Encouraging pulmonary outcome for surviving, neurologically intact, extremely premature infants in the postsurfactant era

OBJECTIVE

The aim of this study was to determine the long-term pulmonary outcome of extreme prematurity at a single tertiary-care center from 1997 to 2001 in the postsurfactant era.

METHODS

We assessed symptoms, exhaled nitric oxide, spirometry, methacholine challenge (provocative concentration of methacholine required to decrease FEV₁ by 20% [PC(20)]), lung volumes, diffusion, and cardiopulmonary exercise tolerance.

RESULTS

Of 279 infants born, 192 survived to discharge, and 79 of these developed bronchopulmonary dysplasia (BPD) (65 mild, 12 moderate, two severe). We studied a subgroup of 53 neurologically intact preterm subjects aged 10 ± 1.5 years (28 with BPD [born, 26.2 ± 1.4 weeks; birth weight, 821 ± 164 g] and 25 without BPD [born, 27.2 ± 1 weeks; birth weight, 1,050 ± 181 g]) and compared them with 23 term control subjects. Of the BPD cases, 21 were mild, seven were moderate, and none was severe; 77.4% of subjects received antenatal steroids, and 83% received postnatal surfactant. Sixty percent of the preterm subjects wheezed at age < 2 years compared with 13% of the control subjects (P < .001), but only 13% wheezed in the past year compared with 0% of control subjects (not significant). For preterm and control subjects, respectively (mean ± SD), FEV₁ % predicted was 85% ± 10% and 94% ± 10% (P < .001), with limited reversibility; residual volume/total lung capacity was 29.3% ± 5.5% and 25% ± 8% (P < .05); diffusing capacity/alveolar volume was 89.6% ± 9.2% and 97% ± 10% (P < .005); and PC(20) was 6.5 ± 5.8 mg/mL and 11.7 ± 5.5 mg/mL (P < .001). PC(20) was < 4 mg/mL in 49% of preterm subjects despite normal exhaled nitric oxide. Most measurements were similar in premature subjects with and without BPD. Peak oxygen consumption and breathing reserve were normal, but % predicted maximal load (measured in Watts) was 69% ± 15% for subjects with BPD compared with 88% ± 23% for subjects without and 86% ± 20% for control subjects (P < .01).

CONCLUSIONS

Pulmonary outcome was encouraging at mid-childhood for neurologically intact survivors in the postsurfactant era. Despite mechanical ventilation and oxygen therapy, most had no or mild BPD. Changes found probably reflect the hypoplastic lungs of prematurity.

Creatinine clearance and blood pressure: a 34-year circadian study

BACKGROUND AND OBJECTIVE

The first circadian study of the 361st Medical Laboratory, USAR, was conducted in May 1969 during the Annual Military Training at Brook Army Hospital, Fort Sam Houston, Texas. The study was approved by the Surgeon General, 5th US Army, and was designed to establish a circadian database for 63 medically relevant variables of 13 young members of the Unit. The subsequent studies, all in the month of May, in 1979, 1988, 1993,1998, and 2003, followed the same protocol and were conducted at Edward Hines Jr., Veterans Administration Hospital, after approval by Human Studies Subcommittees. Since a reduction in Creatinine Clearance (CrCl) to the level of 60 ml/min/1.73m2 signals the onset of kidney malfunction and since a concurrent increase in blood pressure (BP) >140/90 mm Hg, contributes greatly to an unfavorable cardiovascular prognosis, it seemed prudent to examine possible changes in these and in other relevant variables in a group of young Army men, which may have developed over a 34 year period of time.

MATERIAL AND METHODS

Thirteen US Army male volunteers (23-27y of age) served as subjects in the 1969 study. A majority of these men, two additional Army men and two non-military subjects, participated in subsequent studies: 1979 (7,2,1), 1988 (8,2,1), 1993 (5,4,1), 1998 (7,2,2), 2003 (7,2,1). In each study, subjects were admitted to a hospital ward, were given medical examination including a 12-lead electrocardiogram and followed the same Protocol. Lights "OUT" at 22:30h and "ON" at 06:30h. The meals, hospital 2400-calorie diets, were served at 17:30, 07:30 and at 13:30h. Vital signs were measured immediately after each 3h urine collections, around the clock, and bloods were collected every 3h. Blood, plasma, serum, saliva and urines were analyzed for numerous analytes including creatinine, using automated laboratory systems. Kidney functions were assessed using the measured and estimated glomerular filtration rates.

