CITF) grants VR-1 172711 and VS1-175545 (to THW and ACG), CIHR FDN-143250 (to THW), GA2-177716 (to VC, ACG, and THW), and GA1-177703 (to ACG) and the CIHR rapid response network to SARS-CoV-2 variants, CoVaRR-Net (to ACG).

POS1217 ANTI-TNF THERAPY FOR IMMUNE MEDIATED INFLAMMATORY DISEASES MAY BE ASSOCIATED WITH LOWER ANTIBODY LEVELS AND VIRUS NEUTRALIZATION EFFICACY FOLLOWING SARS-CoV-2 mRNA VACCINATION

Background

The impact of immunosuppressants on COVID-19 vaccination response and durability in patients with immune-mediated inflammatory diseases (IMID) is yet to be fully characterized. Humoral response may be attenuated in these patients especially those on B cell depleting therapy and higher doses of corticosteroids, but data regarding other immunosuppressants are scarce.

Objectives

We aimed to investigate antibody and T cell responses and durability to SARS-CoV-2 mRNA vaccines (BNT162b and/or mRNA 1273) in IMID patients on immunomodulatory maintenance therapy other than B-cell depleting therapy and corticosteroids.

Methods

This prospective observational cohort study examined the immunogenicity of SARS-CoV-2 mRNA vaccines in adult patients with IMIDs (psoriatic arthritis, psoriasis, inflammatory bowel disease and rheumatoid arthritis) with or without maintenance immunosuppressive therapies (anti-TNF, methotrexate/azathioprine [MTX/AZA], anti-TNF + MTX/AZA, anti IL12/23, anti-IL-17, anti-IL23) compared to healthy controls. Automated ELISA for IgGs to spike trimer, spike receptor binding domain (RBD) and the nucleocapsid (NP) and T-cell release of 9 cytokines (IFNg, IL2, IL4, IL17A, TNF) and cytotoxic molecules (sFasL, GzmA, GzmB, Perforinin) in cell culture supernatants following stimulation with spike or NP peptide arrays were conducted at 4 time points: T1=pre vaccination, T2=median 26 days after dose 1, T3=median 16 days after dose 2 and T4=median 106 days after dose 2. Neutralization assays against four SARS-CoV-2 variants (wild type, delta, beta and gamma) were conducted at T3.

Results

We followed 150 subjects: 26 healthy controls and 124 IMID patients: 9 untreated, 44 on anti-TNF, 16 on anti-TNF with MTX/AZA, 10 on anti-IL23, 28 on anti-IL12/23, 9 on anti-IL17, 8 on MTX/AZA (Table 1). Most patients mounted antibody and T cell responses with increases from dose 1 to dose 2 (100% seroconversion at T3) and some decline by T4, with variability within groups. Antibody levels and neutralization efficacy was lower in anti-TNFgroups (anti-TNF, anti-TNF + MTX/AZA) compared to controls and waned by T4 (Figure 1). T cell responses were not consistently different between groups. Pooled data showed a higher antibody response to mRNA-1273 compared to BNT162b.

Table 1.

Baseline characteristics of study participants

Controluntreated IMIDAnti- TNFAnti- TNF +MTX/AZAAnti-IL-23Anti -IL-12/23Anti -IL-17MTX/AZAn=26n=9n=44n=16n=10n=28n=9n=8p-valueIMID*N/A IBD9301002704 Psoriasis1318122 PA0732172 AS0830010 RA1100011Age median years [IQR]36 [26-46]33 [27-41]38 [30-51]53 [44-59]48 [45-61]34 [28-47]49 [46-61]42 [31-55]<0.001^Sex male (%)16 (62)5 (56)18 (41)8 (50)5 (50)13 (46)6 (67)4 (50)0.772~BMImedian kg/m2 [IQR]25 [23-28]26 [22-27]22 [24-26]26 [24-28]27 [24-35]22 [21-24]32 [26-34]26[25-33]0.001^Vaccine interval median days [IQR]74 [35-84]54 [31-64]60 [45-69]64 [50-72]74 [35-84]62 [49-69]65 [52-75]58 [21-97]0.372^

*multiple IMIDs per patient possible

Figure 1.

