Rapid switching from levetiracetam to brivaracetam in pharmaco-resistant epilepsy in people with and without intellectual disabilities: a naturalistic case control study

BACKGROUND

Approximately one quarter of people with an intellectual disability (PwID) have epilepsy of whom nearly three-quarters are pharmaco-resistant. There are higher reported neuropsychiatric side-effects to anti-seizure medication (ASM) in this group. Levetiracetam (LEV) is a first-line ASM with a stronger association with neuropsychiatric symptoms for PwID than other ASMs. Brivaracetam (BRV) is a newer ASM. Recent studies suggest a beneficial effect of swapping people who experience neuropsychiatric events with LEV to BRV. However, there is limited evidence of this for PwID. This evaluation analyses real world outcomes of LEV to BRV swap for PwID compared to those without ID.

METHODS

We performed a multicentre, retrospective review of clinical records. Demographic, clinical characteristics and reported adverse events of patients switched from LEV to BRV (2016-2020) were recorded at 3 months pre and 6- and 12-month post-BRV initiation. Outcomes were compared between PwID and those without and summarised using cross-tabulations and logistic regression models. A Bonferroni correction was applied.

RESULTS

Of 77 participants, 46 had ID and 52% had a past psychiatric illness. 71% participants switched overnight from LEV to BRV. Seizure reduction of > 50% was seen in 40% patients. Psychiatric illness history was predictive of having neuropsychiatric side-effects with LEV but not BRV (p = 0.001). There was no significant difference for any primary outcomes between PwID versus without ID.

CONCLUSIONS

Switching from LEV to BRV appears as well tolerated and efficacious in PwID as those without ID with over 90% still on BRV after 12 months.

A lifecycle-based evaluation of greenhouse gas emissions from the plastics industry in South Africa

ncreased production rates of plastic and limited disposal methods have fed concerns regarding environmental degradation. Whilst most of the focus is on plastic litter and marine pollution, greenhouse gas emissions of plastic over its value chains are also of interest and non-trivial at the global scale. To quantify the global warming potential of the local plastics industry, a lifecycle-based carbon footprint is presented encompassing activities such as resource extraction, polymer production and conversion, recycling, and disposal stages. The South African plastics sector is estimated to have emitted 15.8 Mt CO2 eq in 2015, with the granulate production stage bearing the highest environmental load. The consumption of fossil fuel based electricity and the burning of plastic waste also contribute notably to the overall emissions. Additionally, the recycling process in 2015 saved approximately 1.4 Mt of greenhouse gas emissions.

What material flow analysis and life cycle assessment reveal about plastic polymer production and recycling in South Africa

Global production and consumption of plastics have increased significantly in recent years. The environmental impacts associated with this trend have received growing attention internationally with single-use plastic packaging responsible for most plastic pollution. Locally, the SA Plastics Pact, the Industry Master Plan, and the National Waste Management Strategy all aim to transform the current linear sector model into a circular system by setting targets for increased collection and recycling rates and recycled content. However, the associated impacts of implementing such circular interventions have not yet been assessed across the plastics life cycle. Industrial ecology tools, material flow analysis and life cycle assessment, are used to generate mass-based indicators as well as indicators of climate damage in the form of the global warming potential. The carbon footprint of the South African plastics value chain from cradle to grave was estimated at 17.9 Mt CO2eq emissions in 2018, with 52% of these due to the local coal-based monomer production process. The end-of-life stage lacks proper waste collection for a third of the population, but contributes only 2% to the total greenhouse gas emissions, with recycling having a minimal environmental impact. Future projections of plastics production, use, disposal, and recycling for 2025 show that increasing mechanical recycling rates to achieve stated targets would start to have a significant effect on virgin polymer demand (in the order of several billion rands of sales annually) but would also reduce waste disposal by 28% relative to baseline growth and 18% below values calculated for 2018.

