Shoulder dystocia related fetal neurological injuries: the predisposing roles of forceps and ventouse extractions

On the basis of 333 documented cases of permanent perinatal neurological damage, associated with arrest of the shoulders at birth, the authors conducted a retrospective study in order to evaluate the predisposing role, if any, of the utilization of extraction instruments. The investigation revealed that 35% of all injuries occurred in neonates delivered by forceps, ventouse or sequential ventouse-forceps procedures. This frequency was several-fold higher than the prevailing instrument use in the practices of American obstetricians during the same years. A high rate of forceps and ventouse extractions was demonstrable in all birth weight categories. Average weight and moderately large for gestational age fetuses underwent instrumental extractions more often than grossly macrosomic ones. This circumstance indicates that forceps and ventouse are independent risk factors, unrelated to fetal size. Their use entailed central nervous system injuries significantly more often than did spontaneous deliveries. The findings suggest that extraction procedures may be as important as macrosomia among the factors that lead to neurological damage in the child in connection with shoulder dystocia. Because they augment the intrinsic dangers of excessive fetal size exponentially, the authors consider their use in case of > or =4,000 g estimated fetal weight inadvisable. Sequential forceps-ventouse utilization further doubles the risks and is, therefore, to be avoided in all circumstances.

Antibiotic resistance and single-nucleotide polymorphism cluster grouping type in a multinational sample of resistant Mycobacterium tuberculosis isolates

A single-nucleotide polymorphism-based cluster grouping (SCG) classification system for Mycobacterium tuberculosis was used to examine antibiotic resistance type and resistance mutations in relationship to specific evolutionary lineages. Drug resistance and resistance mutations were seen across all SCGs. SCG-2 had higher proportions of katG codon 315 mutations and resistance to four drugs.

Treatment of Clinical Hypothyroidism With Thyroxine and Triiodothyronine: A Literature Review and Metaanalysis

Thyroxine is the standard replacement therapy for patients with clinical hypothyroidism. However, there has been recent interest in examining the potential advantages of combined thyroxine and triiodothyronine treatment for the treatment of hypothyroidism. The authors review the nine studies to-date and conclude that the variability and limitations in study design make definitive and clinically useful recommendations difficult. They therefore conducted a metaanalysis of the nine controlled studies examining the impact of combined thyroxine-plus-triiodothyronine versus thyroxine alone, with measures of psychiatric symptoms as the primary outcome. Their analysis reveals no significant difference in treatment effect on psychiatric symptoms in the nine controlled studies to date.

Maternal oxygen delivery is not related to altitude- and ancestry-associated differences in human fetal growth

Fetal growth is reduced at high altitude, but the decrease is less among long-resident populations. We hypothesized that greater maternal uteroplacental O(2) delivery would explain increased fetal growth in Andean natives versus European migrants to high altitude. O(2) delivery was measured with ultrasound, Doppler and haematological techniques. Participants (n=180) were pregnant women of self-professed European or Andean ancestry living at 3600 m or 400 m in Bolivia. Ancestry was quantified using ancestry-informative single nucleotide polymorphism. The altitude-associated decrement in birth weight was 418 g in European versus 236 g in Andean women (P<0.005). Altitude was associated with decreased uterine artery diameter, volumetric blood flow and O(2) delivery regardless of ancestry. But the hypothesis was rejected as O(2) delivery was similar between ancestry groups at their respective altitudes of residence. Instead, Andean neonates were larger and heavier per unit of O(2) delivery, regardless of altitude (P<0.001). European admixture among Andeans was negatively correlated with birth weight at both altitudes (P<0.01), but admixture was not related to any of the O(2) transport variables. Genetically mediated differences in maternal O(2) delivery are thus unlikely to explain the Andean advantage in fetal growth. Of the other independent variables, only placental weight and gestational age explained significant variation in birth weight. Thus greater placental efficiency in O(2) and nutrient transport, and/or greater fetal efficiency in substrate utilization may contribute to ancestry- and altitude-related differences in fetal growth. Uterine artery O(2) delivery in these pregnancies was 99 +/- 3 ml min(-1), approximately 5-fold greater than near-term fetal O(2) consumption. Deficits in maternal O(2) transport in third trimester normal pregnancy are unlikely to be causally associated with variation in fetal growth.