Antibody responses (A) Anti spike and anti RBD IgG levels at indicated time points. Blue line represents median ratio in convalescent patients. The red line is the seropositivity threshold: the median antibody level of those that pass both a 1% false positive rate and show ≥3SD from the log means of the negative controls. (B) Relative ratio of RBD, spike and NP across time. Black and gray lines indicate median and mean values, respectively. *p≤0.05, **p≤0.01, ***p≤0.001, ****p≤0.0001

Conclusion

Following 2 doses of mRNA vaccination there is 100% seroconversion in IMID patients on maintenance therapy. Antibody levels and neutralization efficacy in anti-TNF group are lower than controls, and wane substantially by 3 months after dose 2. These findings highlight the need for third dose in patients undergoing treatment with anti-TNF therapy and continued monitoring of immunity in these patient groups, taking into consideration newer variants and additional vaccine doses.

Acknowledgements

This work was funded by a donation from Juan and Stefania Speck and by grants VR-1 172711, VS1-175545, FDN-143250, GA1- 177703 and GA2- 177716, from Canadian Institutes of Health Research and COVID Immunity task force and by Sinai Health Foundation

Disclosure of Interests

Naomi Finkelstein: None declared, Roya M. Dayam: None declared, Jaclyn Law: None declared, Rogier Goetgebuer: None declared, Gary Chao: None declared, Kento T. Abe: None declared, Mitchell Sutton: None declared, Joanne M. Stempak: None declared, Daniel Pereira: None declared, David Croitoru: None declared, Lily Acheampong: None declared, Saima Rizwan: None declared, Klaudia Rymaszewski: None declared, Raquel Milgrom: None declared, Darshini Ganatra: None declared, Nathalia V. Batista: None declared, Melanie Girard: None declared, Irene Lau: None declared, Ryan Law: None declared, Michelle Cheung: None declared, Bhavisha Rathod: None declared, Julia Kitaygorodsky: None declared, Reuben Samson: None declared, Queenie Hu: None declared, Nigil Haroon: None declared, Robert Inman Consultant of: AbbVie, Janssen, Lilly, Novartis., Grant/research support from: AbbVie, Novartis, Vincent Piguet Consultant of: AbbVie, Almirall, Celgene, Janssen, Kyowa Kirin Co. Ltd, LEO Pharma,

Novartis, Pfizer, Sanofi, UCB, and Union Therapeutic, Grant/research support from: Unrestricted educational grants from AbbVie, Bausch Health, Celgene, Janssen, LEO Pharma, Lilly, L’Oréal, NAOS, Novartis, Pfizer, Pierre-Fabre, Sandoz, and Sanofi, Mark Silverberg Speakers bureau: AbbVie, Janssen, Takeda, Pfizer, Gilead and Amgen, Consultant of: AbbVie, Janssen, Takeda, Pfizer, Gilead and Amgen, Grant/research support from: AbbVie, Janssen, Takeda, Pfizer, Gilead and Amgen, Anne-Claude Grigras: None declared, Tania H. Watts: None declared, Vinod Chandran Consultant of: AbbVie, Amgen, BMS, Eli Lilly, Janssen, Novartis, Pfizer and UCB, Grant/research support from: AbbVie, Amgen, Eli-Lilly.

Growth performance and survivability of the Asian seabass Lates calcarifer (Bloch, 1790) reared under hyper-saline, hypo-saline and freshwater environments in a closed aquaculture system

