Exploring the diets of mothers and their partners during pregnancy: Findings from the Queensland Family Cohort pilot study

AIM

Modifiable behaviours during the first 1000 days of life influence developmental trajectories of adult chronic diseases. Despite this, sub-optimal dietary intakes during pregnancy and excessive gestational weight gain are common. Very little is known about partners' dietary patterns and the influence on women's pregnancy dietary patterns. We aimed to examine dietary intake during pregnancy among women and their partners, and gestational weight gain patterns in the Queensland Family Cohort pilot study.

METHODS

The Queensland Family Cohort is a prospective, observational study piloted at a Brisbane (Australia) tertiary maternity hospital from 2018 to 2021. Participant characteristics, weight gain, dietary and nutrient intake were assessed.

RESULTS

Data were available for 194 pregnant women and their partners. Poor alignment with Australian Guide to Healthy Eating recommendations was observed. Highest alignment was for fruit (40% women) and meat/alternatives (38% partners) and lowest for breads/cereals (<1% women) and milk/alternatives (13% partners). Fewer women (4.4%-60.3%) than their partners (5.4%-92.3%) met guidelines for all micronutrient intakes from food alone, particularly folic acid, iodine, and iron. Women were more likely to meet daily recommendations for fruit, vegetables, dairy, bread/cereals, and meat/alternatives when their partners also met recommendations. Women with a higher pre-pregnancy body mass index were more likely to gain above recommended weight gain ranges.

CONCLUSIONS

In this contemporary cohort of pregnant women and their partners, sub-optimal dietary patterns and deficits in some nutrients were common. There is an urgent need for evidence-informed public health policy and programs to improve diet quality during pregnancy due to intergenerational effects.

Rural healthcare delivery and maternal and infant outcomes for diabetes in pregnancy: A systematic review

Aim

The aim of this systematic review was to examine the literature regarding rural healthcare delivery for women with any type of diabetes in pregnancy, and subsequent maternal and infant outcomes.

Methods

Eight databases were searched in September 2020, including Medline, EMCare, CINAHL, EMBASE, Maternity and Infant Care, Cochrane, Rural and Remote Health and Aboriginal and Torres Strait Islander Health bibliography. Studies from high‐income countries in rural, regional or remote areas with interventions conducted during the antenatal period were included. Intervention details were reported using the template for intervention description and replication template. Two reviewers independently assessed for risk of bias using the RoB2 and ROBINS I tools.

Results

Three articles met the inclusion criteria: two conducted in Australia and one in the United States. A multidisciplinary approach was reported in two of the included studies, which were modified specifically for their respective rural settings. All three studies reported rates of caesarean section, birthweight (grams) and gestational age at birth as maternal and infant outcomes. One study was considered at moderate risk of bias, and two studies were at serious risk of bias.

Conclusion

There is a significant gap in research relating to healthcare delivery for women with diabetes in pregnancy in rural areas. This lack of research is concerning given that 19% of individuals in high‐income countries reside rurally. Further research is required to understand the implications of healthcare delivery models for diabetes in pregnancy in rural areas.

Current practice, perceived barriers and resource needs related to measurement of dietary intake, analysis and interpretation of data: A survey of Australian nutrition and dietetics practitioners and researchers

AIM

To inform future training and professional development for individuals who measure, analyse and interpret dietary intake data.

METHODS

A cross-sectional online survey was distributed via e-newsletter to members of Dietitians Australia, Dietitian Connection and Nutrition Society Australia. The survey included 37 questions on three key areas of practice: (a) methods used to assess dietary intake, (b) barriers faced when conducting dietary intake assessment and (c) resources needed to optimise collection, analysis and interpretation of dietary intake data.

RESULTS

Of 173 responses, 103 respondents provided complete data over 2 weeks. Of these, 76% were APDs. The majority (90%) indicated that dietary assessment was important in their role. Respondents (63%) undertook dietary assessments to inform individual/patient care. When assessing intakes, the majority (79%) were interested in examining food/food group intakes. Paper based methods were most commonly used and diet histories, food frequency questionnaires and 24-hour recalls were the most frequently used methods. The biggest barrier identified to implementing dietary assessment methods into practice was participant burden. Over a third of respondents reported they had received specific training on selecting an appropriate dietary assessment method. The majority of respondents (83%) believed having access to a dietary assessment methods toolkit would be useful.

CONCLUSION

Survey findings provide insight into the need for further capacity building strategies, including professional development to improve collection, analysis and interpretation of dietary intake for Australian nutritionists and dietitians. The creation of online resources could help overcome identified barriers and provide a link to best practice methodologies and contemporary tools.

Maternal Diet Quality, Body Mass Index and Resource Use in the Perinatal Period: An Observational Study

The impact of pre-pregnancy obesity and maternal diet quality on the use of healthcare resources during the perinatal period is underexplored. We assessed the effects of body mass index (BMI) and diet quality on the use of healthcare resources, to identify whether maternal diet quality may be effectively targeted to reduce antenatal heath care resource use, independent of women’s BMI. Cross-sectional data and inpatient medical records were gathered from pregnant women attending publicly funded antenatal outpatient clinics in Newcastle, Australia. Dietary intake was self-reported, using the Australian Eating Survey (AES) food frequency questionnaire, and diet quality was quantified from the AES subscale, the Australian Recommended Food Score (ARFS). Mean pre-pregnancy BMI was 28.8 kg/m² (range: 14.7 kg/m²–64 kg/m²). Mean ARFS was 28.8 (SD = 13.1). Higher BMI was associated with increased odds of caesarean delivery; women in obese class II (35.0–39.9 kg/m²) had significantly higher odds of caesarean delivery compared to women of normal weight, (OR = 2.13, 95% CI 1.03 to 4.39; p = 0.04). Using Australian Refined Diagnosis Related Group categories for birth admission, the average cost of the birth admission was $1348 more for women in the obese class II, and $1952 more for women in the obese class III, compared to women in a normal BMI weight class. Higher ARFS was associated with a small statistically significant reduction in maternal length of stay (RR = 1.24, 95% CI 1.00, 1.54; p = 0.05). There was no evidence of an association between ARFS and mode of delivery or “midwifery-in-the-home-visits”.

Exploring core food accessibility in Tamworth, NSW, Australia

INTRODUCTION

A lack of core food accessibility negatively affects diet quality, potentially increasing the prevalence of health risk factors such as obesity. The purpose of this study was to investigate core food access in an Australian regional center through the use of data visualization techniques.

METHODS

Supermarkets were used as a proxy for core food accessibility and were identified and mapped by town region with a combination of Google Maps and Stata/IC 15.1 software. A statistical analysis comparing the demographics of each town region was also completed using Stata.

RESULTS

The maps generated suggest that there may be a disparity in core food accessibility between town regions. The analysis of demographics demonstrated that one town region had a greater proportion of disadvantaged residents, with statistically significant variation between regions.

CONCLUSION

Data visualization and analysis may be a useful tool for clinicians to communicate accessibility information experienced by local residents. This need not be limited to food accessibility and extended to health services.

