Tuberculosis testing patterns in South Africa to identify groups that would benefit from increased investigation

The National Health Laboratory Service (NHLS) collects all public health laboratory test results in South Africa, providing a cohort from which to identify groups, by age, sex, HIV, and viral suppression status, that would benefit from increased tuberculosis (TB) testing. Using NHLS data (2012-2016), we assessed levels and trends over time in TB diagnostic tests performed (count and per capita) and TB test positivity. Estimates were stratified by HIV status, viral suppression, age, sex, and province. We used logistic regression to estimate the odds of testing positive for TB by viral suppression status. Nineteen million TB diagnostic tests were conducted during period 2012-2016. Testing per capita was lower among PLHIV with viral suppression than those with unsuppressed HIV (0.08 vs 0.32) but lowest among people without HIV (0.03). Test positivity was highest among young adults (aged 15-35 years), males of all age groups, and people with unsuppressed HIV. Test positivity was higher for males without laboratory evidence of HIV than those with HIV viral suppression, despite similar individual odds of TB. Our results are an important national baseline characterizing who received TB testing in South Africa. People without evidence of HIV, young adults, and males would benefit from increased TB screening given their lower testing rates and higher test positivity. These high-test positivity groups can be used to guide future expansions of TB screening.

Estimating the effect of a rifampicin resistant tuberculosis diagnosis by the Xpert MTB/RIF assay on two-year mortality

Studies assessing patient-centred outcomes of novel rifampicin resistant tuberculosis (RR-TB) diagnostics are rare and mostly apply conventional methods which may not adequately address biases. Even though the Xpert MTB/RIF molecular assay was endorsed a decade ago for simultaneous diagnosis of tuberculosis and RR-TB, the impact of the assay on mortality among people with RR-TB has not yet been assessed. We analysed data of an observational prospective cohort study (EXIT-RIF) performed in South Africa. We applied a causal inference approach using inverse odds of sampling weights to rectify survivor bias and selection bias caused by differing screening guidelines. We also adjusted for confounding using a marginal structural model with inverse probability of treatment weights. We estimated the total effect of an RR-TB diagnosis made by the Xpert assay versus the pre-Xpert diagnostic algorithm (entailing a targeted Line Probe Assay (LPA) among TB-confirmed patients) on two-year mortality and we assessed mediation by RR-treatment initiation. Of the 749 patients diagnosed with RR-TB [247 (33%) by the pre-Xpert diagnostic algorithm and 502 (67%) by the Xpert assay], 42.7% died. Of these, 364 (48.6%) patients died in the pre-Xpert group and 200 (39.8%) in the Xpert group. People diagnosed with RR-TB by the Xpert assay had a higher odds of RR-TB treatment initiation compared to those diagnosed by the targeted LPA-based diagnostic process (OR 2.79; 95%CI 2.19-3.56). Receiving an RR-TB diagnosis by Xpert resulted in a 28% reduction in the odds of mortality within 2 years after presentation to the clinic (ORCI 0.72; 95%CI 0.53-0.99). Causal mediation analysis suggests that the higher rate of RR-TB treatment initiation in people diagnosed by the Xpert assay explains the effect of Xpert on 2-year mortality [natural indirect effect odds ratio 0.90 (95%CI 0.85-0.96). By using causal inference methods in combination with high quality observational data, we could demonstrate that the introduction of the Xpert assay caused a 28% reduction in 2-year odds of mortality of RR-TB. This finding highlights the need for advocacy for a worldwide roll-out of rapid molecular tests. Because the effect is mainly caused by increased RR-TB treatment initiation, health care systems should also ensure timely initiation of effective treatment upon an RR-TB diagnosis.

Aphid BCR4 Structure and Activity Uncover a New Defensin Peptide Superfamily

Aphids (Hemiptera: Aphidoidea) are among the most detrimental insects for agricultural plants, and their management is a great challenge in agronomical research. A new class of proteins, called Bacteriocyte-specific Cysteine-Rich (BCR) peptides, provides an alternative to chemical insecticides for pest control. BCRs were initially identified in the pea aphid Acyrthosiphon pisum. They are small disulfide bond-rich proteins expressed exclusively in aphid bacteriocytes, the insect cells that host intracellular symbiotic bacteria. Here, we show that one of the A. pisum BCRs, BCR4, displays prominent insecticidal activity against the pea aphid, impairing insect survival and nymphal growth, providing evidence for its potential use as a new biopesticide. Our comparative genomics and phylogenetic analyses indicate that BCRs are restricted to the aphid lineage. The 3D structure of BCR4 reveals that this peptide belongs to an as-yet-unknown structural class of peptides and defines a new superfamily of defensins.

Spatial-Spectral Analysis of Hyperspectral Images Reveals Early Detection of Downy Mildew on Grapevine Leaves

Downy mildew is a highly destructive disease of grapevine. Currently, monitoring for its symptoms is time-consuming and requires specialist staff. Therefore, an automated non-destructive method to detect the pathogen before the visible symptoms appear would be beneficial for early targeted treatments. The aim of this study was to detect the disease early in a controlled environment, and to monitor the disease severity evolution in time and space. We used a hyperspectral image database following the development from 0 to 9 days post inoculation (dpi) of three strains of Plasmopara viticola inoculated on grapevine leaves and developed an automatic detection tool based on a Support Vector Machine (SVM) classifier. The SVM obtained promising validation average accuracy scores of 0.96, a test accuracy score of 0.99, and it did not output false positives on the control leaves and detected downy mildew at 2 dpi, 2 days before the clear onset of visual symptoms at 4 dpi. Moreover, the disease area detected over time was higher than that when visually assessed, providing a better evaluation of disease severity. To our knowledge, this is the first study using hyperspectral imaging to automatically detect and show the spatial distribution of downy mildew on grapevine leaves early over time.

Metabolic Cooperation among Commensal Bacteria Supports Drosophila Juvenile Growth under Nutritional Stress

The gut microbiota shapes animal growth trajectory in stressful nutritional environments, but the molecular mechanisms behind such physiological benefits remain poorly understood. The gut microbiota is mostly composed of bacteria, which construct metabolic networks among themselves and with the host. Until now, how the metabolic activities of the microbiota contribute to host juvenile growth remains unknown. Here, using Drosophila as a host model, we report that two of its major bacterial partners, Lactobacillus plantarum and Acetobacter pomorum, engage in a beneficial metabolic dialogue that boosts host juvenile growth despite nutritional stress. We pinpoint that lactate, produced by L. plantarum, is utilized by A. pomorum as an additional carbon source, and A. pomorum provides essential amino acids and vitamins to L. plantarum. Such bacterial cross-feeding provisions a set of anabolic metabolites to the host, which may foster host systemic growth despite poor nutrition.