Salinity is one of the most critical environmental parameters regarding fish physiology, modifying food intake and growth performance in many fish species. The present study has investigated the effects of different salinity levels on growth performance, feeding and survival of Asian seabass Lates calcarifer juveniles. Asian seabass juveniles were reared at 0 (T1), 5 (T2), 22 (T3), 36 (T4), and 42 (T5) ppt salinity. Approximately eight hundred thirty fish individuals with an average weight of 1.24±0.52 g were randomly distributed (166 fish/Tank) in 5 concrete tanks (each tank 30×6×4 ft, volume 19,122 L) for forty days. Juveniles were initially fed 42% crude protein-containing diets at a rate of 6% of their body weight per day. The results showed that salinity level had a significant effect on the weight gain (WG), average daily weight gain (ADWG), specific growth rate (SGR), feed conversion ratio (FCR), survival rate (SR), total biomass and health indices (p<0.05). The highest WG (39.11±1.49 g), ADWG (1.00±0.12 g), SGR (8.74±0.03% d-1) and lowest FCR (0.96±0.20) were observed with T3 treatment, which was significantly higher compared to other treatment groups (p<0.05). Among the health indices, the highest hepatosomatic index and viscerosomatic index were found with T3 treatment, significantly higher than the other groups (p<0.05). No significant differences were found among the treatments in terms of survival rate (p>0.05), but the maximum survival rate (98.89±0.0%) was observed in the T3 and T2 treatments. The maximum level of crude proteins (19.99±1.4%) was found in the whole-body biochemical composition of Asian seabass juveniles in the T3 treatment group. The second-order polynomial regression showed that 20 ppt salinity is optimum for the best growth of Asian seabass. Thus, the present study recommends 20 to 36 ppt salinity for the commercial farming of Asian seabass under a closed aquaculture system.

Biodiversity of commercially important finfish species caught by mid-water and bottom trawls from two different coasts of Arabian Sea: Threats and conservation strategies

This study was conducted to estimate the diversity and the occurrence of commercially important finfish species collected by twenty fish sampling site of Sindh and Baluchistan coasts of the Arabian Sea in Pakistan from January to December 2019. Additionally, physicochemical characteristics of seawater were analyzed from these selected sites and found to be within suitable ranges required for fish growth and survive. A total of 81287 fish individuals were collected and identified as 49 species belonging to 26 families in our study. The most diversified family was Sparidae (13 species) followed by Carangidae and Lutjanidae (4 species), Mullidae, Serranidae, Ariidae (3 species), and Sciaenidae (2 species). The remaining 20 families were represented by only one species. The values of Shannon diversity index calculated for the four selected habitats revealed that high fish diversity was reported at Sonmiani Coast (H'=1.81), while less at Ormara Coast (H'=0.23). Likewise, Evenness index (E) was high at Sonmiani Coast (E=0.50) and less fish diversity was reported at Ormara Coast (E=0.06). Reducing risks to threatened marine species in coastal habitats also requires conservation actions at multiple scales. Thus, it was concluded that our study could be valuable in providing the more information's regarding to the diversity of finfish species and their occurrence along the Pakistan Coast. Further, to better understand the effects, regular monitoring and conservation measures should be taken to mitigate the influence of anthropogenic activities and protect finfish diversity from further decline.

Potential application of immunotherapy for modulation of pulp inflammation: opportunities for vital pulp treatment

Caries results in the demineralization and destruction of enamel and dentine, and as the disease progresses, irreversible pulpitis can occur. Vital pulp therapy (VPT) is directed towards pulp preservation and the prevention of the progression of inflammation. The outcomes of VPT are not always predictable, and there is often a poor correlation between clinical signs and symptoms, and the events occurring at a molecular level. The inflamed pulp expresses increased levels of cytokines, including tumour necrosis factor (TNF)-α, interleukin (IL)-1α, IL-1β, IL-4, IL-6, IL-8, IL-17 and IL-23, which recruit and drive a complex cellular immune response. Chronic inflammation and sustained cytokine release can result in irreversible pulp damage and a decreased capacity for tissue healing. Other chronic inflammatory diseases, such as psoriasis, inflammatory bowel diseases and rheumatoid arthritis, are also characterized by an dysregulated immune response composed of relatively high cytokine levels and increased numbers of immune cells along with microbial and hard-soft tissue destructive pathologies. Whilst anti-cytokine therapies have been successfully applied in the treatment of these diseases, this approach is yet to be attempted in cases of pulp inflammation. This review therefore focuses on the similarities in the aetiology between chronic inflammatory diseases and pulpitis, and explores how anti-cytokine therapies could be applied to manage an inflamed pulp and facilitate healing. Further proof-of-concept studies and clinical trials are justified to determine the effectiveness of these treatments to enable more predictable outcomes in VPT.