The feasibility of a personality targeted intervention for addictive overeating: FoodFix

Recent reviews have identified potential treatment targets for addictive overeating. These include: motivational interviewing, development of specific coping strategies for emotional regulation and the use of harm minimisation strategies based on interventions for substance use disorders. However, there is very little experiential evidence. The aim of this study was to determine the feasibility of a personality-targeted motivational interviewing intervention in adults above the healthy-weight range with symptoms of addictive eating, to reduce symptoms of addictive overeating and improve dietary profiles. Individuals with overweight and obesity (BMI >25 kg/m²) with addictive eating as defined by the modified Yale Food Addiction Scale (mYFAS) were recruited to a three-session intervention held over 3 months. Sessions were conducted by telehealth and facilitated by dietitians. Fifty-two individuals were randomised to either intervention or control (mean age 43.6 ± 12.2yrs, mean BMI 36.7 ± 6.8 kg/m², 96% female). At three month follow up, there were significant reductions from baseline (BL) for both groups in total YFAS 2.0 symptoms, however, these changes were not significantly different between groups (intervention BL 8.0 ± 2.7; 3-months 6.5 ± 3.8, control BL 8.1 ± 2.5; 3-months 6.9 ± 3.9, p > 0.05). At 3 months the intervention group significantly reduced their energy from non-core foods compared with control (intervention BL 48% energy/day; 3-months 38%, control BL 41% energy/day; 3-months 38%, p < 0.01). The FoodFix intervention provides insight to the development of future management interventions for addictive eating.

Dietitians Australia position statement on telehealth

It is the position of Dietitians Australia that clients can receive high‐quality and effective dietetic services such as Medical Nutrition Therapy (MNT) delivered via telehealth. Outcomes of telehealth‐delivered dietetic consultations are comparable to those delivered in‐person, without requiring higher levels of additional training nor compromising quality of service provision. Dietitians Australia recommends that policy makers and healthcare funders broaden the recognition for telehealth‐delivered dietetic consultations as a responsive and cost‐effective alternative or complement to traditional in‐person delivery of dietetic services. The successful implementation of telehealth can help to address health and service inequalities, improve access to effective nutrition services, and support people with chronic disease to optimise their diet‐related health and well‐being, regardless of their location, income or literacy level, thereby addressing current inequities.

Interventions including a nutrition component aimed at managing gestational weight gain or postpartum weight retention: a systematic review and meta-analysis

OBJECTIVES

The objective of this systematic review was to evaluate the effectiveness of interventions that include a nutrition component aimed at improving gestational weight gain and/or postpartum weight retention.

INTRODUCTION

Excessive gestational weight gain and postpartum weight retention increase the risk of adverse maternal and neonatal outcomes. Current evidence comprises many interventions targeting gestational weight gain and postpartum weight retention that incorporate a nutrition component. To date, no review has synthesized evidence from pregnancy through the postpartum period or described the intervention approaches in detail.

INCLUSION CRITERIA

The review included women (≥18 years) during pregnancy and/or up to 12 months postpartum. Studies were included if they involved a weight management intervention with a nutrition component and had the primary objective of determining the impact of gestational weight gain and/or postpartum weight change. Interventions were compared to usual care (i.e. control conditions with no intervention or wait-list control or standard pregnancy or postpartum care) or "other" (alternative intervention). The review considered randomized controlled trials published between 1980 and January 21, 2016. Studies that included a weight related primary outcome measured during pregnancy and/or postpartum were included.

METHODS

Seven databases were searched and the reference lists of included studies were searched for additional studies not previously identified. Two independent reviewers assessed the methodological quality of studies using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI SUMARI). The JBI SUMARI standardized data extraction tool was used to extract data. A narrative synthesis was undertaken to qualitatively synthesize included studies, with meta-analyses used to pool weight outcome data from studies conducted separately for pregnancy and postpartum. Effect sizes for meta-analyses have been expressed as weighted mean differences (95% confidence intervals).

RESULTS

The search yielded 4063 articles of which 48 articles from 39 studies were included. Eleven of 20 studies during pregnancy reported significant reductions in gestational weight gain with the intervention when compared to control groups. One of five studies where the intervention was conducted during both pregnancy and postpartum reported statistically significant reductions in gestational weight gain, and postpartum weight retention between intervention and control groups. Nine of 14 studies conducted after childbirth reported statistically significant intervention effects, indicating lesser postpartum weight retention. Random effects meta-analyses indicated that despite considerable heterogeneity, interventions conducted during pregnancy (-1.25 kg; 95% CI: -2.10 kg, -0.40 kg; p = 0.004), and postpartum (-3.25 kg; 95% CI: -4.69 kg, -1.82 kg; p < 0.001) were significantly more effective at improving weight outcomes compared to usual care or other interventions. Most studies were of moderate quality due to lack of clarity in describing study details required for appraising methodological quality. Few interventions were conducted from pregnancy through the postpartum period (n = 5). Limited interventions adopted online modalities in intervention delivery (n = 4). Intention-to-treat analysis was used in only 12 studies.

CONCLUSIONS

The pregnancy and postpartum period presents a unique opportunity to engage women in interventions to help optimize lifestyle behaviors for weight management, however the optimal approach is unclear. Improving consistency in intervention implementation and reporting will improve future evidence synthesis.

Investigating the Efficacy and Cost-Effectiveness of Technology-Delivered Personalized Feedback on Dietary Patterns in Young Australian Adults in the Advice, Ideas, and Motivation for My Eating (Aim4Me) Study: Protocol for a Randomized Controlled Trial

Background

Web-based health interventions may be easier to access and time efficient relative to face-to-face interventions and therefore may be the most appropriate mode to engage young adults.

Objective

This study aims to investigate the impact of 3 different levels of personalized web-based dietary feedback and support on changes in diet quality.

Methods

The Advice, Ideas, and Motivation for My Eating (Aim4Me) study is a 12-month assessor-blinded, parallel-group randomized controlled trial evaluating the impact of 3 levels of web-based feedback on diet quality, measured using the Australian Recommended Food Score (ARFS). Participants (N=2570) will primarily be recruited via web-based methods and randomized to 1 of 3 groups. Group 1 (control) will receive the Healthy Eating Quiz, a web-based dietary assessment tool that generates a brief feedback report on diet quality. Individuals randomized to this group can use the brief feedback report to make positive dietary changes. Group 2 will receive the Australian Eating Survey, a web-based dietary assessment tool that generates a comprehensive feedback report on diet quality as well as macro- and micronutrient intake. Group 2 will use the comprehensive feedback report to assist in making positive dietary changes. They will also have access to the Aim4Me website with resources on healthy eating and tools to set goals and self-monitor progress. Group 3 will receive the same intervention as Group 2 (ie, the comprehensive feedback report) in addition to a tailored 30-min video consultation with an accredited practicing dietitian who will use the comprehensive feedback report to assist individuals in making positive dietary changes. The self-determination theory was used as the framework for selecting appropriate website features, including goal setting and self-monitoring. The primary outcome measure is change in diet quality. The completion of questionnaires at baseline and 3, 6, and 12 months will be incentivized with a monetary prize draw.

Results

As of December 2019, 1277 participants have been randomized.