Numerical Modelling of Mixing in a Microfluidic Droplet Using a Two-Phase Moving Frame of Reference Approach

Droplets generated in microfluidic channels are effective self-contained micromixers and micro-reactors for use in a multiplicity of chemical synthesis and bioanalytical applications. Droplet microfluidic systems have the ability to generate multitudes of droplets with well-defined reagent volumes and narrow size distributions, providing a means for the replication of mixing within each droplet and thus the scaling of processes. Numerical modelling using computational fluid dynamics (CFD) is a useful technique for analysing and understanding the internal mixing in microfluidic droplets. We present and demonstrate a CFD method for modelling and simulating mixing between two species within a droplet travelling in straight microchannel, using a two-phase moving frame of reference approach. Finite element and level set methods were utilised to solve the equations governing the coupled physics between two-phase flow and mass transport of the chemical species. This approach had not been previously demonstrated for the problem of mixing in droplet microfluidics and requires less computational resources compared to the conventional fixed frame of reference approach. The key conclusions of this work are: (1) a limitation of this method exists for flow conditions where the droplet mobility approaches unity, due to the moving wall boundary condition, which results in an untenable solution under those conditions; (2) the efficiency of the mixing declines as the length of the droplet or plug increases; (3) the initial orientation of the droplet influences the mixing and the transverse orientation provides better mixing performance than the axial orientation and; (4) the recirculation inside the droplet depends on the superficial velocity and the viscosity ratio.

A narrative review of the epidemiology and economics of chronic wounds

Chronic wounds have a debilitating effect on the quality of life of many individuals, and the large economic impact on health system budgets warrants greater attention in policy making and condition management than is currently evident. The aim of this narrative review is to summarize the nature and extent of the chronic wound problem that confronts health systems across the world. The first section is used to highlight the underlying epidemiology relating to chronic wounds, while the second explores the economic costs associated with them and the relative efficiency of measures designed to manage them.

Design and testing of communication materials for a breastfeeding social media marketing campaign: Breastfeed4Ghana

Breastfeed4Ghana was a social media-based campaign implemented to address identified gaps in the protection, promotion, and support of breastfeeding in Ghana. This paper describes the process of campaign materials development and testing to ensure their cultural and content appropriateness. The 60 campaign materials, each consisting of an image and text message, underwent a process of creation, testing, revision, and finalization. Existing research evidence and infant and young child feeding communication tools that were culturally relevant for Ghana were used to develop the materials. All materials were tested and finalized through an iterative process that incorporated input from six focus group discussions (FGDs) with mothers, and content and technical experts. The materials were revised to ensure scientific accuracy, understandability, and cultural appropriateness of the messages, as well as alignment of the messages with the images. Finalized materials were reviewed and approved by the Ghana Food and Drugs Authority. Analysis for this paper involved summarizing and categorizing the types and sources of input as well as the research team's responses to the input received. The 60 campaign materials received a total of 132 inputs. Most inputs came from FGDs (78.4%); and most inputs were on the campaign material images. The evidence-informed process of materials creation, use of multiple input sources, and a broad-based iterative process allowed the creation of 60 evidence-based and culturally appropriate materials for a breastfeeding social media campaign in Ghana. This paper could serve as a guide for other social media campaign efforts looking to develop culturally appropriate materials.

Response rate to a single dose of vinblastine administered to dogs with treatment-naive multicentric lymphoma

Vincristine is included in vincristine, cyclophosphamide, doxorubicin and prednisone (CHOP) chemotherapy protocols, which are the gold-standard treatment for high-grade canine lymphoma. Vincristine can result in relatively high rates of gastrointestinal toxicity, whereas vinblastine is generally well tolerated and thus may represent an under-utilized and minimally toxic alternative to vincristine. Our objective was to determine the response rate and toxicity associated with a single dose of vinblastine administered to dogs with treatment-naïve, intermediate to large-cell, multicentric lymphoma. Twenty client-owned dogs were enrolled with signed owner consent. A Simon's minimax, phase II, two-stage trial was performed to test the efficacy of vinblastine administered at 2 mg/m² IV followed by a pilot trial of vinblastine at 2.5 mg/m² . No dogs were administered concurrent steroids or other chemotherapy. One out of 14 dogs receiving vinblastine at 2 mg/m² demonstrated a partial response. Three out of five dogs demonstrated a partial response to vinblastine at 2.5 mg/m² . Gastrointestinal toxicity was infrequent and low grade for both groups. The majority of dogs (80%) in the 2.5 mg/m² dosing group developed neutropenia 1-week post administration. Vinblastine was well tolerated but minimally efficacious at a dose of 2 mg/m² IV in dogs with treatment-naive, multicentric lymphoma. Because of poor response rates, treatment at this dose is not recommended. A small subset of dogs administered 2.5 mg/m² had significantly improved response rates (P = 0.04), suggesting that higher doses may have improved efficacy, although further research is indicated to confirm these preliminary findings.