Memory-enhancing effect of aspirin is mediated through opioid system modulation in an AlCl3-induced neurotoxicity mouse model

Neurodegenerative disorders such as Alzheimers disease (AD) are multifaceted and there are currently a limited number of therapeutic strategies available to treat them. Aspirin is known to act on multiple therapeutic targets and is a successful anti-inflammatory agent in various tissues. The present study aimed to ascertain the performance of aspirin when employed as a therapeutic agent to treat neurodegeneration on novel targets, including opioid system genes, in an AlCl₃-induced neurotoxicity mouse model. The effects of two doses of aspirin (5 and 20 mg/kg aspirin for 12 days) were investigated in an AlCl₃-induced neurotoxicity mouse model (150 mg/kg AlCl₃ for 12 days). Neurological improvements were assessed through different behavioral tests and the effects of aspirin on opioid system gene expression levels were assessed by reverse transcription-polymerase chain reaction. Both doses resulted in improvements in cognitive behavior. A 5 mg/kg dose of aspirin was revealed to be effective for spatial memory improvement (7.14±0.84 sec), whilst a 20 mg/kg dose was superior for improving extinction learning (7.63±4.04%). Aspirin (5 mg/kg) also significantly improved contextual memory (48.05±10.6%) when compared with the AlCl₃-treated group (1.49±0.62%; P<0.001). Aspirin was also observed to significantly decrease δ-opioid receptor expression in the cortex (1.09±0.08 and 1.27±0.08, respectively) at both doses (5 and 20 mg/kg) when compared with the AlCl₃-treated group (3.69±1.43; P<0.05). Furthermore, aspirin at 5 mg/kg significantly reduced expression of prodynorphin in the cortex (0.57±0.20) when compared with the AlCl₃-treated group (1.95±0.84; P<0.05). Notably, the effect of aspirin was significant in the cortex but not in the hippocampus. In summary, aspirin was effective in ameliorating the AD-like symptoms via the modulation of opioid systems. However, additional studies are required to determine the long term effects of aspirin on such conditions.

Advocacy, communication and social mobilisation for tuberculosis control in Pakistan: a qualitative case study

SETTING

A national-level study in four districts, one each in all four provinces of Pakistan, a high tuberculosis (TB) burden country.

OBJECTIVES

To examine how advocacy, communication and social mobilisation (ACSM) campaigns by the National Tuberculosis Programme (NTP) in Pakistan engaged the populations of interest, to what extent they were successful in promoting services and desired behaviours, and how these campaigns could be improved.

DESIGN

This was a qualitative case study comprising 13 focus groups and 36 individual interviews in four districts. All three levels of the ACSM programme, i.e., planners, implementers and beneficiaries, were included among the respondents.

RESULTS

Improved political commitment, availability of funds, partnership with the private sector, visibility of the NTP and access to directly observed treatment (DOT) were achieved. Individual and social environmental issues of poor patients and marginalised communities were addressed to some extent, and could be improved in the future. Empathy and respect from physicians, and better service delivery of the DOTS-based programme were desired by the patients.

CONCLUSIONS

The strategic advocacy ensured political and financial commitment; however, identification and targeting of vulnerable populations, and carrying out context-based social mobilisation and effective counselling are crucial to increase the use of DOT. Evaluations should be built-in from the beginning to increase the evidence on effectiveness of ACSM campaigns.