Conclusions

The web-based delivery of nutrition interventions has the potential to improve dietary intake of young adults. However, the level of support required to improve intake is unknown.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618000325202; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374420

International Registered Report Identifier (IRRID)

DERR1-10.2196/15999

Light-induced high-spin state in ZnO nanoparticles

The effects of white-light irradiation on ∼15 nm diameter ZnO nanoparticles are investigated by means of electron paramagnetic resonance, near liquid-nitrogen and liquid-helium temperatures. Under dark conditions, usual core- and surface-defects are detected, respectively, at g = 1.960 and g = 2.003. Under white-light illumination, the core-defect signal intensity is strongly increased, which is to be correlated to the light-induced conductivity's augmentation. Beside, a four-lines structure appears, with the same gravity center as that of the surface defects. Simulations and intensity power-dependence measurements show that this four-line-structure is very likely to arise from a localized high spin S = 2, induced by light irradiation, and subjected to a weak axial anisotropy. At 85 K, this high-spin state can last several hours after the light-irradiation removal, probably due to highly spin-forbidden recombination process. The possible excited resonant complexes at the origin of this signal are discussed. Other light-induced S = 1/2-like centers are detected as well, which depend on the nanoparticles growth conditions.

The comparative validity of a brief diet screening tool for adults: The Fruit And Vegetable VAriety index (FAVVA)

BACKGROUND & AIMS

A brief assessment tool on frequency and variety of fruit and vegetable intake could provide a cost-effective and sustainable approach to improving diet. The primary aim was to evaluate the comparative validity of a brief index of Fruit And Vegetable VAriety (FAVVA) relative to food and nutrient intakes derived from a comprehensive food frequency questionnaire (FFQ). The secondary aim was to evaluate the FAVVA index in relation to fasting plasma carotenoid concentrations.

METHODS

Dietary intakes and fasting plasma carotenoid concentrations of 99 overweight and obese adults (49.5% female; 44.6 ± 9.9 years) were assessed at baseline and 3-months. Food and nutrient intakes were assessed using the Australian Eating Survey (AES) FFQ. The FAVVA index was derived from a sub-set of 35 AES questions related to fruit and vegetable intake frequency and variety. Associations were assessed using Spearman's correlation coefficients and linear regression analysis, and agreement using weighted kappa (K_w).

RESULTS

Total FAVVA score demonstrated moderate to strong, significant (all p < 0.01) correlations with total daily intakes of vegetables (r = 0.75), vitamin C (r = 0.71), fruit (r = 0.66), vitamin A (r = 0.49), fibre (r = 0.49), potassium (r = 0.46), magnesium (r = 0.39), iron (r = 0.26), riboflavin (r = 0.24), calcium (r = 0.23), zinc (r = 0.20) and niacin equivalent (r = 0.20). These associations remained significant in the adjusted regression analyses and agreement testing. Total FAVVA was significantly correlated with plasma carotenoid concentrations (μg/dL) of α-carotene (r = 0.22, p < 0.01), β-carotene (r = 0.26, p < 0.001), β-cryptoxanthin (r = 0.22, p < 0.01) and total carotenoids (r = 0.18, p < 0.05). The associations with α-carotene (β = 0.09, p < 0.001), β-carotene (β = 0.42, p < 0.05) and total plasma carotenoids (β = 0.85, p < 0.05) remained significant in the adjusted regression analyses and for agreement testing.

CONCLUSIONS

FAVVA is suitable as a brief tool to rank frequency and variety of fruit and vegetable intake.

The effect of weight management interventions that include a diet component on weight-related outcomes in pregnant and postpartum women: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

What are the effects of weight management interventions that include a diet component on weight-related outcomes in pregnant and postpartum women?The primary objective of this systematic review is to evaluate the effectiveness of weight management interventions which include a diet component and are aimed at limiting gestational weight gain and postpartum weight retention in women.The second objective of this systematic review is to investigate included intervention components with respect to effect on weight-related outcomes. This may include, but is not limited to: length of intervention, use of face-to-face counselling, group or individual consultations, use of other interventions components including exercise, use of goals and use of support tools like food diaries, coaching, including email or text message support.

BACKGROUND

Around half of all women of reproductive age are either overweight or obese, with women aged 25-34 years having a greater risk of substantial weight gain compared with men of all ages. Excessive gestational weight gain (GWG) and postpartum weight retention (PPWR) may play a significant role in long term obesity. Having one child doubles the five- and 10-year obesity incidence for women, with many women who gain excessive weight during pregnancy remaining obese permanently. Excessive GWG and/or PPWR can also significantly contribute to short- and long-term adverse health outcomes for mother, baby and future pregnancies.Maternal obesity increases the risk of pregnancy related complications such as pre-eclampsia, gestational diabetes mellitus, stillbirth and the rate of caesarean section. Childhood obesity is a further long term complication of maternal obesity for offspring, which may persist in to adulthood. Excess GWG is also a risk factor for PPWR both in the short and long-term. Nehring et al. conducted a meta-analysis with over 65,000 women showing that, compared to women who gained weight within recommendations during pregnancy, women with GWG above Institute of Medicine weight gain recommendations, retained an additional 3.1 kg and 4.7kg after three and greater than or equal to 15 years postpartum, respectively. The health risk associated with PPWR is highlighted in a study of 151,025 Swedish women followed between 1992 and 2001.The study identified the risk of adverse pregnancy outcomes for those who gained three or more units of Body Mass Index (kg/m2) between consecutive pregnancies (an average of two years) was much higher compared with women whose BMI changed from -1.0 and 0.9 units. Long-term chronic disease risk may also be affected by PPWR as weight retention at the end of the first year post-partum has been found to be a predictor of maternal overweight 15 years later.With around 14-20% of women retaining 5kg or more 12 months postpartum, the risk of developing conditions like diabetes, metabolic syndrome and cardiovascular disease may be increased. It becomes evident that interventions which aim to support attainment of healthy weight both in the antenatal and postpartum periods are key health priorities for women during this life stage.Lifestyle factors of overweight, having poor diet quality, and not undertaking enough moderate-to-vigorous physical activity are amongst the top five predictors of mortality in women. Additionally it is noted that, for many women, pregnancy and the postpartum period are associated with a reduction in physical activity. It is known that a combination of poor dietary choices, an increase in sedentary time and reduction in physical activity are all contributors to the development of overweight and obesity. With this in mind, current research has focused on lifestyle interventions to limit GWG and PPWR. Thangaratinam et al. reviewed 44 randomized controlled trials (7278 women) where interventions including diet, physical activity or both were evaluated for their influence on maternal weight during pregnancy. Results indicate that all were significantly effective in reducing GWG compared with the control group. More specifically, dietary interventions were the most effective in reducing weight gain, with a mean weight loss of -3.84kg compared with -0.72kg and -1.06kg for physical activity and the mixed (diet plus physical activity) approach, respectively. This finding is supported by Hill and colleagues' recent systematic review of theory based interventions to limit GWG. Included studies in this review reported an underpinning theory base and were classified as adopting a dietary, physical activity or mixed approach. Hill et al. concluded that studies which included a diet intervention were significantly more effective at limiting GWG.In 2011 Tanentsapf et al. reviewed the effect of dietary interventions alone for reducing GWG in normal weight, overweight and obese pregnant women. This review analysed 13 randomized controlled trials and quasi-randomized controlled trials with a dietary intervention to prevent excessive GWG in women. The review concluded that dietary interventions during pregnancy were effective in reducing GWG with an effect of -1.92kg (n=1434) compared with the control group.Tanentsapf et al. identified that trials differed in the conduct of the interventions with various diet and non-diet related components utilised. Dietary approaches were highly variable with some trials focusing only on calorie restriction and others included additional target macronutrient distribution for intake. Some trials further provided feedback based on maternal weight gain guidelines. Interventions also varied in delivery method with a variety of modes used, including face-to-face, individual or group consultations and/or written correspondence. The frequency of communication, despite the type or mix, also changed from trial to trial with additional methods via telephone, posted materials, feedback or food diaries utilised. The inclusion of physical activity in addition to diet intervention was also common. Whilst the recent review by Tanentsapf et al. identified that dietary interventions are effective in reducing GWG, the review did not investigate the impact that different intervention components, delivery methods or dietary counselling approaches had on gestational weight management. It remains unclear as to which intervention components optimize GWG in women.The impact of lifestyle interventions has also been investigated in the postpartum period. The recent systematic review from van der Pligt et al. reported seven of 11 studies reviewed were successful in limiting PPWR. As with studies aimed at limiting GWG, interventions included in van der Pligt et al.'s review differed greatly in their conduct. Six of these seven studies included both dietary and physical activity components for the intervention, with the final successful study including a diet only intervention. Five of the successful studies recruited overweight or obese women only. Intervention time varied considerably in successful studies with some running for as little at ten days, and others up to six months.Bertz et al. demonstrated that their 12-week behavior modification intervention which targeted diet alone or diet and exercise, including two individual sessions with a dietitian and physical therapist, provision of scales for weight self-monitoring and bi-weekly text messages was successful in achieving significant weight loss following the intervention, and sustained at one year. The diet intervention and the diet and exercise intervention yielded significant weight loss compared to the control. Following 12 weeks a reduction of -8.3 +/- 4.2kg for diet intervention and -6.9 +/- 3.0kg for diet and exercise was observed. Additionally after one year, the diet intervention showed -10.2 +/- 5.7kg reduction and -7.3 +/- 6.3kg for the diet and exercise intervention (p<0.001). Colleran et al. also found significant weight change results by implementing a 16-week intervention which consisted of weekly individual sessions with a dietitian regarding calorie restriction, two additional home visits regarding exercise, weekly food diary completion and email support. The intervention group had greater weight loss compared to the control group (-5.8kg +/- 3.5kg vs -1.6kg +/- 5.4kg). It can be seen that various methods have been utilized in investigating the impact of diet and physical activity interventions on PPWR. The review by van der Pligt et al. highlights the impact successful lifestyle interventions can have on postpartum weight change. However, this review did not investigate the different intervention strategies utilized. It remains unclear as to the optimal setting, delivery method, diet strategy, contact frequency or intervention length to limit PPWR.Previous systematic reviews for both GWG and PPWR have focused on the effectiveness of lifestyle interventions as a whole for weight management in pregnant and postpartum women. And despite Tanentsapf et al.'s focus on dietary interventions for GWG, much is still unknown about the effectiveness of differing diet interventions over the antenatal and postpartum period. Specifically, the impact of differing diet intervention strategies on maternal weight gain is not known. Firstly, this systematic review will focus on whether weight management interventions which include a dietary component are effective in pregnant and postpartum women. In addition to this, this review will investigate the different intervention strategies utilized and their effectiveness in maternal weight management. A search of systematic review protocol databases has shown that there is no current review underway for this topic.