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L. plantarum feeds lactate to A. pomorum

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A. pomorum supplies essential amino acids and vitamins to L. plantarum

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Microbiota metabolic dialogue boosts Drosophila's larval growth

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Lactate utilization by Acetobacter releases anabolic metabolites to larvae

Drosophila-associated bacteria differentially shape the nutritional requirements of their host during juvenile growth

The interplay between nutrition and the microbial communities colonizing the gastrointestinal tract (i.e., gut microbiota) determines juvenile growth trajectory. Nutritional deficiencies trigger developmental delays, and an immature gut microbiota is a hallmark of pathologies related to childhood undernutrition. However, how host-associated bacteria modulate the impact of nutrition on juvenile growth remains elusive. Here, using gnotobiotic Drosophila melanogaster larvae independently associated with Acetobacter pomorum^WJL (Ap^WJL) and Lactobacillus plantarum^NC8 (Lp^NC8), 2 model Drosophila-associated bacteria, we performed a large-scale, systematic nutritional screen based on larval growth in 40 different and precisely controlled nutritional environments. We combined these results with genome-based metabolic network reconstruction to define the biosynthetic capacities of Drosophila germ-free (GF) larvae and its 2 bacterial partners. We first established that Ap^WJL and Lp^NC8 differentially fulfill the nutritional requirements of the ex-GF larvae and parsed such difference down to individual amino acids, vitamins, other micronutrients, and trace metals. We found that Drosophila-associated bacteria not only fortify the host’s diet with essential nutrients but, in specific instances, functionally compensate for host auxotrophies by either providing a metabolic intermediate or nutrient derivative to the host or by uptaking, concentrating, and delivering contaminant traces of micronutrients. Our systematic work reveals that beyond the molecular dialogue engaged between the host and its bacterial partners, Drosophila and its associated bacteria establish an integrated nutritional network relying on nutrient provision and utilization.

A study of gnotobiotic fruit flies shows that the animal is involved in an integrated nutritional network with its facultative commensal bacteria, centered around the utilization and sharing of nutrients.

Performance of Xpert MTB/RIF, Xpert Ultra, and Abbott RealTime MTB for Diagnosis of Pulmonary Tuberculosis in a High-HIV-Burden Setting

More sensitive tests are needed for the diagnosis of smear-negative and HIV-associated tuberculosis. This study compares the sensitivities and specificities of three molecular tests, namely, the Xpert MTB/RIF test, the Xpert Ultra (Ultra), and RealTime MTB (RT-MTB), in a high HIV prevalence setting. Symptomatic adults were recruited from three outpatient sites, and each provided 4 sputum specimens. The diagnostic performance of Xpert MTB/RIF, Ultra, and RT-MTB was evaluated, with culture as a reference standard. HIV infection occurred in 62% of patients, with a median CD4 count of 220 cells/µl. The Ultra test had the highest sensitivity of 89.3% (95% confidence interval [CI], 78.1 to 96) compared to those of the Xpert MTB/RIF at 82.1% (95% CI, 69.6 to 91.1; P = 0.12) and RT-MTB at 78.6% (95% CI, 65.6 to 88.4; P = 0.68). The specificity was highest with the Xpert MTB/RIF at 100% (95% CI, 98 to 100), followed by RealTime MTB at 96.7% (95% CI, 92.9 to 98.8; P = 0.03) and the Ultra at 95.6% (95% CI, 91.5 to 98.1; P = 0.08). In patients with smear-negative disease, the Ultra was more sensitive than the Xpert MTB/RIF (64.7% [95% CI, 38.3 to 85.8] versus 41.2% [95% CI, 18.4 to 67.1], respectively; P = 0.12), and RT-MTB performed equally to Xpert MTB/RIF. In a comparison of the Ultra and RT-MTB on the same sputum specimen pellets, the Ultra was more sensitive than RT-MTB in the overall cohort (88.9% [95% CI, 77.4 to 95.8] versus 77.8% [95% CI, 64.4 to 88], respectively; P = 0.03) and among people with HIV (87.5% [95% CI, 71 to 96.5] versus 68.6% [95% CI, 50 to 83.9], respectively; P = 0.03). Although these results did not reach statistical significance, they suggest that the Ultra is more sensitive than the Xpert MTB/RIF and RT-MTB, most prominently in smear-negative disease. This was accompanied by a loss of specificity.

Diagnosis of opportunistic infections: HIV co-infections - tuberculosis

PURPOSE OF REVIEW

Tuberculosis (TB) incidence has declined ∼1.5% annually since 2000, but continued to affect 10.4 million individuals in 2015, with 1/3 remaining undiagnosed or underreported. The diagnosis of TB among those co-infected with HIV is challenging as TB remains the leading cause of death in such individuals. Accurate and rapid diagnosis of active TB will avert mortality in both adults and children, reduce transmission, and assist in timeous decisions for antiretroviral therapy initiation. This review describes advances in diagnosing TB, especially among HIV co-infected individuals, highlights national program's uptake, and impact on patient care.

RECENT FINDINGS

The TB diagnostic landscape has been transformed over the last 5 years. Molecular diagnostics such as Xpert MTB/RIF, which simultaneously detects Mycobacterium tuberculosis (MTB) resistance to rifampicin, has revolutionized TB control programs. WHO endorsed the use of Xpert MTB/RIF in 2010 for use in HIV/TB co-infected patients, and later in 2013 for use as the initial diagnostic test for all adults and children with signs and symptoms of pulmonary TB. Line probe assays (LPAs) are recommended for the detection of rifampicin and isoniazid resistance in sputum smear-positive specimens and mycobacterial cultures. A second-line line probe assay has been recommended for the diagnosis of extensively drug-resistant (XDR)-TB Assays such as the urine lateral flow (LF)-lipoarabinomannan (LAM), can be used at the point of care (POC) and have a niche role to supplement the diagnosis of TB in seriously ill HIV-infected, hospitalized patients with low CD4 cell counts of less than 100 cells/μl. Polyvalent platforms such as the m2000 (Abbott Molecular) and GeneXpert (Cepheid) offer potential for integration of HIV and TB testing services. While the Research and Development (R&D) pipeline appears to be rich at first glance, there are actually few leads for true POC tests that would allow for earlier TB diagnosis or rapid, comprehensive drug susceptibility testing, especially when considering the very high attrition rates observed between biomarker discovery and product market entry.