Dietary flaxseed oil supplementation ameliorates the effect of cisplatin on brush border membrane enzymes and antioxidant system in rat intestine

Cisplatin (CP; cis-diamminedichloroplatinum II) is a drug widely used against different types of solid tumors. Patients receiving CP, however, experience very profound and long lasting gastrointestinal symptoms. Recently, ω-3 polyunsaturated fatty acid-enriched flaxseed/flaxseed oil (FXO) has shown numerous health benefits. The present study was undertaken to investigate whether FXO can prevent CP-induced adverse biochemical changes in the small intestine of rats. A single intraperitoneal dose of CP (6 mg/kg body weight) was administered to male Wistar rats fed with control diet (CP group) and FXO diet (CPFXO group). Administration of CP led to a significant decline in the specific activities of brush border membrane enzymes both in the mucosal homogenates and in the isolated membrane vesicles. Lipid peroxidation and total sulfhydryl groups were altered upon CP treatment, indicating the generation of oxidative stress. The activities of SOD, catalase and glutathione peroxidase also decreased in CP-treated rats. In contrast, dietary supplementation of FXO prior to and following CP treatment significantly attenuated the CP-induced changes in all these parameters. FXO feeding markedly enhanced resistance to CP-elicited adverse gastrointestinal effects. The results suggest that FXO owing to its intrinsic biochemical/antioxidant properties is an effective agent in reducing the adverse effects of CP on intestine.

Electric-field control of nonvolatile magnetization in Co40Fe40B20/Pb(Mg(1/3)Nb(2/3))(0.7)Ti(0.3)O3 structure at room temperature

We report a large and nonvolatile bipolar-electric-field-controlled magnetization at room temperature in a Co(40)Fe(40)B(20)/Pb(Mg(1/3)Nb(2/3))(0.7)Ti(0.3)O(3) structure, which exhibits an electric-field-controlled looplike magnetization. Investigations on the ferroelectric domains and crystal structures with in situ electric fields reveal that the effect is related to the combined action of 109° ferroelastic domain switching and the absence of magnetocrystalline anisotropy in Co(40)Fe(40)B(20). This work provides a route to realize large and nonvolatile magnetoelectric coupling at room temperature and is significant for applications.

Studies on the protective effect of flaxseed oil on cisplatin-induced hepatotoxicity

Cisplatin (CP) is known as one of the most potent chemotherapeutic antitumor drugs. The tissue-specific toxicity of CP in the kidneys is well documented. However, at higher doses less common toxic effects such as hepatotoxicity may arise. Since CP remains one of the most effective antineoplastic drug used in chemotherapy, strategies to protect tissues against CP toxicity are of clinical interest. Recently, ω-3 polyunsaturated fatty acids (PUFAs) from certain plants/seeds notably flaxseed have shown numerous health benefits. In view of this, the present study investigates the protective effect of flaxseed oil (FXO) on CP-induced damage in liver. Rats were pre-fed normal diet and the diet rich in FXO for 10 days and then a single dose of CP (6 mg/kg body weight) was administered intraperitoneally while still on diet. Serum/urine parameters, enzymes of carbohydrate metabolism and oxidative stress were analyzed. CP caused perturbation of the antioxidant defense as reflected by the decrease in the activities of catalase, superoxide dismutase and glutathione peroxidase. Further the activities of various enzymes involved in glycolysis, tricarboxylic acid cycle, gluconeogenesis and hexose monophosphate shunt pathways were determined and were found to be differentially altered by CP treatment. However, these alterations were ameliorated in CP-treated rats fed on FXO. Present results show that dietary supplementation of FXO in CP-treated rats ameliorated CP-induced hepatotoxic and other deleterious effects due to its intrinsic biochemical/antioxidant properties.

Population attributable risk for adverse pregnancy outcomes related to smoking in adolescents and adults

BACKGROUND

Little is known about how population-attributable risks (PAR) for adverse birth outcomes due to smoking differ in adolescent and adult pregnancies.

METHODS

An analysis of community and hospital-based cross-sectional studies in Liverpool was undertaken to estimate the PAR values of low birthweight (LBW), preterm birth, and small for gestational age (SGA) births resulting from pregnancy smoking covering the period between 1983 and 2003. Maternal smoking status and pregnancy outcomes were available for a sample of 12631 women.

RESULTS

The prevalence of maternal pregnancy smoking was 40% in the community sample and 33% in adults and 40% among adolescent pregnancies in the hospital sample. The PAR values (95% CI) associated with LBW, preterm birth and SGA outcomes due to maternal pregnancy smoking in the community sample were 27% (25-30), 13% (11-15) and 25% (23-27), respectively. The PAR values in adults in the hospital sample were 29% (27-31) for LBW, 16% (14-19) for preterm birth and 28% (26-31) for SGA. The corresponding PAR values in adolescents were 39% (34-43), 12% (7-18) and 31% (23-40). The LBW risk attributed to pregnancy smoking in adolescents was significantly higher than for adults (P=0.05).