RESULTS

Over the 34y study span, 16 men provided sixty-one 24h profiles for CrCl-related variables (urine volume, creatinine, and serum creatinine) and fifty-eight profiles for BP. Using all normalized data, a significant circadian rhythm was found for each of these variables. Significant circadian variations in SBP, DBP, serum and urine creatinine, and urine volume, were evident with peak levels, on average, occurring in the evening hours.

CONCLUSIONS

In healthy subjects, age was associated with an increase in SBP and urine volume and with a decrease in urine creatinine. In diabetic subjects, aging was associated with increases in both blood pressure and Creatinine Clearance. It is interesting to note that for the 3 subjects who at a later date developed diabetes, the CrCl levels were higher than the 5 age-matched controls during each study year, over the entire 34y observation span, including the period prior to diagnosis. Clin Ter 2008; 159(6):409-417.

Circadian characteristics of serum calcium, magnesium and eight trace elements and of their metallo-moieties in urine of healthy middle-aged men

OBJECTIVE

To monitor the around-the-clock distribution of serum and urine concentrations of calcium, magnesium and eight trace elements and of those same elements in urine after their dialysis, and to statistically describe their circadian characteristics by chronobiological procedures.

MATERIALS AND METHODS

Serum and urine samples were collected every 3h over a single 24h period from eleven clinically-healthy male subjects, 41-60 years of age, and were analyzed for calcium (Ca), magnesium (Mg), iron (Fe), copper (Cu), zinc (Zn), lead (Pb), cadmium (Cd), cobalt (Co), chromium (Cr), and nickel (Ni). Urines were also sequentially dialyzed against ammonium-barbituric acid buffer at pH 7.35+/-0.02 using a 12.000-14.000 molecular weight exclusion sieve and then reanalyzed for the same elements. Urine concentrations were adjusted by urine volume to reflect a 3h excretion rate. Time-series were analyzed for circadian time-effect by ANOVA and for rhythm characteristics by the single cosinor fitting procedure.

RESULTS

The dialysis effectively removed 90% of total solids, 97% of urea, 92% creatinine, 72% uric acid, and essentially all of glucose. It also removed 99% of potassium (K), 96% of sodium (Na), 65% of Ca and P, 55% of Mg, 41% of Zn and 88% of Ni. A significant or borderline-significant 24h rhythm in serum was detected for Ca, Mg, Fe, Cu, Zn, Cd and Cr; in untreated urine for Ca, Fe, Cu, Zn, Ni, creatinine and volume; and in dialyzed urine for Ca, Fe, Cu, Zn, Pb, Cr, Cd and Ni. A 12h component was significant or borderline-significant in serum for Mg, Fe, Zn, and Cd; in untreated urine for volume, creatinine, Ca, Mg, Cu, and Ni; and in dialyzed urine for Ca, Mg, Fe, Cu, Zn, and Cr. In general, values in serum were lowest near the onset of sleep and highest in the first half of the day (between 02:28 and 13:56 h), while highest values in untreated or dialyzed urine were found several hours later in the day and at night.

CONCLUSIONS

Significant circadian variations were found in levels of nearly every element that was measured in blood and urine of 11 healthy men, but with highest and lowest levels occurring at different times. This suggests not only that urine concentrations need to be adjusted for collection time interval and urine volume, but that different biological limits at different times of the 24h day should be applied for serum and urinary monitoring of trace elements. We also found that the non-dialyzable segments of these elements in urine represent metallo-moieties composed of proteinacious matter greater than 12,000-14,000 Daltons. Further studies would be of interest to reveal time specificity for metabolic functions associated with any of these trace elements.