Familial risk factors in autism

Familial history risk factors in relation to autism were examined in a cohort of 164 autistic children referred to The Autism Center at New Jersey Medical School-University of Medicine and Dentistry of New Jersey, Newark, over a 2-year period (2001-2003). Information related to familial history was obtained from each family and reviewed by a clinician. It is shown that these families carry a higher overall burden of psychiatric and developmental illnesses compared to reported national levels. These families also carry a relatively high incidence of medical disorders, independently of developmental and psychiatric disorders. This work supports the underlying presence of genetic factors in the etiology of autism.

The risk of shoulder dystocia related permanent fetal injury in relation to birth weight

OBJECTIVE

To examine birth weight related risks of fetal injury in connection with shoulder dystocia.

STUDY DESIGN

The investigation was based on a retrospective analysis of 316 fetal neurological injuries associated with deliveries complicated by arrest of the shoulders that occurred across the United States.

RESULTS

The study revealed that the distribution of birthweights for the high risk shoulder dystocia population differs from the standard birthweight distribution. The relative difference per birthweight interval is used to adjust an assumed 1:1000 baseline risk of injury due to shoulder dystocia following vaginal deliveries. These adjusted risks show a need to consider new thresholds for elective cesarean delivery.

CONCLUSIONS

Current North American and British guidelines, that set 5000 g as minimum estimated fetal weight limit for elective cesarean section in non-diabetic and 4500 g for diabetic gravidas, may expose some macrosomic fetuses to a high risk of permanent neurological damage. The authors present the opinion that the mother, having been informed of the risks of vaginal versus abdominal delivery, should be allowed to play an active role in the critical management decisions.

Stereotactic accuracy of a compact intraoperative MRI system

OBJECTIVE

To analyze the stereotactic accuracy of the PoleStar N-20, a compact intraoperative magnetic resonance imaging (iMRI) system, based on a 0.15-Tesla (T) magnet.

METHODS

An MRI-compatible phantom was scanned after being positioned in both the center of the magnetic field (COF) and the periphery of the field (POF) of the PoleStar N-20 magnet. Scans were acquired at various slice thicknesses in 3 sequences: T(1) weighted, T(2) weighted and Esteady (reversed fast imaging with steady-state precession, also known as 'PSIF'). The distance between the actual location of the probe tip in space and the location of the target on the image was measured on the axial, coronal, and sagittal planes for 9 points on each image. Each measurement was repeated 3 times. We also compared the structural features of the PoleStar N-20 to those of its predecessor.

RESULTS

T(1)-weighted scans yielded the most accurate measurements. There was no statistically significant difference between scans acquired at thicknesses of 2, 3, 4 and 8 mm; all were accurate for clinical purposes. Comparison of COF with POF measurements using T(1)-weighted scans did not demonstrate a statistically significant difference in accuracy.

CONCLUSIONS

The PoleStar N-20 0.15-T iMRI system provides surgical navigation that is at least as accurate as the first generation model of this system, which employed a 0.12-T magnet. Further analysis of stereotactic accuracy on clinical cases using the PoleStar N-20 is needed to confirm that these results will bear out in surgical reality.

Prenatal and birth complications in autism

OBJECTIVES

Prenatal and birth history as potential sources of risk factors in relation to the onset of autism were examined.

METHODS

A cohort of 164 families of autistic children referred to The Autism Center at New Jersey Medical School-UMDNJ, Newark, New Jersey, over a two-year period was studied. Intake prenatal and birth history information was obtained from each family and reviewed by a clinician.

RESULTS

Prevalence rates in this cohort for vaginal bleeding, prolonged labor and prematurity were higher than comparable rates reported nationally and in New Jersey. Clustering of multiple prenatal risk factors was observed. This clustering was associated with the age of the mother, but uncorrelated with birth order.