The health literacy demands of electronic personal health records (e-PHRs): An integrative review to inform future inclusive research

OBJECTIVE

To integrate the findings of research on electronic personal health records (e-PHRs) for an understanding of their health literacy demands on both patients and providers.

METHODS

We sought peer-reviewed primary research in English addressing the health literacy demands of e-PHRs that are online and allow patients any degree of control or input to the record. A synthesis of three theoretical models was used to frame the analysis of 24 studies.

RESULTS

e-PHRs pose a wide range of health literacy demands on both patients and health service providers. Patient participation in e-PHRs relies not only on their level of education and computer literacy, and attitudes to sharing health information, but also upon their executive function, verbal expression, and understanding of spoken and written language.

CONCLUSION

The multiple health literacy demands of e-PHRs must be considered when implementing population-wide initiatives for storing and sharing health information using these systems.

PRACTICE IMPLICATIONS

The health literacy demands of e-PHRs are high and could potentially exclude many patients unless strategies are adopted to support their use of these systems. Developing strategies for all patients to meet or reduce the high health literacy demands of e-PHRs will be important in population-wide implementation.

Comparison of Australian Recommended Food Score (ARFS) and Plasma Carotenoid Concentrations: A Validation Study in Adults

Diet quality indices can predict nutritional adequacy of usual intake, but validity should be determined. The aim was to assess the validity of total and sub-scale score within the Australian Recommended Food Score (ARFS), in relation to fasting plasma carotenoid concentrations. Diet quality and fasting plasma carotenoid concentrations were assessed in 99 overweight and obese adults (49.5% female, aged 44.6 ± 9.9 years) at baseline and after three months (198 paired observations). Associations were assessed using Spearman’s correlation coefficients and regression analysis, and agreement using weighted kappa (K_w). Small, significantly positive correlations were found between total ARFS and plasma concentrations of total carotenoids (r = 0.17, p < 0.05), β-cryptoxanthin (r = 0.18, p < 0.05), β-carotene (r = 0.20, p < 0.01), and α-carotene (r = 0.19, p < 0.01). Significant agreement between ARFS categories and plasma carotenoid concentrations was found for total carotenoids (K_w 0.12, p = 0.02), β-carotene (K_w 0.14, p < 0.01), and α-carotene (K_w 0.13, p < 0.01). In fully-adjusted regression models the only signification association with ARFS total score was for α-carotene (β = 0.19, p < 0.01), while ARFS meat and fruit sub-scales demonstrated significant relationships with α-carotene, β-carotene, and total carotenoids (p < 0.05). The weak associations highlight the issues with self-reporting dietary intakes in overweight and obese populations. Further research is required to evaluate the use of the ARFS in more diverse populations.

Food Addiction, Binge Eating Disorder, and Obesity: Is There a Relationship?

Existing research suggests that there is an overlap between binge eating disorder (BED) and the construct of 'food addiction' (FA). The objective of this study was to determine the overlapping features of BED and FA through a comparison of the individual scales of commonly used tools including the Binge Eating Scale (BES) and the Yale Food Addiction Scale (YFAS) in a sample of Australian adults. Adults (>18 years of age) were invited to complete an anonymous online survey on FA. Binge eating was assessed through the BES and addictive eating behaviours were assessed through the YFAS (n = 1344). The prevalence and severity of both FA and binge eating increased across weight categories. The overall correlation between the total score from the BES and FA symptoms was r = 0.76, p < 0.001; for females it was r = 0.77, p < 0.001, and for males it was r = 0.65, p < 0.001. Total BES score and the BES emotion factor were most often associated with FA symptoms, as was demonstrated to produce stronger correlations with FA symptoms. In contrast, the BES behaviour factor was less strongly associated to FA with the majority of correlations <0.6. This study demonstrates the overlap between BED and FA, and highlights the possible unique differences between the forms of disordered eating.