CONCLUSION

About one-third of LBW, one-quarter of SGA and one-sixth of preterm births could be attributed to maternal smoking during pregnancy. The magnitude of the problem was greater among adolescent pregnancies, among whom a sub-group of mothers with very high risk for adverse birth outcomes due to pregnancy smoking was identified.

Maternal smoking during pregnancy and possible effects of in utero testosterone: evidence from the 2D:4D finger length ratio

OBJECTIVES

Maternal smoking during pregnancy is linked to high fetal testosterone (FT), and an increased risk in offspring for autism, ADHD, conduct disorder, antisocial behaviour and criminal outcomes. The ratio of the length of the 2nd and 4th fingers (2D:4D) is thought to be negatively related to FT concentration, and is related to autism, hyperactivity, poor social behaviour, and physical aggression. We compare the 2D:4D ratio of children whose mothers smoked during pregnancy with the 2D:4D of children whose mother did not smoke.

METHOD

Cross-sectional survey in two primary schools. Questionnaires were distributed to 710 children and 546 were returned. Of these the 2nd and 4th digits of 520 children (259 females and 261 males) were measured. The main outcome measures were 2nd and 4th digit length, smoking history of mother and father.

RESULTS

Boys had lower mean 2D:4D than girls and right 2D:4D was lower than left. Among boys, those whose mother's smoked during pregnancy had lower right hand 2D:4D ratio than those whose mother did not smoke. The difference remained significant after the effects of age, height, weight and birth weight were removed. Other household smoking patterns were not associated with male offspring 2D:4D. Female offspring 2D:4D did not differ on the basis of maternal smoking.

CONCLUSIONS

Maternal smoking during pregnancy was associated with low right 2D:4D in children, but the effect was restricted to boys. A link between maternal smoking during pregnancy and 2D:4D supports a causal association between FT and such behaviours as hyperactivity and conduct disorder.

Trends in childhood and parental asthma prevalence in Merseyside, 1991-1998

OBJECTIVE

To determine changes in childhood and parental asthma prevalence in Merseyside between 1991 and 1998.

METHODS

Three standardized cross-sectional respiratory health surveys using a parent-completed questionnaire were completed in 1991 (n = 1171), 1993 (n = 2368) and 1998 (n = 1964) amongst primary school children (5-11 years) attending the same 10 schools. The main outcome measures were prevalence of reported doctor diagnosed asthma, the symptom triad of cough, wheeze and breathlessness (C+W+B+) and parental asthma.

RESULTS

Significant changes in prevalence for all respiratory variables occurred between 1991 and 1998, except for the symptom triad C+W+B+. Between 1991 and 1998 the prevalence of reported doctor diagnosed asthma increased from 17.7 to 29.8 per cent (p < 0.001), history of wheezing increased from 22.5 to 29.4 per cent (p < 0.001). The symptom triad of C+W+B+ changed from 9.6 to 9.9 per cent (p = 0.78). Childhood reported hospital admissions for respiratory illness increased from 5.5 to 10.7 per cent (p < 0.001). Paternal asthma increased from 6.5 per cent in 1991, to 8.6 per cent in 1998 (p = 0.031), and maternal asthma almost doubled in the same period from 6.6 to 11.2 per cent (p < 0.001). Children living in poorer areas (Townsend score 8-11) were more likely to have doctor diagnosed asthma (OR = 2.99, 95 per cent CI, 2.06 to 4.33) and C+W+B+ (OR = 2.17, CI 1.13 to 4.18). Childhood obesity was significantly associated with increased risk of both doctor diagnosed asthma (OR = 1.74, 95 per cent CI, 1.29 to 2.37) and C+W+B+ (OR = 1.88, 95 per cent CI, 1.21 to 2.90).