SUMMARY

In this review, we describe diagnostic strategies specifically for HIV and TB co-infected individuals. Molecular diagnostics in particular within the past 5 years have revolutionized and 'disrupted' this field. They lend themselves to integration of services with platforms capable of polyvalent testing. Impact on patient care is, however, still debatable. What has been highlighted is the need for health system strengthening and for true POC testing that can be used in active case finding.

Synthesis of new dicinnamoyl 4-deoxy quinic acid and methyl ester derivatives and evaluation of the toxicity against the pea aphid Acyrthosiphon pisum

New dicinnamoyl (caffeoyl, feruloyl, ortho and para-coumaroyl) 4-deoxyquinic acid and esters were synthesized by using a new 4-deoxy quinic acid triol intermediate. The optimisation of both coupling and deprotection steps allowed the preparation in good yields of the target products either as the carboxylic acid or the methyl ester form. Eight new compounds were evaluated for their ability to influence the feeding behaviour of the pea aphid Acyrthosiphon pisum. Artificial diet bioassays showed that two compounds are toxic (mortality and growth inhibition) at lower concentrations than the reference 3,5-dicaffeoyl quinic acid.

Levels and trends of smokeless tobacco use among youth in countries of the World Health Organization South-East Asia Region

BACKGROUND

At least two rounds of the Global Youth Tobacco Survey (GYTS) have been completed in most of the countries in the World Health Organization South-East Asia region. Comparing findings from these two rounds provides trend data on smokeless tobacco (SLT) use for the first time.

METHODS

This study uses GYTS data from Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste during 2006-2013. GYTS is a nationally representative survey of 13-15-year-old students using a consistent and standard protocol. Current SLT use is defined as using any kind of SLT products, such as chewing betel quid or nonbetel quid or snuffing any other products orally or through the nasal route, during the 30 days preceding the survey. Prevalence and 95% confidence intervals were computed using SAS/SUDAAN software.

RESULTS

According to most recent GYTS data available in each country, the prevalence of current use of SLT among youth varied from 5.7% in Thailand to 23.2% in Bhutan; among boys, from 7.1% in Bangladesh to 27.2% in Bhutan; and among girls, from 3.7% in Bangladesh to 19.8% in Bhutan. Prevalence of SLT was reported significantly higher among boys than girls in Bhutan (boys 27.2%; girls 19.8%), India (boys 11.1%; girls 6.0%), Maldives (boys 9.2%; girls 2.9%), Myanmar (boys 15.2%; girls 4.0%), and Sri Lanka (boys 13.0%; girls 4.1%). Prevalence of current SLT use increased in Bhutan from 9.4% in 2009 to 23.2% in 2013, and in Nepal from 6.1% in 2007 to 16.2% in 2011.

CONCLUSION

The findings call for countries to implement corrective measures through strengthened policy and enforcement.

Effects of a pediatric emergency department febrile infant protocol on time to antibiotic therapy

The purpose of this study was to examine the effect of an Emergency Department (ED) protocol to reduce time to antibiotic administration in the febrile infant less than 3 months of age with a rectal temperature > or =38.0 degrees C. We conducted a before-after study of a febrile infant quality improvement initiative in an urban pediatric ED with approximately 35,000 patient visits per year. Records of infants less than 3 months of age presenting with a rectal temperature > or =38.0 degrees C, who underwent a full septic work-up (blood, urine, and cerebrospinal fluid studies, and possibly chest radiography), were identified by using daily ED logs. This review was performed in the month before and then 12 months after institution of the "Septic Infant Work-up Sheet" and a set of interventions (Febrile Infant Protocol) designed to streamline care of the febrile infant and to reduce the time to antibiotic administration. Data were analyzed by using the Kaplan-Meier survival estimate and the log-rank test. Patient demographic characteristics and severity of illness were similar across months; however, ED process of care was significantly changed. Initial analysis revealed a median time to antibiotics of 142 min. Subsequent analysis after implementation of the Febrile Infant Protocol revealed a median time to antibiotics of 105 min. This represents an overall time reduction of 25% from time of presentation to antibiotic administration. In conclusion, a guideline-based ED febrile infant protocol changed clinical practice and improved time to antibiotics.

Foster parents of medically fragile children can improve their BLS scores: results of a demonstration project

OBJECTIVES

1) To assess performance and comfort level with cardiopulmonary resuscitation (CPR), foreign body removal (FBR), and seizure management in foster parents of medically fragile children; 2) To determine if the parents' performance and comfort levels increase with an individual teaching session with a medical professional to review CPR and FBR.

METHODS

In this single cohort pilot study, 18 foster parents of medically fragile children were asked to rate their comfort level with pediatric CPR and FBR on a 5-point scale (1 = very uncomfortable, 5 = very comfortable). They then underwent five mock code scenarios and were evaluated using a 5-point scale (1 = poor performance, 5 = outstanding performance). A 6-month follow-up evaluation using similar scenarios was conducted.

RESULTS

At visit 1, the percentage of parents demonstrating adequate performance of CPR, FBR, and seizure management was: 1) CPR: infant (78%); child (78%); 2) Foreign body removal: age <1 year (17%); age >1 year (65%); 3) Seizures (94%). At visit 2, performance improved in all areas, especially FBR, where the percentage of parents demonstrating adequate performance increased to 71% for children <1 year and 82% for children >1 year. As measured by the 5-point scales, CPR and FBR performance and parent comfort level with CPR improved significantly (Wilcoxon signed-ranks test, P < 0.004), but parent comfort level with FBR did not (P = 0.12).

CONCLUSIONS

Based on this pilot study, foster parents of medically fragile children benefit from an individual teaching session by a medical professional. CPR instruction for this group of foster parents should include adequate review and assessment of foreign body removal procedures.