Twenty-nine year study on circadian distribution of urinary zinc levels of same male subjects

OBJECTIVES

To examine the circadian distribution and total 24h levels of urinary zinc (Zn) in same male subjects over an extended period of time in order to ascertain their relationship with aging.

MATERIALS AND METHODS

Eight young army volunteers served as subjects over a period of 29 years: 1969, 1979, 1988, 1998. By 1979 three of them became latent diabetics. Complete physical examination, anthropometric measurements and same procedural protocol was followed in each study. Samples were collected over 3 hour periods for 24 hours in the middle of each month of May. Urine aliquots were analyzed for creatinine, using conventional laboratory procedure. Zn was analyzed using Atomic Absorption Spectrophotometry in 1969, and 1979 and by Inductively Coupled Plasma, in 1988 and 1998.

RESULTS

Over the course of 29 years the circadian distribution of Zn was altered by decrease in amplitude in Zn levels, while the 24h concentrations of Zn decreased progressively with increasing age in healthy and diabetic subjects: Healthy; 966+/-130 microg at age of 29; 666+/-14 microg at 39; 511+/-80 microg at 48; and 555+/-71 microg at age of 58y; Diabetics exhibited similar trend; 1757+/-60 microg at age 28; 1253+/-40 microg at age 38, 1132+/-31 microg at 47, and 1025+/-11 microg at the age of 57. Anthropometric measurements in each study period revealed significant increases in diabetic subjects for body weight, body surface area, BMI and significant decrease in body heights of both groups.

CONCLUSIONS

The daily excretion of urinary Zn over the 29 years period decreased by 42% in healthy and diabetic subjects. Although there appears to be a lack of a reliable index of intracellular Zn status to accurately monitor and control zinc deficiency in younger and older populations, the present data suggest that depletions of Zn are also evident in healthy aging subjects whose daily diet was not deficient in zinc.

Protracted febrile myalgia in children and young adults with familial Mediterranean fever: analysis of 15 patients and suggested criteria for working diagnosis

OBJECTIVES

To present an analysis of patients with protracted febrile myalgia (PFM), a rarely reported manifestation of familial Mediterranean fever (FMF), and propose clinical criteria for working diagnosis.

METHODS

A multicenter retrospective cohort study of children with PFM was performed. Clinical and laboratory data were obtained by medical record review.

RESULTS

The study group included 15 patients with PFM. PFM occurred as the presenting sign of FMF in 33%. FMF was diagnosed clinically in all and by genetic analysis in 93%. M694V allelic involvement was noted in 93% of the patients. PFM occurred at a mean age of 9 +/- 3.4 years and was characterized by severe generalized muscle pain in all patients and fever in 71%. Mean duration up to diagnosis was 15.5 +/- 6 days. Mean erythrocyte sedimentation rate was 104 +/- 26 mm/h; mean C-reactive protein was 15.4 +/- 6.3 mg%. Creatine kinase was normal. Treatment included corticosteroids (4 patients) and nonsteroidal anti-inflammatory drugs (NSAIDs) (9 patients) with a symptomatic relief achieved at a mean of 7.7 +/- 4.3 days and 5 +/- 3.8 days, respectively (p = 0.14) (mean severity score 3 and 2.2, respectively, p = 0.075). Symptomatic relief in 2 untreated patients was achieved at a mean of 45.5 days.

CONCLUSION

Based on our data, we propose criteria for working diagnosis including: severe disabling myalgia of at least 5 days in a young patient with FMF, associated with fever, elevated levels of inflammatory markers and presence of at least one M694V mutation.

Relationships between 24h observations in intraocular pressure vs blood pressure, heart rate, nitric oxide and age in the medical chronobiology aging project

OBJECTIVE

To evaluate associations between intraocular pressure (IOP) and blood pressure (BP), heart rate (HR), serum nitric oxide (NO), diurnal variations, diabetes and aging in data collected during 24h studies of men conducted over 34y.