Trends in Food and Beverage Portion Sizes in Australian Children; a Time-Series Analysis Comparing 2007 and 2011-2012 National Data

In 2011–2012 approximately 26% of Australian children aged between 5–17 years were reported to be overweight or obese. Furthermore, the increase in prevalence of overweight and obesity among US children parallels reported increases in energy intake and portion sizes of common foods, leading to the recognition that availability of larger portion sizes contributes to the rise in overweight and obesity prevalence. Thus, the aim of this time-series analysis was to investigate whether selected food portion sizes in Australian children aged 2–16 years changed between 2007 and 2011–2012. Portion size data from 24-h recalls collected in Australian nutrition surveys were compared between 2007 and 2011–2012. Portion sizes changed significantly in 23% of items with increases in 15% and decreases in 8%. Changes in portion sizes varied by age, sex, and food group. Changes occurred for many meat-based items, energy-dense, nutrient-poor food items, breads, cereals, and some fruits and vegetables. Vegetable and fruit portion sizes were below the respective serving sizes of 75 g and 150 g in the Australian Guide to Healthy Eating, while portion sizes of some energy-dense, nutrient-poor foods have increased. These findings suggest approaches to increasing consumption of nutrient-dense core foods and reducing energy-dense, nutrient-poor food items in children are warranted.

An integrative review of patient safety in studies on the care and safety of patients with communication disabilities in hospital

OBJECTIVE

To review the research literature on the experiences of patients with communication disabilities in hospital according to the Generic Model of patient safety.

METHODS

In 2014 and 2015, we searched four scientific databases for studies with an aim or result relevant to safety of hospital patients with communication disabilities. The review included 27 studies.

RESULTS

A range of adverse event types were outlined in qualitative research. Little detail was provided about contributing or protective factors for safety incidents in hospital for these patients or the impact of the incidents on the patient or organisations involved.

CONCLUSION

Further research addressing the safety of patients with communication disabilities is needed. Sufficient detail is required to identify the nature, timing, and detection of incidents; factors that contribute to or prevent adverse events; and detail the impact of the adverse events.

PRACTICE IMPLICATIONS

In order to provide safe and effective care to people with communication disabilities in hospital, a priority for health and disability services must be the design and evaluation of ecologically appropriate and evidence-based interventions to improve patient care, communication, and reduce the risk of costly and harmful patient safety incidents.

Nutrition Interventions for Prevention and Management of Childhood Obesity: What Do Parents Want from an eHealth Program?

With the growth of Internet technologies, offering interventions for child and family weight management in an online format may address barriers to accessing services. This study aimed to investigate (i) whether an eHealth family healthy lifestyle program would be of interest to parents; and (ii) preferences and/or expectations for program components and features. Parents of children aged four to18 years were recruited through social media and completed an online survey (54 items) including closed and open-ended questions. Responses were collated using descriptive statistics and thematic analysis. Seventy-five participants were included (92% mothers, mean age 39.1 ± 8.6 years, mean BMI 27.6 ± 6.3 kg/m²). The index child had a mean age of 11 ± 6.2 years with 24% overweight/obese. The majority of parents (90.3%) reported interest in an online program, with preference expressed for a non-structured program to allow flexibility users to log-on and off as desired. Parents wanted a program that was easy to use, practical, engaging, endorsed by a reputable source, and able to provide individual tailoring and for their children to be directly involved. The current study supports the need for online delivery of a healthy lifestyle program that targets greater parental concerns of diet rather than child weight.

Validity of the Australian Recommended Food Score as a diet quality index for Pre-schoolers

BACKGROUND

Diet quality tools provide researchers with brief methods to assess the nutrient adequacy of usual dietary intake. This study describes the development and validation of a pediatric diet quality index, the Australian Recommended Food Scores for Pre-schoolers (ARFS-P), for use with children aged two to five years.

METHODS

The ARFS-P was derived from a 120-item food frequency questionnaire, with eight sub-scales, and was scored from zero to 73. Linear regressions were used to estimate the relationship between diet quality score and nutrient intakes, in 142 children (mean age 4 years) in rural localities in New South Wales, Australia.

RESULTS

Total ARFS-P and component scores were highly related to dietary intake of the majority of macronutrients and micronutrients including protein, β-carotene, vitamin C, vitamin A. Total ARFS-P was also positively related to total consumption of nutrient dense foods, such as fruits and vegetables, and negatively related to total consumption of discretionary choices, such as sugar sweetened drinks and packaged snacks.

CONCLUSION

ARFS-P is a valid measure that can be used to characterise nutrient intakes for children aged two to five years. Further research could assess the utility of the ARFS-P for monitoring of usual dietary intake over time or as part of clinical management.

Anatomical variants of the basal vein of Rosenthal: prevalence in idiopathic subarachnoid hemorrhage

BACKGROUND

Spontaneous, non traumatic subarachnoid hemorrhage (SAH) is a significant clinical problem that occurs most commonly as a result of aneurysm rupture. In approximately 15 % of cases, nor aneurysm or other vascular malformation can be identified by cerebral angiography as origin of the hemorrhage, and these are commonly defined as idiopathic SAH (ISAH). Because of the negative angiography, limited extension of the bleeding with prevalent prepontine pattern and the benign prognosis, the venous causes has been preferred rather than the arterial ones. In the literature recent studies have suggested a possible contribution by primitive variants of Basal vein of Rosenthal (BVR) in its the pathogenesis of ISAH, commonly grouped according Watanabe classification (type A, B and C). In this paper we evaluated the prevalence of anatomical variants of BVR in ISAH.

METHODS

Venous drainage at angiography was retrospectively analyzed in 40 patients with ISAH and in 40 with unruptured aneurysms as controls.

RESULTS AND CONCLUSIONS

Previous studies displayed a significant prevalence of BVR type C variants in ISAH. Conversely in our study we recognized variant B as prevalent, in which the BVR bifurcates to drain anteriorly into the uncal vein and posteriorly into the Galenic system. Similarly to variant C (in which the BVR drains via perimesencephalic "bridging" veins into cavernous, sphenoparietal, petrosal sinus or directly into transverse sinus) also variant B might be subjected to those stress mechanisms and intrinsic system 'fragility' and for reasons yet to determine, sets off a consequent hemorrhage with clinical and radiological features typical of ISAH.