CONCLUSIONS

These findings support the general hypothesis that systemic problems at the prenatal stage may form a distinct dimension of risk associated with autism.

Population genetics study of isoniazid resistance mutations and evolution of multidrug-resistant Mycobacterium tuberculosis

The molecular basis for isoniazid resistance in Mycobacterium tuberculosis is complex. Putative isoniazid resistance mutations have been identified in katG, ahpC, inhA, kasA, and ndh. However, small sample sizes and related potential biases in sample selection have precluded the development of statistically valid and significant population genetic analyses of clinical isoniazid resistance. We present the first large-scale analysis of 240 alleles previously associated with isoniazid resistance in a diverse set of 608 isoniazid-susceptible and 403 isoniazid-resistant clinical M. tuberculosis isolates. We detected 12 mutant alleles in isoniazid-susceptible isolates, suggesting that these alleles are not involved in isoniazid resistance. However, mutations in katG, ahpC, and inhA were strongly associated with isoniazid resistance, while kasA mutations were associated with isoniazid susceptibility. Remarkably, the distribution of isoniazid resistance-associated mutations was different in isoniazid-monoresistant isolates from that in multidrug-resistant isolates, with significantly fewer isoniazid resistance mutations in the isoniazid-monoresistant group. Mutations in katG315 were significantly more common in the multidrug-resistant isolates. Conversely, mutations in the inhA promoter were significantly more common in isoniazid-monoresistant isolates. We tested for interactions among mutations and resistance to different drugs. Mutations in katG, ahpC, and inhA were associated with rifampin resistance, but only katG315 mutations were associated with ethambutol resistance. There was also a significant inverse association between katG315 mutations and mutations in ahpC or inhA and between mutations in kasA and mutations in ahpC. Our results suggest that isoniazid resistance and the evolution of multidrug-resistant strains are complex dynamic processes that may be influenced by interactions between genes and drug-resistant phenotypes.

Pediatricians' knowledge, training, and experience in the care of children with fetal alcohol syndrome

OBJECTIVES

Prenatal exposure to alcohol interferes with fetal development and is the leading preventable cause of birth defects and developmental disabilities. The purpose of this study was to identify current knowledge, diagnosis, prevention, and intervention practices related to fetal alcohol syndrome and related conditions by members of the American Academy of Pediatrics.

METHODS

This study was developed collaboratively by the American Academy of Pediatrics and the Centers for Disease Control and Prevention. Questionnaires were mailed to a 3% random sample (n = 1600) of American Academy of Pediatrics members in the United States. General pediatricians, pediatric subspecialists, and pediatric residents were included.

RESULTS

Participation rate was 55% (n = 879). Respondents almost universally knew the teratology and clinical presentation of fetal alcohol spectrum disorders. However, they were less likely to report comfort with routine pediatric care of these children. Whereas 62% felt prepared to identify and 50% felt prepared to diagnose, only 34% felt prepared to manage and coordinate the treatment of children with fetal alcohol spectrum disorders. Even fewer (n = 114 [13%]) reported that they routinely counsel adolescent patients about the risks of drinking and pregnancy.

CONCLUSIONS

The survey confirms that pediatricians are knowledgeable about fetal alcohol syndrome but do not feel adequately trained to integrate the management of this diagnosis or prevention efforts into everyday practice. Furthermore, the respondents were not active in routine anticipatory guidance with adolescents for prevention of alcohol-affected pregnancies. The development, dissemination, and implementation of best practice tools for prevention, diagnosis, and referral of fetal alcohol syndrome that are specific for general and subspecialist pediatricians are recommended.

Cranial surgery with an expanded compact intraoperative magnetic resonance imager

✓In this article the authors report the implementation of an expanded compact intraoperative magnetic resonance (iMR) imager that is designed to overcome significant limitations of an earlier unit.

The PoleStar N20 iMR imager has a stronger magnetic field than its predecessor (0.15 tesla compared with 0.12 tesla), a wider gap between magnet poles, and an ergonomically improved gantry design. The additional time needed in the operating room (OR) for use of iMR imaging and the number of sessions per patient were recorded. Stereotactic accuracy of the integrated navigational tool was assessed using a water-covered phantom.