MATERIALS AND METHODS

As part of the Medical Chronobiology Aging Project, male Army veterans, ages 22 to 81y, without a history of eye disease, were studied around-the-clock in May 1969 (n = 13), 1979 (n = 11), 1988 (n = 11), 1993 (n = 11), 1998 (n =12) and 2003 (n = 10). Measurements of IOP (R & L eyes, supine position), BP and HR (sitting position), and collection of blood were obtained every 3h (8 readings/24h) from 19:00h to 16:00h the next day. Individual time series were analyzed for circadian characteristics by the least-squares fit of a 24& 12h cosine. After normalizing all data to percent of mean to reduce inter-subject variability in levels, grouped data were analyzed for time-effect by ANOVA and for circadian rhythm by multiple component (24h&12h) cosine fitting. Individual 24h averages were analyzed by simple and multiple regression for relationships between IOP and systemic variables, diabetic status and age.

RESULTS

Over the 34y study span, 22 men provided sixty-three 24h profiles for IOP & HR, 61 for BP, and 21 for NO. Using all normalized data, a significant circadian rhythm was found for each variable at p <0.001. Circadian peaks (orthophases) are located in the late morning for IOP-R (10:20h) and IOP-L (10:52h), and in the evening for HR (18:52h), NO (20:00h), SBP (20:40h) and DBP (21:44h). An out-of-phase relationship of about 10h is noted on a group basis between IOP vs BP, HR and NO. The locations of individual circadian peaks for IOP-R were found around the clock, but with a significant predominance between 10:00 and 16:00h (day type), and 04:00-10:00h (morning type). In contrast, BP, HR and NO showed a significant clustering of evening type or night type peaks. The overall mean IOP for the right eye was slightly, but not significantly, higher than the left eye (17.60+/-0.21 vs 17.34+/-0.18 mmHg; p = 0.385), with a strong positive correlation between both eyes (R = 0.952, p <0.0001). IOP showed a significant positive correlation with SBP (R = 0.49, p <0.001), diabetic status (R = 0.47, p <0.001), age (R = 0.32, p = 0.011), and HR (R = 0.28, p = 0.031). A multiple regression using SBP, DBP, HR, age and diabetic status (5 men became diabetic over the 34y study span) as independent variables resulted in SBP being the strongest predictor of IOP (p = 0.0001), followed by DBP (p = 0.0103). After adjustment for BP, independent effects of age (p = 0.187), HR (p = 0.789) and diabetic status (p = 0.153) were eliminated from the prediction equation.

CONCLUSIONS

The results of these studies reveal significant circadian variations in IOP, BP, HR and NO, with peak levels, on average, near noon for IOP and in the evening for BP, HR and NO. An increase in SBP was associated with an increase in IOP. While SBP and DBP are significant predictors of IOP levels, single measurements during regular clinic hours may not reveal the full functional relationship between the variables measured in our studies. Therefore, circadian information on total 24h patterns may contribute to the reliability of diagnosis and guide proper individualized timing of optimal patient management (e.g., for glaucoma, hypertension, diabetes, among other conditions).

Long term efficacy of peripheral androgen blockade on prostate cancer: CALGB 9782

4573

Background: The treatment of patients with a rising PSA after definitive local therapy is controversial. Patients are reluctant to undergo androgen suppression due to side effects and interest focuses on the timing and intensity of additional therapy. The use of peripheral androgen blockade in this setting is appealing. Methods: Patients with a rising PSA after definitive local therapy were enrolled in a multi-institutional trial. Accrual of 101 patients lasted from Sept 30, 1998 to July 16, 2001. All patients had undergone previous definitive local therapy at least 1 year, and no more than 10 years prior to enrollment. All patients had a repeated rising PSA, above 1 ng/ml, with no detectable evidence of recurrent disease. CT and bone scans were negative. Patients received a combination of oral therapy consisting of Finasteride, at a dose of 5 mg/day, and Flutamide, at a dose of 250 mg TID. Results: The median age was 71, with a median baseline testosterone level of 322 ng/dl. A >80% PSA decline was seen in 91/94, (97%) of the patients. Three other patients had PSA declines of 77%, 73% and 38%, all of which were maintained for at least 28 days. The median time to PSA nadir was 3.2 months. The current median follow-up is 59 months. To date, only 22 patients have progressed, with 47 patients still on peripheral androgen blockade. Eight patients have died without progression, and 22 patients went off therapy for other reasons not related to progression. Also noted were patients showing PSA responses to Flutamide withdrawal, and per protocol remaining on Finasteride. Toxicity to date remains very mild. Conclusions: Peripheral androgen blockade showed excellent activity produced durable PSA responses in this select group of patients. While the clinical significance of a decline in PSA alone is not fully understood_the durability of these PSA responses is encouraging. The median duration of progression free survival and overall survival has not been reached, and is likely to be longer than five years. Quality of life data is undergoing further analysis. This report supports further study of less aggressive treatments for patients who have only a rising PSA after definitive local therapy.