CONCLUSION

A rising prevalence of reported doctor diagnosed asthma, but not C+W+B+ was observed during the 1990s in a low socio-economic area of Liverpool. Asthma prevalence was related to socio-economic deprivation and was associated with obesity. The rising prevalence of reported doctor diagnosed asthma is likely to be attributable to several factors, including changes in diagnostic labelling and the distribution of factors related to socio-economic status.

High venous urea concentrations in the opposite arm. A consequence of hemodialysis-induced compartment disequilibrium

Resistance to urea diffusion among body fluid compartments diminishes the therapeutic effectiveness of hemodialysis. Cell membrane or capillary wall resistance is thought to be responsible for hemodialysis-induced urea disequilibrium. The authors examined the possibility that reduced blood flow might contribute to urea disequilibrium in the arm opposite the blood access site. Blood samples were taken simultaneously from a vein in the arm opposite the access site and from the arterial port after occluding the access graft between the needle sites for 1 min. Venous urea nitrogen levels from the opposite arm averaged 10% higher after 5 min, 26% higher after 60 min, and 36% higher after 120 min of dialysis. A three-compartment model of urea kinetics that includes a blood flow term accurately predicted all measured urea nitrogen concentrations in both arms. These data suggest that the opposite arm often behaves as a compartment with high resistance to urea diffusion. Slow diffusion from this compartment is partially due to reduced blood flow/compartment volume, and results in a delayed fall in venous blood urea nitrogen (BUN).

Effectiveness of low dose erythropoietin: a possible advantage of high flux hemodialysis

Recombinant human erythropoietin (EPO) was administered to 32 stable out-patients with end-stage renal disease (ESRD) on a priority basis three times a week. All patients underwent dialysis with polysulfone hollow fiber dialyzers. Mean time-averaged blood urea nitrogen (BUN) value was 50 +/- 12 mg/dl, and Kt/V for urea was 1.20 +/- 0.34/dialysis. The initial dose of EPO was 2,800 +/- 950 U/dialysis (45 +/- 17 U/kg/dialysis). The maintenance dose averaged 2,500 U/dialysis. Within the mean time of observation, 15 +/- 4 weeks, all but one patient responded to EPO by eliminating transfusion requirements, and 29 of 32 achieved the target hematocrit of 30-33%. For patients with hematocrits below 25% before EPO, the increase averaged 1.6 +/- 0.8%/week. The dose of EPO was lower and the hematocrit response was higher than reported previously. The rate of increase in hematocrit did not correlate with small molecular weight solute removal. Mean red blood cell survival was 52 +/- 18 days. No adjustments in blood pressure (BP) medications or dry weight were required to control BP. These data and earlier experiences with recovery from the anemia of ESRD after more effective dialysis suggest that the bone marrow response to EPO may be augmented by high flux hemodialysis.

Pressure effects on roller pump blood flow during hemodialysis

Accurate measurement of blood flow during hemodialysis is essential to avoid underdialysis. When blood roller pumps are pushed to the high-flow rates demanded by high performance dialyzers, flow may be overestimated. This study examined the effect of inflow (Pa) and outflow (Pv) pressures induced by hemodialysis roller pumps on flow in vitro and in vivo. Blood flow was measured volumetrically, and with an ultrasonic flow probe, whereas Pa was adjusted from -50 to -400 torr and Pv from 50 to 300 torr. Only Pa influenced flow. At -200 torr, true flow measured volumetrically averaged 8.5% +/- 1.3% less than the blood pump revolutions per minute (RPM) meter reading. At -400 torr, the difference was 33.0% +/- 1.9%. There was no visible indication that flow was reduced to less than pump meter readings. Pv, hematocrit, and the source of pump tubing had no significant effect. Flow measured with an ultrasonic transit-time probe during routine hemodialysis in 64 patients was 9.0% +/- 2.7% less than pump meter readings when Pa varied from -180 to -220 torr. Blood pump meter readings greater than 400 ml/min were usually inaccurate because of low Pa. Prepump monitoring of arterial inflow pressure can prevent hidden reductions in blood flow that decrease dialysis efficiency.