Of the 55 patients who have undergone surgery in the PoleStar N20 device, diagnoses included glioma in 13, meningioma in 12, pituitary adenoma in nine, other skull base lesions in seven, and miscellaneous other diagnoses. The extra time required for use of the system averaged 1.1 hours (range 0.5–2 hours). Imaging sessions averaged 2.3 per surgery (range one–six sessions).

Measurement of stereotactic accuracy revealed that T1-weighted images were the most accurate. Thinner slices yielded measurably greater accuracy, although this was of questionable clinical significance (all sequences ≤ 4 mm had a mean error of ≤ 1.8 mm). The position of the phantom in the center compared with the periphery of the magnetic field did not affect accuracy (mean error 0.9 mm for each).

The PoleStar N20 appears to make intraoperative neuroimaging with a low-field-strength magnet much more practical than it was with the first-generation device. Greater ease of positioning resulted in a decrease in added time in the OR and encouraged a larger number of imaging sessions.

Role of embB codon 306 mutations in Mycobacterium tuberculosis revisited: a novel association with broad drug resistance and IS6110 clustering rather than ethambutol resistance

Mutations at position 306 of embB (embB306) have been proposed as a marker for ethambutol resistance in Mycobacterium tuberculosis; however, recent reports of embB306 mutations in ethambutol-susceptible isolates caused us to question the biological role of this mutation. We tested 1,020 clinical M. tuberculosis isolates with different drug susceptibility patterns and of different geographical origins for associations between embB306 mutations, drug resistance patterns, and major genetic group. One hundred isolates (10%) contained a mutation in embB306; however, only 55 of these mutants were ethambutol resistant. Mutations in embB306 could not be uniquely associated with any particular type of drug resistance and were found in all three major genetic groups. A striking association was observed between these mutations and resistance to any drug (P < 0.001), and the association between embB306 mutations and resistance to increasing numbers of drugs was highly significant (P < 0.001 for trend). We examined the association between embB306 mutations and IS6110 clustering (as a proxy for transmission) among all drug-resistant isolates. Mutations in embB306 were significantly associated with clustering by univariate analysis (odds ratio, 2.44; P = 0.004). In a multivariate model that also included mutations in katG315, katG463, gyrA95, and kasA269, only mutations in embB306 (odds ratio, 2.14; P = 0.008) and katG315 (odds ratio, 1.99; P = 0.015) were found to be independently associated with clustering. In conclusion, embB306 mutations do not cause classical ethambutol resistance but may predispose M. tuberculosis isolates to the development of resistance to increasing numbers of antibiotics and may increase the ability of drug-resistant isolates to be transmitted between subjects.

Increased excretion of a lipid peroxidation biomarker in autism

It is thought that autism could result from an interaction between genetic and environmental factors with oxidative stress as a potential mechanism linking the two. One genetic factor may be altered oxidative-reductive capacity. This study tested the hypothesis that children with autism have increased oxidative stress. We evaluated children with autism for the presence of two oxidative stress biomarkers. Urinary excretion of 8-hydroxy-2-deoxyguanosine (8-OHdG) and 8-isoprostane-F2alpha (8-iso-PGF2alpha) were determined in 33 children with autism and 29 healthy controls. 8-iso-PGF2alpha levels were significantly higher in children with autism. The isoprostane levels in autistic subjects were variable with a bimodal distribution. The majority of autistic subjects showed a moderate increase in isoprostane levels while a smaller group of autistic children showed dramatic increases in their isoprostane levels. There was a trend of an increase in 8-OHdG levels in children with autism but it did not reach statistical significance. There was no significant correlation between the levels of the biomarkers and vitamin intake, dietary supplements, medicine, medical disorders, or history of regression. These results suggest that the lipid peroxidation biomarker is increased in this cohort of autistic children, especially in the subgroup of autistic children.