Intrathoracic petechiae in sudden infant death syndrome: relationship to face position when found

Previous studies have not addressed the relationship of intrathoracic petechiae (IP) to the position of the face when a caretaker finds a victim of sudden infant death syndrome (SIDS). The aims of this retrospective study were to determine (1) the rate of the facedown position in SIDS (not to be confused with the prone body position), (2) if the facedown position occurred more frequently among SIDS victims with intrathoracic petechiae than those without petechiae, and (3) if the facedown position occurred more frequently among cases with more severe petechial hemorrhage of the thymus. We selected 199 SIDS cases from the San Diego SIDS Research Project database and grouped them as IP-present and IP-absent. Each case was analyzed with regard to the face position when found unresponsive or dead. Among these 199 cases, 37% were found face-down, which represents 51% of the 142 cases found prone. The two groups were similar with respect to age, sex, and rate of premature birth. Thirty-nine percent (39%) of the IP-present group and 9% of the IP-absent group were found in the facedown position (P = 0.057; 95% confidence interval for the difference = 0.3%, 40%). Cases were also grouped by severity of thymic petechiae and analyzed regarding face position. Neither age nor the facedown position was associated with greater severity of thymic petechiae. The wide confidence interval yielded by our analysis of IP limits our ability to clarify the precise pathophysiologic role of external oronasal obstruction in SIDS. While it remains possible that a subset of SIDS cases occur as a result of external obstruction, we are unable to generalize its importance. Internal airway obstruction and rebreathing with terminal gasping, both of which have been documented in sudden infant death, remain other possible scenarios leading to the production of IP.

Neck extension and rotation in sudden infant death syndrome and other natural infant deaths

It has been hypothesized that some cases of sudden infant death syndrome (SIDS) are a result of neck extension and/or rotation that causes vertebral artery (VA) compression and brain stem ischemia. There is a paucity of relevant literature on this topic. Therefore, our aim was to compare neck rotation and extension in SIDS and other natural infant deaths. Cases of SIDS and other natural infant deaths within the San Diego SIDS Research Project database were analyzed retrospectively with respect to neck and body position as reported by the trained, experienced scene investigators and/or the caretakers who discovered the infants. Information was used from 246 SIDS cases and 56 cases of other natural deaths. Simultaneous neck extension and rotation was not reported in either group. When data regarding neutral/flexed/extended position and rotation of the neck were combined, no significant differences were found between the two groups (P = 0.94); 40% of the SIDS cases and 41% of the other natural death cases were found with the neck either extended or rotated (odds ratio [OR] 0.97, [reference group = neck either neutral or flexed, and not rotated], 95% confidence interval [CI] 0.45, 2.11). There were also no significant differences between the groups when neck rotation and neck extension were analyzed independent of one another. Neck rotation among cases found in the prone position was common and was not significantly different between the two groups (49% of 146 SIDS cases, 58% of 24 other natural death cases, P = 0.38, OR 0.68, 95% CI 0.28, 1.62). Neck rotation among infants found in the supine position occurred one-third as often in the SIDS group (9% of 33 cases) as in the other natural death group (29% of 14 cases); however, the difference was not significant (P = 0.17; OR 0.25, 95% CI 0.05, 1.31). Although our analysis does not exclude VA compression and brain stem ischemia in some cases of SIDS, we found no evidence to affirm its importance. This study demonstrates the importance of meticulous scene descriptions, including neck position.

Successful treatment of retrograde ejaculation with sperm recovered from bladder washings. A report of two cases

BACKGROUND

Retrograde ejaculation causes < 2% of male infertility but is the leading cause of aspermia. The incidence of retrograde ejaculation is increasing due to the aggressiveness of modern urologic cancer surgery and an increase in diabetes mellitus. Generally, the only adverse effect is on fertility. Various approaches have been proposed for treatment, ranging from insemination with sperm-rich urine obtained after masturbation to intracytoplasmic sperm injection (ICSI). We used a protocol involving bladder washing.

CASES

Case 1 involved a man with retrograde ejaculation secondary to a successful right orchiectomy and retroperitoneal lymph node dissection for stage B1 embryonal cell carcinoma. He was treated with bladder washing and intrauterine insemination. He fathered three children from six insemination cycles. Case 2 involved a man with idiopathic retrograde ejaculation and a wife with ovulatory dysfunction. He received treatment similar to that in case 1 and fathered one child from two insemination cycles.

CONCLUSION

Larger studies need to be done specifically comparing treatments. Our method resulted in four normal infants in two couples over eight total insemination cycles and, taken together with other results from the literature, seems a good choice for clinicians who are treating retrograde ejaculation for the first time. We agree with others who have recommended that in vitro fertilization/ICSI not be the first step for treating the usual couples with retrograde ejaculation.

Laparoscopic removal of a perforated intrauterine device from the perirectal fat

BACKGROUND

The intrauterine device (IUD) was a very common form of birth control in the United States. The most serious potential complication of IUD use is uterine perforation. Uterine perforation is common among women with "lost" IUDs and can cause severe morbidity and mortality and should be carefully managed. The recommended treatment is removal of the perforating IUD. This can usually be managed laparoscopically unless bowel perforation or other severe sepsis is present.

METHODS

An intra-abdominal IUD was removed laparoscopically from the perirectal fat of a 49-year-old woman who had been diagnosed over 20 years earlier with an "expelled" IUD.

CONCLUSIONS

It is important that the possibility of uterine perforation be considered in anyone who has had a diagnosis of an expelled IUD without actual confirmation that the IUD is no longer present in the body. In any woman who presents with pelvic pain and a history of a "lost" IUD, the surgeon should have a high index of suspicion and obtain radiological studies. It may be advisable to question women about possible IUD use when they present with pelvic pain of unknown origin.

The effect of valproic acid on blood loss in patients with cerebral palsy

Valproic acid (VPA) is used in the treatment of seizure disorders often present in patients with cerebral palsy. The charts of 114 patients with cerebral palsy were reviewed to evaluate the effect of VPA on blood loss during spine surgery. Forty-one patients had seizure disorders. Of these, 18 were taking VPA as monotherapy (group III) and the remaining 23 patients were taking other antiseizure medications, including two taking VPA (group II). There was a significant increase in the number of patients with abnormal bleeding times and a significant difference (p < 0.001) in blood loss (ml/kg) in patients taking VPA as monotherapy (38.6 ml/kg vs. 30.0 ml/kg). There was also increased blood-product administration postoperatively in the VPA monotherapy patients. Physicians should be aware of this potential association between VPA use and increased blood loss. The routine laboratory tests of complete blood count, prothrombin time, and partial thromboplastin time will not adequately screen for the platelet-mediated effects of VPA.