Quantification of reductions in ammonia emissions from fertiliser urea and animal urine in grazed pastures with urease inhibitors for agriculture inventory: New Zealand as a case study

Urea is the key nitrogen (N) fertiliser for grazed pastures, and is also present in excreted animal urine. In soil, urea hydrolyses rapidly to ammonium (NH4(+)) and may be lost as ammonia (NH3) gas. Unlike nitrous oxide (N2O), however, NH3 is not a greenhouse gas although it can act as a secondary source of N2O, and hence contribute indirectly to global warming and stratospheric ozone depletion. Various urease inhibitors (UIs) have been used over the last 30 years to reduce NH3 losses. Among these, N-(n-butyl) thiophosphoric triamide (nBTPT), sold under the trade name Agrotain®, is currently the most promising and effective when applied with urea or urine. Here we conduct a critical analysis of the published and non-published data on the effectiveness of nBTPT in reducing NH3 emission, from which adjusted values for FracGASF (fraction of total N fertiliser emitted as NH3) and FracGASM (fraction of total N from, animal manure and urine emitted as NH3) for the national agriculture greenhouse gas (GHG) inventory are recommended in order to provide accurate data for the inventory. We use New Zealand as a case study to assess and quantify the overall reduction in NH3 emission from urea and animal urine with the application of UI nBTPT. The available literature indicates that an application rate of 0.025% w/w (nBTPT per unit of N) is optimum for reducing NH3 emissions from temperate grasslands. UI-treated urine studies gave highly variable reductions (11-93%) with an average of 53% and a 95% confidence interval of 33-73%. New Zealand studies, using UI-treated urea, suggest that nBTPT (0.025% w/w) reduces NH3 emissions by 44.7%, on average, with a confidence interval of 39-50%. On this basis, a New Zealand specific value of 0.055 for FracGASF FNUI (fraction of urease inhibitor treated total fertiliser N emitted as NH3) is recommended for adoption where urea containing UI are applied as nBTPT at a rate of 0.025% w/w. Only a limited number of published data sets are available on the effectiveness of UI for reducing NH3 losses from animal urine-N deposited during grazing in a grazed pasture system. The same can be said about mixing UI with urine, rather than spraying UI before or after urine application. Since it was not possible to accurately measure the efficacy of UI in reducing NH3 emissions from animal urine-N deposited during grazing, we currently cannot recommend the adoption of a FracGASM value adjusted for the inclusion of UI.

Reproducibility and comparative validity of a food frequency questionnaire for Australian adults

BACKGROUND

Food frequency questionnaires (FFQ) are used in epidemiological studies to investigate the relationship between diet and disease. There is a need for a valid and reliable adult FFQ with a contemporary food list in Australia.

AIMS

To evaluate the reproducibility and comparative validity of the Australian Eating Survey (AES) FFQ in adults compared to weighed food records (WFRs).

METHODS

Two rounds of AES and three-day WFRs were conducted in 97 adults (31 males, median age and BMI for males of 44.9 years, 26.2 kg/m(2), females 41.3 years, 24.0 kg/m(2). Reproducibility was assessed over six months using Wilcoxon signed-rank tests and comparative validity was assessed by intraclass correlation coefficients (ICC) estimated by fitting a mixed effects model for each nutrient to account for age, sex and BMI to allow estimation of between and within person variance.

RESULTS

Reproducibility was found to be good for both WFR and FFQ since there were no significant differences between round 1 and 2 administrations. For comparative validity, FFQ ICCs were at least as large as those for WFR. The ICC of the WFR-FFQ difference for total energy intake was 0.6 (95% CI 0.43, 0.77) and the median ICC for all nutrients was 0.47, with all ICCs between 0.15 (%E from saturated fat) and 0.7 (g/day sugars).

CONCLUSIONS

Compared to WFR the AES FFQ is suitable for reliably estimating the dietary intakes of Australian adults across a wide range of nutrients.

Three-dimensional rotational angiography for craniotomy planning and postintervention evaluation of intracranial aneurysms

PURPOSE

The authors evaluated the usefulness of three-dimensional rotational angiography (3DRA) in surgical planning and postoperative evaluation of cerebral aneurysms.

MATERIALS AND METHODS

A total of 111 consecutive aneurysms in 100 patients (32 emergency referrals due to haemorrhage) were evaluated with 3DRA over a period of 3 years. The rotational study was always performed with a single injection of 20 cc of contrast agent in the afferent vessel after diagnostic cerebral angiography in the two orthogonal projections. Three-dimensional reconstructions were obtained for the pre- and postoperative assessment.

RESULTS

Three-dimensional RA provides a virtual view of the surgical field with the same orientation required for the surgical approach and, compared with surgical findings, reliably defined location, orientation, morphology and relationship with parent vessels of the aneurysm in all cases. Postoperatively, it allowed better assessment of any residual lesion and of the relationship between surgical clips and parent vessels, compared with standard 2D angiography.

CONCLUSIONS

3DRA is a reliable method for preliminary assessment of cerebral aneurysms undergoing surgery. It provides multiple projections with a preview of the surgical field and study of lesion characteristics, which can help achieve faster and safer surgery. Compared with 2D angiography, the 3D model, with its multiple views, allows better assessment of postoperative outcomes. The method also significantly reduces the number of angiographic projections and therefore radiation and contrast-medium dose to the patient.

3D rotational angiography for the diagnosis and preoperative assessment of intracranial aneurysms: preliminary experience

PURPOSE

The aim of this study was to assess the value of the systematic use of 3D rotational angiography (3DRA) in the diagnosis and preoperative evaluation of cerebral aneurysms with a view to planning endovascular embolisation.

MATERIALS AND METHODS

Thirty-five consecutive aneurysms (20 incidental and 15 after subarachnoid haemorrhage) were studied and treated by means of 3DRA over a 1-year period. All rotational studies were conducted by selective cannulation of the vessel supplying the lesion (internal carotid artery or vertebral artery) with a single injection of 20 cc of contrast agent after diagnostic angiography in anterior-posterior (AP) and laterolateral (LL) views. Three-dimensional reconstructions were generated within a mean time of 5 min, and coil embolisation was performed on the basis of the 3D images.

RESULTS

Three-dimensional RA enabled accurate definition of site, orientation, morphology and size of the sac and its relationship with the parent arteries and helped us choose the most appropriate angulation of the C-arm for guiding and controlling the embolisation procedure. Furthermore, the technique allowed us to detect six aneurysms for which conventional imaging had yielded equivocal results.

CONCLUSIONS

Based on our experience before RA equipment became available and in agreement with the literature, we believe that 3DRA improves the identification of all lesions and helps refine the choice of the most suitable embolisation material and technique. Three-dimensional RA requires substantially fewer projections and thus reduces radiation dose and volume of contrast material to the patient. The use of 3DRA most likely results in a shorter procedure time and fewer risks and complications for the patient.

Craniopagus: the Thessaloniki-Rome experience

OBJECT

A case of two female Greek twins conjoined at the left frontal and orbital regions is described. These conjoined twins were transferred to the Pediatric Neurosurgical Unit of the Gemelli Hospital, Catholic University Medical School, at the age of 4 months for possible surgical division.

METHOD

Multiple diagnostic investigations, which included in particular advanced imaging techniques, demonstrated an independent cerebral vascularization of the two babies and excluded significant intracranial malformations. Such an accurate evaluation of the anatomy of the craniopagus at the level of the cranial junction allowed the feasibility of the surgical correction to be established.

CONCLUSIONS

The operation was carried out by a multidisciplinary team in a single stage. The operating team included two distinct teams of neurosurgeons and anesthesiologists as well as a plastic surgeons' team. Both babies survived the operation. The postoperative course was uneventful. Both twins were discharged in good clinical and neurological condition after a 3-week period of hospitalization.