Reduced cardiac parasympathetic activity in children with autism

Many of the clinical symptoms of autism suggest autonomic dysfunction. The aim of this study was to measure baseline cardiovascular autonomic function in children with autism using the NeuroScope, a device that can measure this brainstem function in real-time. Resting cardiac vagal tone (CVT), cardiac sensitivity to baroreflex (CSB), mean arterial blood pressure (MAP), diastolic blood pressure (DBP), systolic blood pressure (SBP) and heart rate (HR) were recorded in three different groups of children. The symptomatic group (n = 15) consisted of those with autism who exhibited symptoms or signs of autonomic dysfunction. The asymptomatic group (n = 13) consisted of children with autism but without symptoms or signs of autonomic dysfunction and the healthy children were in the control group (n = 17) [corrected]. The CVT and CSB were significantly lower in association with a significant elevation in HR, MAP and DBP in all children with autism compared with the healthy controls. Further more, the levels of CVT and CSB were lower in the symptomatic than in the asymptomatic group. The levels of CVT and CSB were not related to age in all the three groups. These results suggest that there is low baseline cardiac parasympathetic activity with evidence of elevated sympathetic tone in children with autism whether or not they have symptoms or signs of autonomic abnormalities.

Dopamine receptor 4 (DRD4) 7-repeat allele predicts methylphenidate dose response in children with attention deficit hyperactivity disorder: a pharmacogenetic study

OBJECTIVE

Genetic polymorphisms of the dopamine neurotransmitter system have been identified in attention deficit hyperactivity disorder (ADHD). Since stimulant medications act through this system, we sought to determine if the 48 base pair VNTR polymorphism (7- repeat allele) of dopamine receptor gene DRD4 predicts methylphenidate responsiveness.

METHODS

Forty-five children, aged 7-15 years, with ADHD, confirmed by NIMH-DISC-IV, participated in this prospective pharmacogenetic study. Subjects received increasing methylphenidate doses based on serial Conners' Global Index-Parent assessments. Doses to obtain a 10-point improvement and normalization (T-score, 60) were determined. Blood and buccal screening for DRD4 7R was correlated with outcomes.

RESULTS

Mean dose for a 10-point CGI-P improvement with DRD4 7R (n=20) was 30 mg (1.00 mg/kg) versus 20 mg (0.49 mg/kg) without 7R (n=25) (log rank=13.69; df=1; p=0.0002). Mean dose for CGI-P normalization for children with 7R was 47 mg (1.70 mg/kg) of methylphenidate versus 31 mg (0.79 mg/kg) of methylphenidate without 7R (log rank=14.17; df=1; p=0.0002). ADHD symptom normalization at < or =50 mg methylphenidate was achieved in 58% with 7R versus 95% without (log rank=9.45; df=1; p=0.002).

CONCLUSIONS

Children with ADHD possessing the DRD4 7R allele require higher doses of methylphenidate for symptom improvement and symptom normalization. This pharmacogenetic study demonstrates that the 7-repeat allele of the DRD4 gene VNTR polymorphism correlates with treatment outcomes.

Seasonal patterns in monthly hemoglobin A1c values

The purpose of this study was to investigate seasonal variations in population monthly hemoglobin A(1c) (A1c) values over 2 years (from October 1998 to September 2000) among US diabetic veterans. The study cohort included 285,705 veterans with 856,181 A1c tests. The authors calculated the monthly average A1c values for the overall population and for subpopulations defined by age, sex, race, insulin use, and climate regions. A1c values were higher in winter and lower in summer with a difference of 0.22. The proportion of A1c values greater than 9.0% followed a similar seasonal pattern that varied from 17.3% to 25.3%. Seasonal autoregressive models including trigonometric function terms were fit to the monthly average A1c values. There were significant seasonal effects; the seasonal variation was consistent across different subpopulations. Regions with colder winter temperatures had larger winter-summer contrasts than did those with warmer winter temperatures. The seasonal patterns followed trends similar to those of many physiologic markers, cardiovascular and other diabetes outcomes, and mortality. These findings have implications for health-care service research in quality-of-care assessment, epidemiologic studies investigating population trends and risk factors, and clinical trials or program evaluations of treatments or interventions.