Comparative Biology of Cycad Pollen, Seed and Tissue - A Plant Conservation Perspective

Cycads are the most endangered of plant groups based on IUCN Red List assessments; all are in Appendix I or II of CITES, about 40% are within biodiversity 'hotspots,' and the call for action to improve their protection is long-standing. We contend that progress in this direction will not be made until there is better understanding of cycad pollen, seed and tissue biology, which at the moment is limited to relatively few (<10%) species. We review what is known about germplasm (seed and pollen) storage and germination, together with recent developments in the application of contemporary technologies to tissues, such as isotype labelling, biomolecular markers and tissue culture. Whilst progress is being made, we conclude that an acceleration of comparative studies is needed to facilitate the integration of in situ and ex situ conservation programmes to better safeguard endangered cycads.

Levels of wound calprotectin and other inflammatory biomarkers aid in deciding which patients with a diabetic foot ulcer need antibiotic therapy (INDUCE study)

AIMS

Deciding if a diabetic foot ulcer is infected in a community setting is challenging without validated point-of-care tests. Four inflammatory biomarkers were investigated to develop a composite algorithm for mildly infected diabetic foot ulcers: venous white cell count, C-reactive protein (CRP) and procalcitonin, and a novel wound exudate calprotectin assay. Calprotectin is a marker of neutrophilic inflammation.

METHODS

In a prospective study, people with uninfected or mildly infected diabetic foot ulcers who had not received oral antibiotics in the preceding 2 weeks were recruited from community podiatry clinics for measurement of inflammatory biomarkers. Antibiotic prescribing decisions were based on clinicians' baseline assessments and participants were reviewed 1 week later; ulcer infection was defined by clinicians' overall impression from their two assessments.

RESULTS

Some 363 potential participants were screened, of whom 67 were recruited, 29 with mildly infected diabetic foot ulcers and 38 with no infection. One participant withdrew early in each group. Ulcer area was 1.32 cm² [interquartile range (IQR) 0.32-3.61 cm² ] in infected ulcers and 0.22 cm² (IQR 0.09-1.46 cm² ) in uninfected ulcers. Baseline CRP for mild infection was 9.00 mg/ml and 6.00 mg/ml for uninfected ulcers; most procalcitonin levels were undetectable. Median calprotectin level in infected diabetic foot ulcers was 1437 ng/ml and 879 ng/ml in uninfected diabetic foot ulcers. Area under the receiver operating characteristic curve for a composite algorithm incorporating calprotectin, CRP, white cell count and ulcer area was 0.68 (95% confidence intervals 0.52-0.82), sensitivity 0.64, specificity 0.81.

CONCLUSIONS

A composite algorithm including CRP, calprotectin, white cell count and ulcer area may help to distinguish uninfected from mildly infected diabetic foot ulcers. Venous procalcitonin is unhelpful for mild diabetic foot ulcer infection.

Alginate Encapsulation to Enhance Biopreservation Scope and Success: A Multidisciplinary Review of Current Ideas and Applications in Cryopreservation and Non-Freezing Storage

BACKGROUND

The development of encapsulation technologies has played an important role in improving cryopreservation outcomes for many cell and tissue types over the past 20 years. Alginate encapsulation cryopreservation (AECryo) has been incorporated into a range of applications in biotechnology, species conservation and clinical therapies, using cells from many different phyla, including higher plants, animal and human cells. This review describes the background to the origins of AECryo, the development of AECryo in higher plant tissues, broadening to current applications in algal conservation, the roles for AECryo in preserving phytodiversity, fungal species and in animal and human cells.

OBJECTIVE

The main aims are to provide information resources on AECryo in different areas of biology and to stimulate new ideas for wider applications and future improvement. The translation of this useful biopreservation strategy into new opportunities for cell cryopreservation and storage at non-freezing temperatures are also discussed.