Impact of lifestyle choices on female infertility

OBJECTIVE

To inform physicians who are involved in the primary care of reproductive-age women of the specific relationships between lifestyle choices and infertility so that they can use this knowledge to educate their patients and encourage changes in behavior.

STUDY DESIGN

A review of the relevant literature, performed via Medline search.

RESULTS

Prevention of chlamydial and gonorrheal infections; maintenance of the proper body weight; increased individual awareness about the effects of age on fecundity; and reduced intake of caffeine, tobacco and alcohol are all possible avenues for primary prevention of infertility.

CONCLUSION

Lifestyle choices can be made that influence the reproductive capability of women. It may be worthwhile for primary care physicians to use information on lifestyle to encourage their patients to improve their overall health while positively affecting their ability to reproduce.

Gamete intrafallopian transfer. A cost-effective alternative to donor oocyte in vitro fertilization in women aged 40-42 years

OBJECTIVE

To investigate whether gamete intrafallopian transfer (GIFT) may be a cost-effective alternative to donor oocyte procedures in women 40 and older with good ovarian reserve.

STUDY DESIGN

Retrospective review of records at an infertility clinic in a large multispecialty group practice. Twenty two consecutive women aged 40 and older underwent 24 stimulation cycles for laparoscopic GIFT procedures from 1988 to 1997.

RESULTS

The mean GIFT cycle cost was $5,731. The delivery rate per stimulation cycle was 25.0%. The patients who gave birth were 40-42 years of age. The mean cost per delivered infant was $22,924. A previously reported value for mean cost per pregnancy for donor oocyte in vitro fertilization (IVF) was $30,457. Theoretical costs per delivery, generated from Society for Assisted Reproductive Technology outcome data for anonymous donor oocyte IVF in 1994 (delivery rate per transfer, 34.4%) for $8,000, $9,000 and $10,000 cycle costs were $23,256, $26,163 and $29,070, respectively.

CONCLUSION

In women with good ovarian reserve, GIFT may be a cost-effective alternative to donor oocyte IVF at age 40-42.

Ice-cream truck-related injuries to children

Few studies exist on the cause and nature of injuries to children from ice-cream truck-related accidents. We reviewed the medical records of 11 children with orthopedic injuries treated at Children's Hospital-San Diego from 1985 to 1995 for injuries in such accidents. Of nine children on their way to or from an ice-cream truck who were struck by an oncoming vehicle, all were girls; eight had pelvic or lower-extremity fractures. When ice-cream trucks park on the street, they pose a danger to children, because children are drawn to them, and the trucks' large size blocks the vision of oncoming drivers.

Etiology of supracondylar humerus fractures

The specific etiology of supracondylar humerus fractures in children is not well known. All supracondylar humerus fractures treated at Children's Hospital and Health Center, San Diego (CHSD) over an 8-year period (n = 391) were reviewed to determine specific information about the manner in which the injury occurred. Girls tended to sustain these fractures more often, and the nondominant arm was more often injured. Falls from a height accounted for 70% of the fractures. Children < or = 3 years old tended to fall off of household objects (beds, couches, other objects 3-6 feet high), and children 4 years and older tended to fall from playground equipment such as monkey bars, slides, and swings. Safety precautions should be implemented in homes of young children and at playgrounds to avoid these fractures.

Laparoscopic removal of virilizing hilar cell tumor in a postmenopausal patient

A postmenopausal woman experienced rapidly progressing hirsutism and signs of virilization. Hormone evaluations showed markedly elevated serum testosterone levels and no evidence of excess cortisol or dehydroepiandrosterone sulfate production. A computerized tomographic scan of the adrenals and ovaries was normal, and transvaginal ultrasound revealed a left ovary with a maximum diameter of 3.2 cm. At outpatient laparoscopic bilateral oophorectomy, the left ovary had a benign, 2.5-cm Leydig cell tumor, hilar cell variant. Laparoscopy may be useful in the diagnosis and treatment of select cases of virilizing tumors of the ovary.

Improving the cost-to-benefit ratio of in-vitro fertilization

In-vitro fertilization (IVF) has been criticized for being too costly to permit ready access to needy patients, either through their own funds or through those of third party providers. European groups have managed to offer these procedures at a fraction of the cost incurred by their United States counterparts by streamlining their protocols. Accordingly, we present our methods for reducing the cost of IVF. The main modification was made by performing the IVF procedures in the clinic under i.m. analgesia, avoiding the costs of a surgery suite and anaesthesia. In addition, donor, oocyte, micromanipulation, and cryopreservation services were not offered, reducing overall personnel and equipment costs. Overall costs were reduced from customary levels of $7,000--$11,000 in the United States to $3,409 per cycle initiated, while maintaining good ongoing/delivered pregnancy rates (30.0% versus 18.6% nationally) per cycle reaching aspiration. We conclude that, through the elimination of less necessary and/or utilized procedures, IVF may be performed in a more cost-effective manner while maintaining good success rates. For the patients who desire IVF services not offered under such a system, referral to a more specialized IVF center is appropriate.

High-frequency pressure-control ventilation with high positive end-expiratory pressure in children with acute respiratory distress syndrome

OBJECTIVE

Animal models suggest that high-frequency ventilation with low tidal volumes and high positive end-expiratory pressure (PEEP) minimize secondary injury to the lung. We hypothesized that using a high-frequency pressure-control mode of ventilation with high PEEP in children with severe acute respiratory distress syndrome (ARDS) would be associated with improved survival.