No significant financial relationships to disclose.

Post-phototherapy neonatal bilirubin rebound: a potential cause of significant hyperbilirubinaemia

AIM

To determine the incidence of post-phototherapy neonatal plasma total bilirubin (PTB) rebound.

METHODS

A prospective clinical survey was performed on 226 term and near-term neonates treated with phototherapy in the well baby nursery of the Shaare Zedek Medical Center from January 2001 to September 2002. Neonates were tested for PTB 24 hours (between 12 and 36 hours) after discontinuation of phototherapy, with additional testing as clinically indicated. The main outcome measure, significant bilirubin rebound, was defined as a post-phototherapy PTB > or =256 micromol/l. Phototherapy was not reinstituted in all cases of rebound, but rather according to clinical indications.

RESULTS

A total of 30 (13.3%) neonates developed significant rebound (mean (SD) PTB 287 (27) micromol/l, upper range 351 micromol/l). Twenty two of these (73%) were retreated with phototherapy at mean PTB 296 (29) micromol/l. Multiple logistic regression analysis showed significant risk for aetiological risk factors including positive direct Coombs test (odds ratio 2.44, 95% CI 1.25 to 4.74) and gestational age <37 weeks (odds ratio 3.21, 95% CI 1.29 to 7.96). A greater number of neonates rebounded among those in whom phototherapy was commenced < or =72 hours (26/152, 17%) compared with >72 hours (4/74, 5.4%) (odds ratio 3.61, 95% CI 1.21 to 10.77).

CONCLUSION

Post-phototherapy neonatal bilirubin rebound to clinically significant levels may occur, especially in cases of prematurity, direct Coombs test positivity, and those treated < or =72 hours. These risk factors should be taken into account when planning post-phototherapy follow up.

Spatiotemporal analysis of optical imaging data

Previous methods for analyzing optical imaging data have relied heavily on temporal averaging. However, response dynamics are rich sources of information. Here, we develop and present a method that combines principal component analysis and multitaper harmonic analysis to extract the statistically significant spatial and temporal response from optical imaging data. We apply the method to both simulated data and experimental optical imaging data from the cat primary visual cortex.

A population study of integrate-and-fire-or-burst neurons

Any realistic model of the neuronal pathway from the retina to the visual cortex (V1) must account for the bursting behavior of neurons in the lateral geniculate nucleus (LGN). A robust but minimal model, the integrate-and-fire-or-burst (IFB) model, has recently been proposed for individual LGN neurons. Based on this, we derive a dynamic population model and study a population of such LGN cells. This population model, the first simulation of its kind evolving in a two-dimensional phase space, is used to study the behavior of bursting populations in response to diverse stimulus conditions.

The dynamics of primate retinal ganglion cells

A knowledge of the dynamics (temporal properties) of neuronal populations is essential for an understanding of their function, and is also crucial when one attempts to develop computational or mathematical models of the neurons. Here we review the temporal properties of the receptive fields (RFs) of the two best-studied types of ganglion cells in the primate retina, those that project to the parvocellular (P) and magnocellular (M) layers of the dorsal lateral geniculate nucleus. The center and surround mechanisms of the P RFs are approximately linear, and their impulse responses are very similar, although the surround lags the center by a few milliseconds. The center and surround are chromatically opponent. With the appropriate stimulus, one can find significant nonlinearities in their responses, and also in the interaction between the center and surround. The phase lag between the responses of the center and surround depends on the temporal frequency, so that at high temporal frequency the antagonism between them is reduced or abolished. The temporal responses of M cells are nonlinear, and with increasing contrast they show the effects of a contrast gain control. The different dynamical properties of the two populations suggest that M cells participate in motion analysis, while P cells are used for the analysis of form, texture, and perhaps color.