New horizons in the understanding of the causes and management of diabetic foot disease: report from the 2017 Diabetes UK Annual Professional Conference Symposium

Diabetes-related foot disease remains a common problem. For wounds, classic teaching recommends the treatment of any infection, offloading the wound and ensuring a good blood supply, as well as ensuring that the other modifiable risk factors are addressed and optimized. There remain, however, several questions about these and other aspects of the care of diabetes-related foot disease. Some of these questions are addressed in the present report; in particular, the impact of newer technologies in the identification of any organisms present in a wound, as well as the use of novel approaches to treat infections. The use of new remote sensing technology to identify people at risk of developing foot ulceration is also considered, in an attempt to allow early intervention and prevention of foot ulcers. The psychological impact of foot disease is often overlooked, but with an increasing number of publications on the subject, the cause-and-effect role that psychology plays in foot disease, such as ulcers and Charcot neuroarthropathy, is considered. Finally, because of heterogeneity in diabetic foot studies, comparing results is difficult. A recently published document focusing on ensuring a standardized way of reporting foot disease trials is discussed.

The administration of intermittent parathyroid hormone affects functional recovery from trochanteric fractured neck of femur: a randomised prospective mixed method pilot study

Aims

We wished to assess the feasibility of a future randomised controlled trial of parathyroid hormone (PTH) supplements to aid healing of trochanteric fractures of the hip, by an open label prospective feasibility and pilot study with a nested qualitative sub study. This aimed to inform the design of a future powered study comparing the functional recovery after trochanteric hip fracture in patients undergoing standard care, versus those who undergo administration of subcutaneous injection of PTH for six weeks.

Patients and Methods

We undertook a pilot study comparing the functional recovery after trochanteric hip fracture in patients 60 years or older, admitted with a trochanteric hip fracture, and potentially eligible to be randomised to either standard care or the administration of subcutaneous PTH for six weeks. Our desired outcomes were functional testing and measures to assess the feasibility and acceptability of the study.

Results

A total of 724 patients were screened, of whom 143 (20%) were eligible for recruitment. Of these, 123 were approached and 29 (4%) elected to take part. However, seven patients did not complete the study. Compliance with the injections was 11 out of 15 (73%) showing the intervention to be acceptable and feasible in this patient population.

Take home message: Only 4% of patients who met the inclusion criteria were both eligible and willing to consent to a study involving injections of PTH, so delivering this study on a large scale would carry challenges in recruitment and retention. Methodological and sample size planning would have to take this into account. PTH administration to patients to enhance fracture healing should still be considered experimental.

Cite this article: Bone Joint J 2016;98-B:840–5.

Understanding the LCA and ISO water footprint: A response to Hoekstra (2016) "A critique on the water-scarcity weighted water footprint in LCA"

Water footprinting has emerged as an important approach to assess water use related effects from consumption of goods and services. Assessment methods are proposed by two different communities, the Water Footprint Network (WFN) and the Life Cycle Assessment (LCA) community. The proposed methods are broadly similar and encompass both the computation of water use and its impacts, but differ in communication of a water footprint result. In this paper, we explain the role and goal of LCA and ISO-compatible water footprinting and resolve the six issues raised by Hoekstra (2016) in "A critique on the water-scarcity weighted water footprint in LCA". By clarifying the concerns, we identify both the overlapping goals in the WFN and LCA water footprint assessments and discrepancies between them. The main differing perspective between the WFN and LCA-based approach seems to relate to the fact that LCA aims to account for environmental impacts, while the WFN aims to account for water productivity of global fresh water as a limited resource. We conclude that there is potential to use synergies in research for the two approaches and highlight the need for proper declaration of the methods applied.

Measurement of Peripheral Venous Oxygen Saturation in the Leg Using Near-Infrared Spectroscopy

Background:

It has been suggested that poor healing of wounds may be associated with reduced tissue oxygenation. A non-invasive method of assessing peripheral venous oxygenation has been investigated.

Method:

Changes in oxyhaemoglobin (O2Hb), deoxyhaemoglobin (HHb), oxidized cytochrome aa3 (cyt aa3) and total haemoglobin (tHb) were monitored in the left lower leg of seven healthy volunteers. A short period of venous occlusion was achieved by rapidly inflating a sphygmomanometer cuff placed around the leg to 60 mmHg. The changes in O2Hb and tHb, with respect to the baseline readings, were evaluated. PSvO2 was calculated from (ΔO2Hb/ΔtHb) × 100%.

Results:

From 17 sets of readings on the seven volunteers the median PSvO2 calculated was 64% (range 50–86%).