Characterisation of intestinal peptide transporter of the Antarctic haemoglobinless teleost Chionodraco hamatus

H(+)/peptide cotransport was studied in brush-border membrane vesicles (BBMV) from the intestine of the haemoglobinless Antarctic teleost Chionodraco hamatus by monitoring peptide-dependent intravesicular acidification with the pH-sensitive dye Acridine Orange. Diethylpyrocarbonate-inhibited intravesicular acidification was specifically achieved in the presence of extravesicular glycyl-L-proline (Gly-L-Pro) as well as of glycyl-L-alanine (Gly-L-Ala) and D-phenylalanyl-L-alanine (D-Phe-L-Ala). H(+)/Gly-L-Pro cotransport displayed saturable kinetics, involving a single carrier system with an apparent substrate affinity (K(m,app)) of 0.806+/-0.161 mmol l(-1). Using degenerated primers from eel and human (PepT1) transporter sequence, a reverse transcription-polymerase chain reaction (RT-PCR) signal was detected in C. hamatus intestine. RT-PCR paralleled kinetic analysis, confirming the hypothesis of the existence of a PepT1-type transport system in the brush-border membranes of icefish intestine. Functional expression of H(+)/peptide cotransport was successfully performed in Xenopus laevis oocytes after injection of poly(A)(+) RNA (mRNA) isolated from icefish intestinal mucosa. Injection of mRNA stimulated D-Phe-L-Ala uptake in a dose-dependent manner and an excess of glycyl-L-glutamine inhibited this transport. H(+)/peptide cotransport in the Antarctic teleost BBMV exhibited a marked difference in temperature optimum with respect to the temperate teleost Anguilla anguilla, the maximal activity rate occurring at approximately 0 degrees C for the former and 25 degrees C for the latter. Temperature dependence of icefish and eel intestinal mRNA-stimulated uptake in the heterologous system (oocytes) was comparable.

Bilateral renal vein thrombosis as a complication of gangrenous appendicitis

Bilateral renal vein thrombosis after an appendectomy has never been reported in the pediatric literature. We describe the case of a 10-year-old boy who developed this very unusual complication following appendectomy for gangrenous appendicitis with peritonitis. Color duplex Doppler is the most appropriate investigation to allow correct diagnosis and immediate medical treatment. Peritoneal dialysis is a simple and effective tool to prevent permanent damage to renal function.

Spinal cord stimulation and early experimental cerebral spasm: the "functional monitoring" and the "preventing effect"

BACKGROUND

Clinical and experimental data on cerebral blood flow (CBF) changes during spinal cord stimulation (SCS) were published since 1986. The aims of the present work are: 1. To find an experimental model of reliable, simple and in vivo monitoring of "early" basilar artery spasm after subarachnoid haemorrhage (SAH) and 2. To investigate the effects of cervical spinal cord stimulation (CSCS) on it. Vasospasm due to SAH is both "acute" and "recurrent". Early spasm occurs within minutes of the SAH. its duration is approximately 1 hour. The need of different morphological and haemodynamic methods to evaluate experimental early spasm is reported. To overcome intracranial surgical manipulations and biological effects of contrast and fixation media we designed a model that allows "in vivo" functional monitoring of basilar blood flow far away from the spasm without direct surgical and chemical interference. Subsequently we investigated the effects of CSCS on the new model of "functional monitoring" of the "early" cerebral vasospasm.

METHOD

29 adult Burgundy rabbits were studied. Group 1: under homeostatic monitoring, "on-line" carotid blood flow (carotid BF) changes produced by SAH in cisterna magna of 12 (plus 5 sham treated) animals were studied from the common carotid artery after external carotid artery occlusion before, during SAH and up to the end of the experiments. All the animals underwent digital subtraction cerebral panangiography (CPA) after SAH obtaining a significant increase of carotid BF only when basilar vasospasm was shown by CPA. Carotid BF increase during basilar vasospasm was defined "functional monitoring" of early spasm. Group 2: Twelve animals wearing a cervical epidural electrode underwent carotid BF "functional monitoring" of early basilar spasm before and during CSCS.

FINDINGS

Carotid BF changes during CSCS occurred in 10 animals. No carotid BF changes (i.e. no basilar vasospasm) occurred after SAH up to the end of the experiments in all the stimulated animals.

INTERPRETATION

CSCS is able to prevent "early spasm" due to SAH in all the animals studied with the new model of "functional monitoring" described, independently from the occurence and the sign for stimulation-induced carotid BF variations. The role and the limits of reversible functional sympathectomy in mediating the effect of CSCS on early vasospam are discussed.

Carbonic anhydrase activity in tissues of the icefish Chionodraco hamatus and of the red-blooded teleosts Trematomus bernacchii and Anguilla anguilla

Carbonic anhydrase (CA) activity was measured in blood, intestine, kidney and gill of two Antarctic teleosts, the haemoglobinless Chionodraco hamatus and the red-blooded Trematomus bernacchii, and of the temperate teleost Anguilla anguilla. In all species, the highest CA activity was in the gills, with the greatest activity in C. hamatus. CA activity in the blood was highest in A. anguilla, but none was detected in the blood of C. hamatus despite the presence of plasma CA inhibitors. The enzyme was present but its activity was low in the intestine and kidney of all three species.

The existence of very high CA activity in C. hamatus gills compared with the red-blooded species was investigated further by isolating and characterising the branchial cytosolic CA isoforms. The turnover rate of the C. hamatus isoform was significantly higher than that of T. bernacchii and A. anguilla. The isoforms from both the Antarctic species exhibited lower apparent Km (Km,app) and heat stability than those from A. anguilla. Sensitivity to sulphonamides was similar in all species and was within the range of the mammalian CA II isoform. The branchial CA isoforms of C. hamatus, T. bernacchii and A. anguilla displayed relative molecular masses of 28.9, 29.9 and 31.2 kDa, respectively.

The results suggest that the hemoglobinless teleost possesses a different branchial cytosolic CA isoform from that of red-blooded teleosts.

Atherosclerosis of carotid and intracranial arteries

The role of diagnostic imaging in the study of atherosclerosis of carotid and intracranial vessels is analyzed, after the illustration of the main characteristics of the disease. Atherosclerosis should be considered a systemic disease, however it tends to be segmental. The commonest sites are the coronary artery, the superficial femoral artery, the subrenal aorta and the carotid arteries at the level of the bifurcation. Traditionally, the percentage of intraluminal stenosis has represented the standard measurement of the severity of atheromatosis. However, the grade of stenosis is not the only sign predictive of clinical complications. The most vulnerable plaques show predominant core necrosis or hemorrhage, separated from the vascular lumen by a thin unstable fibrous cap. The two major aspects of lesions at high risk of rupture are the presence of a large soft core and the status of the fibrous cap that can be intact, ruptured or infiltrated by inflammatory cells. Imaging procedures should be addressed to the identification of these pathologic conditions predisposing to the embolic-thrombotic complication. However, additional information on blood flow dynamics, vascular collateral compensation and brain perfusion is useful for decision-making about the therapeutic approach. This is the reason why in diagnostic imaging of atheromatosis, digital angiography should be combined with color Doppler-US, CT and MRI.

Deletion of the alpha(1,3)galactosyl transferase (GGTA1) gene and the prion protein (PrP) gene in sheep

Nuclear transfer offers a cell-based route for producing precise genetic modifications in a range of animal species. Using sheep, we report reproducible targeted gene deletion at two independent loci in fetal fibro-blasts. Vital regions were deleted from the alpha(1,3)galactosyl transferase (GGTA1) gene, which may account for the hyperacute rejection of xenografted organs, and from the prion protein (PrP) gene, which is directly associated with spongiform encephalopathies in humans and animals. Reconstructed embryos were prepared using cultures of targeted or nontargeted donor cells. Eight pregnancies were maintained to term and four PrP-/+ lambs were born. Although three of these perished soon after birth, one survived for 12 days. These data show that lambs carrying targeted gene deletions can be generated by nuclear transfer.