Patterns of object relations and reality testing deficits in schizophrenia: clusters and their symptom and personality correlates

Bell Object Relations Reality Testing Inventory (BORRTI) profile scores were used to cluster 222 outpatients with schizophrenia or schizoaffective disorder. An eight-cluster solution was subjected to replication analysis, and six clusters were found valid and replicable. These clusters were sorted into three pairs that were interpreted as follows: Residually Impaired consisted of Sealed-Over Recovery and Integrated Recovery; Socially Withdrawn consisted of Socially Withdrawn and Socially Withdrawn-Autistic; and Psychotically Egocentric consisted of Psychotically Egocentric and Psychotically Egocentric-Severe. Clusters were compared on Positive and Negative Syndrome Scale ratings and on subscales from the Eysenck Personality Questionnaire. MANOVAs indicated significant differences among clusters. These differences provided further interpretations of cluster membership. Implications for the use of BORRTI profiles for treatment and rehabilitation planning are discussed.

Colonic J-pouch function in rectal cancer patients: impact of adjuvant chemoradiotherapy

PURPOSE

The colonic J-pouch technique of reconstruction optimizes functional outcome after proctectomy with coloanal anastomosis. However, the impact of adjuvant chemoradiation therapy on pouch function in rectal cancer patients has not been investigated.

METHODS

From January 1994 to December 1999, 74 patients with midrectal or low rectal tumors (less than 10 cm from the anal verge) underwent a proctectomy with coloanal anastomosis with colonic J-pouch reconstruction. Chemoradiation was offered in patients with Stage II and III disease. Radiation therapy was administered using a four-field technique including the anal canal, for a total dose of 50.4 Gy (1.8 Gy/fraction/day). Fifteen patients (20 percent) died with metastatic disease, five (6.8 percent) died of other causes without evidence of recurrence, and five (6.8 percent) were lost to follow-up. In addition, two patients had local recurrence (2.7 percent) at the time of follow-up. Forty-five of 47 eligible patients (96 percent) responded to a questionnaire designed to evaluate specifically the degree of continence and pouch evacuation.

RESULTS

The mean age of patients was 68.9 (range, 42-88) years and the mean duration of follow-up was 28.8 (range, 1-69) months. There were 28 patients in the surgery alone group and 17 patients who received either preoperative (13) or postoperative (4) adjuvant chemoradiation therapy. Patients in the surgery alone group had a significantly better degree of continence (mean +/- standard deviation continence score: 18.1 +/- 2.9 vs. 13.3 +/- 4.1, P < 0.001) and were less likely to experience evacuatory problems (mean +/- standard deviation evacuation score: 21.3 +/- 3.7 vs. 16.4 +/- 3.5, P < 0.001). Use of a pad was more frequent in the chemoradiation therapy than in the surgery alone group (53 vs. 18 percent, P = 0.02). The incidence after functional disorders was also more frequent in the irradiated group of patients: incontinence to gas (76 vs. 43 percent, P = 0.03), to liquid stool (64 vs. 25 percent, P = 0.01), and to solid stool (47 vs. 11 percent, P = 0.01). Moreover, irradiated patients reported more frequent pouch-related specific problems, such as clustering (82 vs. 32 percent, P = 0.001), and sensation of incomplete evacuation (82 vs. 32 percent, P = 0.001). Finally, regression analysis demonstrated that radiation-induced sphincter dysfunction was progressive over time.

CONCLUSIONS

Both preoperative and postoperative chemoradiation therapy adversely affects continence and evacuation in patients with colonic J-pouch. Because radiation-induced damage to the normal tissues is known to be cumulative over time, long-term progressive dysfunction of the anal sphincter and neorectum are causes of concern. Consideration should be given to excluding the anal canal from the field of irradiation in patients with Stage II and III rectal cancer, whenever a sphincter-preserving procedure is planned.