Conclusion:

This method appears to be a simple means of evaluating PSvO2. A change in cyt aa3 was often seen associated with the venous occlusion.

Optimization of Water Content for the Cryopreservation Of Allium sativum In Vitro Cultures by Encapsulation-Dehydration

BACKGROUND

There is a general requirement to determine and correlate water content to viability for the standardization of conservation protocols to facilitate effective cryostorage of plant germplasm.

OBJECTIVE

This study examined water content as a critical factor to optimize the cryostorage of Allium sativum.

MATERIALS AND METHODS

Stem discs were excised from post-harvest, stored bulbs prior to cryopreservation by encapsulation-dehydration and water content was determined gravimetrically.

RESULTS

Survival of cryopreserved stem discs was 42.5 %, with 22.5 % exhibiting shoot regrowth following 6 h desiccation. Gravimetric data demonstrated a correlation between water content corresponding with survival / regrowth from desiccated, cryopreserved stem discs. For encapsulated stem discs a 25 % residual moisture and corresponding water content of 0.36 g H2O g^-1 d.wt correlated with maximal survival following ~6.5 h of desiccation.

CONCLUSION

The data concurs with the literature suggesting the formation of a stable vitrified state and a 'window' for optimal survival and regrowth that is between 6 - 10 h desiccation. Further studies using differential scanning calorimetry (DSC) are suggested to substantiate these findings.

Duration of ruptured membranes and mother-to-child HIV transmission: a prospective population-based surveillance study

OBJECTIVE

To investigate the association between duration of rupture of membranes (ROM) and mother-to-child HIV transmission (MTCT) rates in the era of combination antiretroviral therapy (cART).

DESIGN

The National Study of HIV in Pregnancy and Childhood (NSHPC) undertakes comprehensive population-based surveillance of HIV in pregnant women and children.

SETTING

UK and Ireland.

POPULATION

A cohort of 2398 singleton pregnancies delivered vaginally, or by emergency caesarean section, in women on cART in pregnancy during the period 2007-2012 with information on duration of ROM; HIV infection status was available for 1898 infants.

METHODS

Descriptive analysis of NSHPC data.

MAIN OUTCOME MEASURES

Rates of MTCT.

RESULTS

In 2116 pregnancies delivered at term, the median duration of ROM was 3 hours 30 minutes (interquartile range, IQR 1-8 hours). The overall MTCT rate for women delivering at term with duration of ROM ≥4 hours was 0.64% compared with 0.34% for ROM <4 hours, with no significant difference between the groups (OR 1.90, 95% CI 0.45-7.97). In women delivering at term with a viral load of <50 copies/ml, there was no evidence of a difference in MTCT rates with duration of ROM ≥4 hours, compared with <4 hours (0.14% for ≥4 hours versus 0.12% for <4 hour; OR 1.14, 95% CI 0.07-18.27). Among infants born preterm with infection status available, there were no transmissions in 163 deliveries where the maternal viral load was <50 copies/ml.

CONCLUSIONS

No association was found between duration of ROM and MTCT in women taking cART.

TWEETABLE ABSTRACT

Rupture of membranes of more than 4 hours is not associated with MTCT of HIV in women on effective ART delivering at term.

Translating cryobiology principles into trans-disciplinary storage guidelines for biorepositories and biobanks: a concept paper

Low temperatures are used routinely to preserve diverse biospecimens, genetic resources and non-viable or viable biosamples for medical and clinical research in hospital-based biobanks and non-medical biorepositories, such as genebanks and culture, scientific, museum, and environmental collections. However, the basic knowledge underpinning preservation can sometimes be overlooked by practitioners who are unfamiliar with fundamental cryobiological principles which are more usually described in research literature rather than in quality and risk management documents. Whilst procedures vary, low temperature storage is a common requirement and reaching consensus as to how best it is applied could facilitate the entire biopreservation sector. This may be achieved by encouraging an understanding of cryoprotection theory and emphasizing the criticality of thermal events (glass transitions, ice nucleation, thawing) for sample integrity, functionality and stability. The objective of this paper is to inspire diverse biopreservation sectors to communicate more clearly about low temperature storage and, raise awareness of the importance of cryobiology principles to field newcomers and biopreservation practitioners, by considering how the principles may be translated into evidence-based guidelines for biobank and biorepository operations.