DESIGN

The study was a retrospective and prospective clinical study at a 24-bed tertiary care pediatric critical care unit. Fifty-three patients with severe ARDS were studied during a 37-month period, 30 prospectively and 23 retrospectively. Severe ARDS was defined as (1) rapid onset of severe bilateral infiltrates of noncardiac origin, (2) partial pressure of oxygen (arterial)/fraction of inspired oxygen less than 200 on PEEP of 6 cm H2O or more for 24 hours or longer, and (3) Murray disease severity score greater than 2.5. All patients meeting these criteria underwent ventilation in the pressure-control mode; the protocol for ventilation had the following general guidelines: (1) fraction of inspired oxygen limited to 0.5, (2) mean airway pressure titrated with PEEP to maintain arterial partial pressure of oxygen of 55 mm Hg or greater (7.3 kPa), (3) peak inspiratory pressure minimized to allow hypercapnia (arterial partial pressure of carbon dioxide, 45 to 60 mm Hg (6.0 to 8.0 kPa), and (4) ventilator rates of 40 to 120/min. Percutaneous thoracostomy and mediastinal tubes were placed for treatment of air leak.

RESULTS

The survival rate was 89% (47/53) in children with severe ARDS. Nonsurvivors had significantly higher peak inspiratory pressures (75 vs 40 cm H2O, p = 0.0006), PEEP (23 vs 17 cm H2O, p = 0.0004), mean airway pressure (40 vs 28 cm H2O, p = 0.04), alveolar-arterial oxygen gradient (579 vs 540 mm Hg, p = 0.03), and oxygenation index (43 vs 19, p = 0.0008) than survivors. Air leak was present in 51% of patients; there was no difference in the incidence of air leak between survivors and nonsurvivors (p = 0.42).

CONCLUSIONS

The high-frequency positive-pressure mode of ventilation was safe and was associated with an improved survival rate (89%) for children with severe ARDS. Limitation of both inspired oxygen and tidal volume, along with aggressive treatment of air leak, may have contributed to the improved survival rate.

Outpatient minilaparotomy ovarian cystectomy for benign teratomas in teenagers

Benign cystic teratomas are the most common ovarian neoplasms in adolescents. An ovary-conserving method was developed for outpatient surgical removal of benign cystic teratomas by minilaparotomy in teenagers. The technique requires no specialized training, laser devices, or expensive disposable instrumentation. As a precaution, the first teenager in whom the technique was used was observed as an inpatient for 3 days. Following this, the method was used as an outpatient procedure in three further cases. No complications occurred in any of the four patients, and the mean operating time of 85 minutes (range, 60 to 95 minutes) was similar to the reported time for removal of benign cystic teratomas by laparotomy. Although a randomized controlled study with many more patients would be necessary for a definitive conclusion, considerable cost savings and reduction in morbidity over traditional laparotomy are suggested by this experience.

Laparoscopic diagnosis and treatment of an infarcted epiploic appendage

A patient experienced acute abdominal pain that was diagnosed at laparoscopy as being due to an infarcted epiploic appendage. To our knowledge, this is the second report of laparoscopic diagnosis and treatment of an epipolic disorder. Infarcted epiploic appendages may be associated with bowel obstruction and abscess formation. Therefore, they should be looked for at the time of diagnostic laparoscopy for acute abdominal pain of unclear etiology, and removed if present.

Peripheral joint laxity increases in pregnancy but does not correlate with serum relaxin levels

OBJECTIVE

Our purpose was to evaluate peripheral joint laxity during pregnancy and to determine whether serum relaxin levels are associated with increased joint laxity.

STUDY DESIGN

A prospective observational study was performed.

RESULTS

A significant increase in joint laxity was found in five of seven peripheral joints over the course of the pregnancy and post partum. There was no correlation with serum relaxin levels. There were no significant differences in joint laxity on the basis of parity, age, or prepregnancy exercise levels.

CONCLUSIONS

Peripheral joint laxity is noted to increase as pregnancy progresses. The cause of this change is undetermined.

Equal effectiveness of electrical and volitional strength training for quadriceps femoris muscles after anterior cruciate ligament surgery

Neuromuscular electrical stimulation and voluntary muscle contraction are two exercise modes widely used in rehabilitation to strengthen skeletal muscle. Since there is no debate as to which mode is most effective, we compared electrical stimulation with voluntary contraction performed at matched intensities following reconstructive surgery of the anterior cruciate ligament. Forty men and women, aged 15-44, were randomly assigned to either an electrical stimulation or a voluntary contraction group. None of the subjects had a previous history of neuromuscular injury. The subjects received treatment for 30 minutes a day, 5 days a week, for 4 weeks. Knee extension torque was monitored during treatment to try to match the absolute muscular tensions (quantified as "activity") achieved during therapy. To match the activity of the subjects in the electrical stimulation group, who were treated at the highest stimulation intensity they could tolerate, the subjects in the voluntary contraction group were paced at progressively increasing intensities corresponding to 15, 25, 35, and 45% of the injured limb's maximum voluntary torque during weeks 1, 2, 3, and 4, respectively. We found no significant difference between the groups in terms of maximum voluntary knee extension torque throughout the study period. In addition, 1 year after surgery, there was still no significant difference between groups with regard to knee extension torque (p > 0.4). These data suggest that neuromuscular electrical stimulation and voluntary muscle contraction treatments, when performed at the same intensity, are equally effective in strengthening skeletal muscle that has been weakened by surgical repair of the anterior cruciate ligament.

Factors associated with improving success rates with gamete intrafallopian transfer under thin-needle spinal anesthesia

PURPOSE

In order to reduce the risk of major anesthetic complications associated with laparoscopic gamete intrafallopian transfer procedures, we have exclusively used thin-needle spinal anesthesia over the years 1991 - 1994. This paper will review complication rates in order to further establish the safety profile of GIFT under thin-needle anesthesia and report the changes in our GIFT protocol from 1991 to 1994 which have been associated with a statistical improvement in the implantation rate from 11% to 23% (P = 0.01) and an increase in delivery rates from 29% to 42% per transfer procedure.

METHODS

Sixty-eight laparoscopic GIFT procedures were done in women with at least one patent oviduct and failure to respond to less invasive treatment. Clinical variables were analyzed to determine if similar patient populations had been treated over the study period.

RESULTS

The improved delivery rates and implantation rates could not be explained by patient selection. No major perioperative complications occurred. Minor perioperative complications and difficulties included one patient requiring general anesthesia, one patient developing a spinal headache which could be managed conservatively at home, and one patient requiring a minilaparotomy to complete the GIFT procedure. The more serious complications occurred as a result of the superovulation and multiple oocyte transfer rather than the surgical or anesthetic technique. These included two patients with severe ovarian hyperstimulation requiring hospitalization, and five delivered triplet pregnancies. Factors associated with improving success rates included improvements in semen and equipment preparation as well as an increase in the number of sperm transferred from 200,000 to 500,000.