Craniovertebral junction malformation and rotational occlusion of the vertebral artery

An unusual case of rotational occlusion of a non-dominant vertebral artery (VA) is presented. This clinical syndrome is associated for the first time with a complex craniovertebral junction malformation. Rotational occlusion of the VA is usually asymptomatic, vertebro-basilar insufficiency has been rarely observed in cases of involvement of a dominant VA, and concomitant occlusion or hypoplasia of the contralateral artery. Diagnosis of rotational VA occlusion is based on haemodynamic demonstration of the effects of head rotation. The importance of the awareness of this syndrome is stressed.

Cerebral arteriovenous malformations in children

In spite of their congenital origin, only 18-20% of cerebral AVMs are diagnosed during infancy and childhood. Intracranial haemorrhage is the presenting clinical manifestation in 75-80% of paediatric patients and is associated with a high morbidity and mortality. The natural history of untreated cerebral AVMs in children is worse than in adults, in relation to a longer life expectation, a higher annual risk of AVM bleeding (3.2% vs. 2.2%) and a higher incidence of posterior fossa and basal ganglia AVMs, most of which present with massive haemorrhages. The surgical excision remains the treatment of choice for parenchymal AVMs in children; AVM complete removal is currently achieved in 70-90% of the patients. With the advent of new agents for endovascular management, preoperative AVM embolization has further improved surgical results. Stereotactic radiosurgery appears to be a successful treatment option in small or moderate sized AVMs. Recent studies have demonstrated low complication rates with this technique in paediatric patients. We reviewed our experience with 37 paediatric AVMs treated at the Section of Paediatric Neurosurgery of the Catholic University of Rome between 1980 and 1997. Twenty-three patients underwent surgery as the only treatment modality; endovascular embolization was combined with the surgical treatment in a further four cases. Radiosurgery was utilized as the only treatment in three patients and in combination with other techniques in an other three children (with surgery in one case and with AVM embolization in the remaining two subjects). No treatment was carried out in three patients because of excessively critical condition on admission; endovascular embolization failed in a further patient because of the anatomical complexity of the malformation. Previous studies have demonstrated a quite strict correlation between AVM complexity based on Spetzler and Martin's grading system and patients outcome. A less direct relationship has been observed in the present study. In our experience the factors which were more closely predictive of patients' outcome were the occurrence of an AVM bleeding and the neurological status on admission. In spite of the low number of cases in the single subsets of patients this study seems to support the role of AVM embolization and radiosurgery as effective adjuvant techniques in the management of cerebral AVMs in children.

Injury of the vertebral artery after closed head trauma

Two case reports characterized by the complete occlusion of the basilar artery, secondary to dissection of the vertebral artery after closed head trauma are described. These lesions, often clinically silent in the beginning, were able to cause severe neurologic impairment, even after minor head trauma in healthy individuals without predisposing structural disorders. Early detection, based upon the knowledge of the modality of the trauma and upon a correct diagnostic approach, is mandatory to reduce secondary injury. The authors suggest an extensive use of cerebral angiography or angio-magnetic resonance in all cases where clinical conditions are more severe than the computed tomography scan, particularly if the trauma produced a cervical injury with a movement of flexo-extension of the neck. Therapeutic management is discussed. Anti-coagulants, thrombolytic agents or surgical ligation of the vessel has been proposed to prevent the extension of the lesion and to improve the outcome.

Body composition and energy expenditure of patients with chronic cardiac failure

BACKGROUND

Patients with acute cardiac failure have excess body water, and it is commonly assumed that this is also so in patients with stable chronic cardiac failure (CCF).

METHODS

To investigate this, we measured total body water (TBW) using stable isotope dilution and single-frequency bioelectrical impedance (BIA), and also extracellular volume (ECV) using bromide dilution in 12 patients with CCF and eight matched control subjects.

RESULTS

TBW [kg(-1) bodyweight] was similar in the two groups [median 18O dilution 53.2% (range 46.5-57.1%) in patients vs. 54.8% (47.9-62.7) in control subjects; BIA 56.6% (42.7-73.1) vs. 58.0% (52.0-68.6)]. ECV was also similar in the two groups [0.25 Lkg(-1) (0.20-0.29) vs. 0.25 (0.19-0.35)]. There was a strong correlation between stable isotope and BIA measurements of TBW for all subjects (r = 0.76), but BIA overestimated TBW by a mean difference of 2.4 kg (limits of agreement of -4.1 kg to +8.9 kg). Body fat content was similar in the two groups, whether measured by skinfold anthropometry, whole-body densitometry or by 18O dilution. Resting energy expenditure (REE), calculated from indirect calorimetry, and total energy expenditure (TEE), calculated from the ratio of 2H to 18O elimination rate after drinking doubly labelled water, were also similar in the two groups.

CONCLUSION

It is concluded that the patients with stable CCF in this study had normal ECV and TBW, and so excess body water did not account for their persistent symptoms.

Combined management of intracranial vascular malformations in children

We have reviewed 39 cases of intracranial vascular malformations, observed in the Section of Paediatric Neurosurgery of the Catholic University of Rome between 1980 and 1995 (age 1-15 years). Diagnosis was of parenchimal AVM in 26 cases, in 7 cases of AVM of the Galen region, in 5 cases of dural AVM and in 1 case of venous angioma.

RESULTS AND CONCLUSIONS

Haemorrhage was the prevalent clinical onset in patients with parenchimal AVMs (57.7% of cases). Only one patient with a Galen region AVM presented cardiovascular symptoms, while 2/5 children observed for a dural AVM complained a congestive heart failure. Total surgical excision was performed in 17 of the 26 patients with parenchimal AVMs; moreover surgery was combined with preoperative endovascular embolization in 2 cases and with radiosurgery in 1 patient; we think that surgery is still the treatment of choice in patients with parenchimal AVMs. Endovascular treatment and radiosurgery have mainly an adjuvant role; nevertheless we agree that a preoperative endovascular management of parenchimal AVMs reduces the surgical risk, especially in cases of huge AVMs or AVMs localized in eloquent areas of the brain. Radiosurgery may be an alternative choice for complex or deeply sited AVMs; however in most cases, a combination with surgery or endovascular treatment is necessary to reduce the "target" size. AVM embolization was the only treatment in 2 of the 6 cases of dural AVMs; dural AVM embolization was combined with surgery in 1 case. Endovascular AVM exclusion is the treatment of choice in these patients. Surgery may be combined with endovascular treatment in case of a partial persistence of the AVM, or if signs of revascularization are present on control angiography. A conservative management is justified in patients with carotido-cavernous fistulae; in fact a complete spontaneous thrombosis is very frequent in these cases. A high rate of cardiovascular symptoms is reported in patients with Galen region AVMs diagnosed in the 1st year of life, but only 1 of our patients complained of congestive cardiac symptoms. Surgical treatment of Galen region AVMs is associated with a high morbidity and mortality. Actually a transarterial embolization of afferent vessels represents the treatment of choice in these patients; it can be combined with transvenous approach in case of complex AVMs and/or a non complete AVM exclusion.