A life cycle model to enable research of cryostorage recalcitrance in temperate woody species: the case of sitka spruce (Picea sitchensis)

Empirical testing of protocols and fundamental investigations are the approaches usually applied to study germplasm storage recalcitrance in temperate plants. However, they can fall short of practicable solutions, even after exhaustive experimentation, and the generation of negative survival data makes it difficult to plan further investigations. Picea sitchensis somatic embryos are amenable to cryopreservation whereas in vitro shoot meristems, although able to survive, are incapable of sustained recovery. Differential Scanning Calorimetry (DSC) revealed that these disparate responses could not be attributed to biophysical factors. A model is presented hypothesising that in some cases life cycle adaptations (cold hardening, dormancy) may have opposing influences on survival causing delayed-onset, cryogenically-induced loss of viability in temperate tree species.

British HIV Association guidelines for the management of HIV infection in pregnant women 2012

The overall purpose of these guidelines is to provide guidance on best clinical practice in the treatment and management of human immunodeficiency virus (HIV)-positive pregnant women in the UK. The scope includes guidance on the use of antiretroviral therapy (ART) both to prevent HIV mother-to-child transmission (MTCT) and for the welfare of the mother herself, guidance on mode of delivery and recommendations in specific patient populations where other factors need to be taken into consideration,such as coinfection with other agents. The guidelines are aimed at clinical professionals directly involved with, and responsible for, the care of pregnant women with HIV infection.

Modulation of nutrient sensing nuclear hormone receptors promotes weight loss through appetite suppression in mice

AIM

Peroxisome proliferator activated receptors (PPARs) are nuclear receptors involved in glucose and lipid metabolism. Three isoforms of PPARs have been identified with different tissue distribution and biological functions. Although the pharmacology of each receptor is well studied, the physiological effect of simultaneous activation of PPARalpha, gamma and delta is only starting to emerge. We sought to determine the biological effects of a novel PPAR pan activator and elucidate the physiological mechanisms involved.

METHODS

Ob/ob, diet-induced obese (DIO) or PPARalpha knockout mice were administered a novel agonist that activates all PPARs to various degrees to determine the effect on body weight, body composition, food intake and energy expenditure. In addition, serum parameters including glucose, insulin, triglycerides and ketone bodies as well as tissue acylcarnitine were evaluated. The effect of the novel agonist on liver and skeletal muscle histopathology was also studied.

RESULTS

We report that simultaneous activation of all PPARs resulted in substantial weight loss in ob/ob and DIO mice. Consistent with known PPAR pharmacology, we observed that agonist treatment increased lipid oxidation, although appetite suppression was mainly responsible for the weight loss. Agonist-induced weight loss was completely absent in PPARalpha knockout mice suggesting that PPARalpha pharmacology was the major contributor to weight regulation in mice.

CONCLUSIONS

Our work provides evidence that simultaneous activation of PPARalpha, gamma and delta decreases body weight by regulating appetite. These effects of the pan agonist were completely absent in PPARalpha knockout mice, suggesting that PPARalpha pharmacology was the major contributor to weight loss.

Detection of 8-hydroxy-2-deoxyguanosine as a marker of oxidative damage in DNA and germplasm exposed to cryogenic treatments

An HPLC method has been optimised to measure 8-hydroxy-2-deoxyguanosine (8OHdG) in DNA and germplasm with the objective of using the adduct as a marker of cryostorage stability. The encapsulation-dehydration cryopreservation protocol was adapted as a model system for assessing the formation of 8OHdG from alginate-encapsulated DNA of calf thymus (CT) and currant species (Ribes) exposed to temperatures of -20 and -196 degree C. The presence of H2O2 exacerbated the formation of 8OHdG in encapsulated CT and Ribes DNA. Production of the oxidized adduct was lower in the plant system. A reduction in residual water following osmotic dehydration and evaporative desiccation was associated with reduced adduct formation in encapsulated DNA. No significant differences in 8OHdG adduct formation were observed in plants regenerated from cryopreserved Ribes meristems derived from genotypes known to have differential tolerance to cryopreservation.