CONCLUSIONS

GIFT can be performed with relative safety under thin needle spinal anesthesia with high implantation and delivery rates if care is made to optimize sperm and equipment preparation. GIFT under thin-needle spinal anesthesia may be an attractive alternative for treatment of longstanding nontubal infertility in couples willing to take the risk of ovarian hyperstimulation and multiple pregnancy.

Improved combined laparoscopic and minilaparotomy technique to allow for reversal of extensive tubal sterilization

We assessed the efficacy of combined laparoscopic and minilaparotomy for outpatient microsurgical reversal of extensive tubal sterilization in 11 women undergoing the procedure and followed for a mean of 24.7 months. All patients desired reversal of extensive tubal sterilization, and had 4 cm or less of the longer oviduct remaining. The mean operating time was 110 minutes, and the mean total cost was $5067. There were no major complications. Two women were treated for uncomplicated cystitis within 1 month of surgery. Five (45%) of 11 women delivered viable infants; one patient had two ectopic pregnancies. These preliminary data suggest that outpatient combined laparoscopy and minilaparotomy may be effective in patients who desire restoration of fertility after extensive tubal sterilization.

Serum parathyroid hormone-related protein levels during lactation

We measured parathyroid hormone-related protein (PTHrP) in the serum of 15 healthy women within three days of beginning breast-feeding and within one hour of completing nursing. A sensitive immunoradiometric assay that measures N-terminal PTHrP containing at least the first 74 amino acids was used. We found normal PTHrP values in all patients. Values one day before and two days after delivery in a hypoparathyroid woman who chose not to breast-feed were also normal. Since N-terminal PTHrP fragments of 1-36 amino acids or more are biologically active, we believe additional studies using sensitive PTHrP assays that measure smaller fragments and investigations performed under other conditions of breast-feeding are necessary before concluding that PTHrP does not have a role in calcium homeostasis in nursing mothers. Furthermore, additional studies in hypoparathyroid nursing mothers should be performed.

Laparoscopic treatment of heterotopic pregnancy

The increasing frequency of pelvic inflammatory disease and use of ovulation-induction agents has resulted in a corresponding increase in the frequency of heterotopic pregnancy. In most reported cases the diagnosis was made retrospectively at the time of laparotomy. With improvements in ultrasonography and operative laparoscopy, the diagnosis can be made preoperatively and the disease treated surgically with low morbidity. In a woman who had received clomiphene citrate for ovulation induction, the diagnosis of heterotopic pregnancy was suspected preoperatively based on transvaginal ultrasonography. The patient was treated laparoscopically by partial salpingectomy, and subsequently delivered a normal infant.

Spontaneously acquired, unilateral absence of the adnexa. A case report

A free-floating, calcified cyst was found in the peritoneal cavity in association with unilateral absence of the adnexa. The evidence was that it was due to torsion and separation of the adnexa from their supporting structures. This phenomenon may be a cause of congenital absence of the ovary.

Use of the Edinburgh Postnatal Depression Scale to identify postpartum depression in a clinical setting

The Edinburgh Postnatal Depression Scale (EPDS) is a validated instrument developed specifically to identify women experiencing postpartum depression (PPD). This study sought to determine the extent of postpartum depression in our population and the maternal characteristics associated with it and to also determine if the scale increased practitioner awareness and treatment of PPD. Two hundred eighty-seven women from the total population completing the EPDS in 1991 (n = 1,139) were randomly selected for retrospective chart review to identify relationships between maternal characteristics and elevated EPDS scores. Charts were also reviewed for outcomes related to depression for the six-month period after delivery. Statistical analysis of the data revealed that 17.4% of the total population had an EPDS score of > or = 10, indicating a potential risk of developing PPD. Eight percent scored > or = 13, suggesting that further assessment was necessary. Marital instability, lack of medical insurance and a history of depression were the factors found to correlate most significantly with elevated EPDS scores. The physicians and midwives providing service for our population were interviewed, and 83% reported that the EPDS had increased their awareness of PPD, while 92% reported having referred for treatment patients with high EPDS scores. Use of the EPDS scale can improve practitioner awareness and aid in the diagnosis of PPD. Several easily identifiable variables are associated with PPD.

Reproductive potential after treatment for persistent ectopic pregnancy

We examined the success rate and reproductive outcome of 50 patients who had been treated for persistent EP after initial unsuccessful salpingostomy. All who underwent salpingectomy had successful treatment of their persistent EP. One treatment failure occurred after MTX. Of 50 women, 32 (61.5%) attempted conception after treatment for persistent EP. The cumulative clinical pregnancy rate after treatment for persistent EP was 59% at 36 months. There was a significant association between clinical pregnancy rate after persistent EP and those with normal contralateral fallopian tubes (P < 0.005). The relative risk of having a clinical pregnancy among those who attempted conception was 2.3 for those having a normal contralateral fallopian tube compared with those with a contralateral fallopian tube with obvious pathology. Intrauterine pregnancy rates after treatment of persistent EP were similar to those reported for primary treatment of EP.

Identifying hearing loss in the intensive care nursery: a 20-year summary

The outcome of a study on hearing loss in graduates of one third-level and two second-level intensive care nurseries (ICN) is reported. The goals were to identify, test, and fit hearing aids on those who need them. Initial hearing-threshold estimates were obtained by auditory brainstem response (ABR) analyses at the time of discharge from the hospital; the mean percentage of failures to respond to 30-dB nHL clicks (in one or both ears) was 19.8 percent for the third-level ICN graduates (N = 4374), and 12.0 percent for the second-level graduates (N = 1527). About half of those with hearing loss at the initial Test were returned for a ReTest 6-20 weeks later, at which time 48.7 percent of the third-level and 44.0 percent of the second-level group were judged normal because they delivered 25-dB click ABRs bilaterally. Following conventional audiological work-ups of the ones with unilateral or bilateral hearing loss, hearing aids were fitted to 92 in the third-level group (2.1% of those Tested) and 22 of the second-level group (1.4%). Not quite half of these fittings occurred within 1 year of the hospital Test that initially diagnosed the loss.