The prediction of pregnancy outcome by haemoglobin measurement before 20 weeks` gestation

Maternal haemoglobin levels were measured before 21 weeks' gestation in a prospective study of 1276 singleton pregnancies. Reference ranges were constructed and then applied to a further cohort of 1227 singleton pregnancies to determine the ability of haemoglobin level before 21 weeks' gestation to predict pregnancy outcome. Haemoglobin level decreased significantly with advancing gestational age from 6 to 21 weeks (P < 0.05). Low haemoglobin level was associated with a decreased risk of pregnancy-induced hypertension (adjusted odds ratio 0.51, 95% CI 0.35-0.74). High haemoglobin level was positively correlated with subsequent pregnancy-induced hypertension (P = 0.002) with values > 95th percentile for gestational age having positive and negative predictive values of 33% and 94% respectively. Haemoglobin values (either high or low) were not predictive of proteinuric pre-eclampsia, preterm prelabour rupture of the membranes, preterm birth, low birth weight or the need for neonatal resuscitation of admission to the special care baby unit. The finding of a high maternal haemoglobin before 21 weeks' gestation is not sufficiently predictive of pregnancyinduced hypertension to be of clinical use, but the ability of a low level to predict favourable outcome may be of use in a scoring system designed to identify women suitable for midwifery-based care.

Comparative analysis of distribution and abundance of West Nile and eastern equine encephalomyelitis virus vectors in Suffolk County, New York, using human population density and land use/cover data

Five years of CDC light trap data from Suffolk County, NY, were analyzed to compare the applicability of human population density (HPD) and land use/cover (LUC) classification systems to describe mosquito abundance and to determine whether certain mosquito species of medical importance tend to be more common in urban (defined by HPD) or residential (defined by LUC) areas. Eleven study sites were categorized as urban or rural using U.S. Census Bureau data and by LUC types using geographic information systems (GISs). Abundance and percent composition of nine mosquito taxa, all known or potential vectors of arboviruses, were analyzed to determine spatial patterns. By HPD definitions, three mosquito species, Aedes canadensis (Theobald), Coquillettidia perturbans (Walker), and Culiseta melanura (Coquillett), differed significantly between habitat types, with higher abundance and percent composition in rural areas. Abundance and percent composition of these three species also increased with freshwater wetland, natural vegetation areas, or a combination when using LUC definitions. Additionally, two species, Ae. canadensis and Cs. melanura, were negatively affected by increased residential area. One species, Aedes vexans (Meigen), had higher percent composition in urban areas. Two medically important taxa, Culex spp. and Aedes triseriatus (Say), were proportionally more prevalent in residential areas by LUC classification, as was Aedes trivittatus (Coquillett). Although HPD classification was readily available and had some predictive value, LUC classification resulted in higher spatial resolution and better ability to develop location specific predictive models.

Walking performance in people with diabetic neuropathy: benefits and threats

AIMS/HYPOTHESIS

Walking is recommended as an adjunct therapy to diet and medication in diabetic patients, with the aim of improving physical fitness, glycaemic control and body weight reduction. Therefore we evaluated walking activity on the basis of capacity, performance and potential risk of plantar injury in the diabetic population before it can be prescribed safely.

SUBJECTS, MATERIALS AND METHODS

Twenty-three subjects with diabetic neuropathy (DMPN) were compared with 23 patients with current diabetic foot ulcers, 16 patients with partial foot amputations and 22 patients with trans-tibial amputations. The capacity for walking was measured using a total heart beat index (THBI). Gait velocity and average daily strides were measured to assess the performance of walking, and its impact on weight-bearing was studied using maximum peak pressure.

RESULTS

THBI increased (p<0.01) and gait velocity and daily stride count fell (p<0.001 for both) with progression of foot complications. The maximum peak pressures over the affected foot of patients with diabetic foot ulcers (p<0.05) and partial foot amputations (p<0.01) were higher than in the group with DMPN. On the contralateral side, the diabetic foot ulcer group showed higher maximum peak pressure over the total foot (p<0.05), and patients with partial foot amputations (p<0.01) and trans-tibial amputations (p<0.05) showed higher maximum peak pressure over the heel.

CONCLUSIONS/INTERPRETATION

Walking capacity and performance decrease with progression of foot complications. Although walking is recommended to improve fitness, it cannot be prescribed in isolation, considering the increased risk of plantar injury. For essential walking we therefore recommend the use of protective footwear. Walking exercise should be supplemented by partial or non-weight-bearing exercises to improve physical fitness in diabetic populations.