Live birth after treatment of severe adenomyosis with a gonadotropin-releasing hormone agonist

A patient with a 10-year history of secondary infertility underwent GnRH-a therapy with LA for 5 months to control symptoms of severe adenomyosis and to avoid an unwanted hysterectomy. Shortly after cessation of treatment, the patient conceived. A healthy male was delivered at term by cesarean section, which makes this the first report of a live birth after treatment of severe adenomyosis with a GnRH-a.

Reproductive outcome after 143 laparoscopic procedures for ectopic pregnancy

OBJECTIVE

To analyze reproductive outcome after laparoscopic procedures for ectopic pregnancy, with particular attention to laparoscopic salpingectomy.

METHODS

In a 260-physician multispecialty clinic in the rural upper midwestern United States, 143 patients were followed prospectively after undergoing laparoscopic procedures for ectopic pregnancy. Ninety-five who sought further pregnancies during the study period were analyzed for reproductive outcome. Intrauterine pregnancy rates were compared by age, parity, size of ectopic gestation, and evidence of prior tubal damage. Life table analysis was also performed.

RESULTS

The overall intrauterine pregnancy rates for laparoscopic salpingostomy (60%) and laparoscopic salpingectomy (54%) were not significantly different from each other. However, intrauterine pregnancy rates differed significantly by history of prior tubal damage. The pregnancy rate was 79% among women without tubal damage and 42% among women with damage.

CONCLUSIONS

Our intrauterine pregnancy rates after both laparoscopic salpingectomy and laparoscopic salpingostomy are similar to those reported in the literature for similar procedures performed at laparotomy. In predicting pregnancy outcome after laparoscopic procedures for ectopic pregnancy, the major variable seemed to be evidence of prior tubal damage. With no evidence of previous damage, we found similarly high pregnancy rates for laparoscopic salpingostomy and salpingectomy.

Gamete intrafallopian transfer with spinal anesthesia

OBJECTIVE

To investigate the feasibility of performing GIFT under spinal anesthesia administered through a thin (27-gauge) needle.

DESIGN

Prospectively studied case series.

SETTING

A tertiary care center staffed by a 260 physician multispecialty group.

PATIENTS

Twenty-seven consecutive fertility patients underwent 28 laparoscopic GIFT procedures, electing to receive spinal anesthesia administered through a thin (27-gauge) needle.

INTERVENTIONS

Laparoscopic GIFT and thin-needle spinal anesthesia.

MAIN OUTCOME MEASURES

Assessment of anesthetic complications and reproductive outcome.

RESULTS

Satisfactory anesthesia was obtained in 27 of the 28 cases (96%). One patient required additional general anesthesia because of failed spinal anesthesia. All patients were discharged from the hospital on the day of surgery and no postdural headache, persistent back pain, meningitis, or neurological deficit was reported on a 7-day follow-up. Of the 12 clinical pregnancies (43%), 9 ongoing/delivered pregnancies occurred (32%). Six patients had livebirths, and three patients have ongoing second or third trimester pregnancies; there were three spontaneous abortions.

CONCLUSIONS

Spinal anesthesia administered through a 27-gauge needle is an attractive option for laparoscopic GIFT. The risk of serious morbidity because of an anesthetic-related complications may be reduced, and the oocytes are not exposed to the potentially deleterious effects of the drugs associated with general anesthesia.

Laparoscopic diagnosis of puerperal ovarian vein thrombophlebitis. A case report

Puerperal ovarian vein thrombophlebitis is a relatively rare postpartum complication that may result in serious complications. The syndrome may be diagnosed through exploratory surgery or diagnostic imaging, although the best method remains unclear. In one case, open laparoscopy yielded a swift diagnosis and ensured prompt treatment without necessitating further diagnostic studies.

The history and current status of nurse midwifery in Wisconsin

Two editorials in the June 1991 Wisconsin Medical Journal communicated a concern for the equitable provision of health care to all Wisconsin residents. They requested greater commitment to this goal by the state government, and cited quality obstetric care as a worthwhile investment of the public dollar for long-term public health. As part of the discussion of resources available to improve obstetrical care, this paper will present a summary of the current status and potential expansion of midwifery practice in Wisconsin after a synopsis of the relevant historical information.

Laparoscopic treatment of recurrent small bowel obstruction

The treatment of recurrent small bowel obstruction due to postoperative adhesions has traditionally consisted of lysis at laparotomy. We report interval open laparoscopic lysis of adhesions to manage one patient. This technique was safely and effectively applied. Additional cases, however, will need to be analyzed to determine the applicability and indications for a laparoscopic approach to recurrent small bowel obstruction.

Outpatient microsurgical reversal of tubal sterilization by a combined approach of laparoscopy and minilaparotomy

A prospective study of 17 cases of microsurgical reversal of tubal sterilization by a combined approach of laparoscopy and minilaparotomy was performed. Inclusion criteria included age less than 43; weight less than ideal body weight plus 20%; documentation of ovulation; 2 cm of proximal oviduct on hysterosalpingography; and a normal semen analysis or postcoital test. A comparison group of the 5 cases of sterilization reversal performed by a standard inpatient technique during the same period was analyzed. The study technique was performed on an outpatient basis in 15 of the 17 cases, 12 patients (71%) conceived 13 intrauterine pregnancies, one ectopic pregnancy occurred, and total patient costs and time until return to work were significantly less with the study versus standard technique.

Open laparoscopy simplifies instrumentation required for laparoscopic oophorectomy and salpingo-oophorectomy

Eight consecutive cases of open laparoscopic oophorectomy and salpingo-oophorectomy are reported. A modified technique that requires fewer specialized instruments and includes removal of the intact adnexa is demonstrated. Patients were not included if there was any suspicion of malignancy. Indications for surgery included chronic pelvic pain after hysterectomy (N = 5), endometriosis (N = 1), estrogen receptor-positive metastatic breast carcinoma that had not responded to chemotherapy (N = 1), and tuboovarian ectopic pregnancy (N = 1). No intraoperative or postoperative complications occurred. The average hospital stay was 1.1 days, and patients were released 3-14 days postoperatively. Five of the six patients with chronic pelvic pain had prompt resolution of their symptoms. In one patient who had a unilateral salpingo-oophorectomy, a contralateral procedure was required 3 months later because of continued chronic pelvic pain; her pain subsequently resolved. Laparoscopic salpingo-oophorectomy has the potential to decrease morbidity as compared with laparotomy in appropriately selected cases.