Report from the CDC. Physician and allied health professionals' training and fetal alcohol syndrome

Maternal prenatal alcohol use is one of the leading preventable causes of birth defects and developmental disabilities. On the severe end of the spectrum of conditions related to drinking during pregnancy is fetal alcohol syndrome (FAS). Physicians and other health practitioners play a critical role in diagnosing FAS and in screening women of childbearing age for alcohol use during pregnancy. The Fetal Alcohol Syndrome Prevention Team at CDC's National Center on Birth Defects and Developmental Disabilities awarded funds to four medical school partners (Meharry and Morehouse Medical Colleges, St. Louis University, the University of Medicine and Dentistry of New Jersey, and the University of California at Los Angeles) to develop FAS regional training centers (RTCs). The RTCs are developing, implementing, evaluating, and disseminating educational curricula for medical and allied health students and practitioners that incorporate evidence-based diagnostic guidelines for FAS and other prenatal alcohol-related disorders.

Applying diabetes-related Prevention Quality Indicators to a national cohort of veterans with diabetes

OBJECTIVE

The Prevention Quality Indicators (PQIs) are measures of hospitalizations that reflect quality of ambulatory care. We applied the PQIs of metabolic decompensation to Veterans Health Administration (VHA) utilizers with diabetes. We identified patient-level characteristics associated with hospitalization for metabolic decompensation, developed a risk-adjustment model for the measures, and compared regional network performance using these PQIs.

RESEARCH DESIGN AND METHODS

This was a retrospective cohort study of 406575 veterans with diabetes who used the VHA between 1997 and 1999. The outcomes were the PQIs of uncontrolled diabetes, short-term complications, or a combined measure. Patient-level variables were identified from administrative databases. Variation in performance of the networks was compared between full risk adjustment and age and sex adjustment only.

RESULTS

In fiscal year 1999, there were 1719 VHA discharges (4.2 per 1000 cohort members) for uncontrolled and short-term complications of diabetes. A logistic regression model including age, sex, marital status, Charlson Comorbidity Index, mental health condition, insulin use, and oral antiglycemic medication use was developed for risk adjustment of the combined PQI. Full risk adjustment changed performance ranks of the networks using the combined PQI outcome relative to age and sex adjustment only. Ten networks remained in the same quartile of performance, five moved one quartile, and seven moved two or more quartiles.

CONCLUSIONS

The PQIs of uncontrolled and short-term complications of diabetes are uncommon outcomes among veterans with diabetes and should be used only as a combined outcome. More complete risk adjustment should be used when comparing systems of care using the combined measure.

Disparities in use of lipid-lowering medications among people with type 2 diabetes mellitus

BACKGROUND

People with diabetes are at high risk for cardiovascular events regardless of known heart disease. Physicians may underrecognize the excess cardiovascular risk conferred by diabetes alone, without a recent cardiovascular event. Other disparities in the receipt of lipid-lowering medications (LLMs) may exist.

METHODS

We studied veterans with diabetes in fiscal years 1998 and 1999 cross-sectionally. We used administrative data (demographic information, International Classification of Diseases, Ninth Revision [ICD-9] codes, utilization information, medications, and laboratory tests) to evaluate associations between use of LLMs and age, ethnicity, sex, marital status, Charlson Index, heart disease ICD-9 codes, oral agents and insulin, hospitalization status, and low-density lipoprotein cholesterol levels. We constructed separate logistic regression models to evaluate associations between low-density lipoprotein cholesterol and similar predictor variables.

RESULTS

Odds ratios were similar in both years. For fiscal year 1999, patients without recent ICD-9 codes in their administrative data indicating heart disease were 0.35 times less likely to be given LLMs than those with such codes. Individuals older than 75 years were 0.65 times less likely to be given LLMs than those younger than 65 years. African Americans were 0.72 times less likely than whites to be given LLMs. In fiscal years 1999 and 1998, 27% and 36% of individuals given LLMs had low-density lipoprotein cholesterol levels higher than 130 mg/dL (3.37 mmol/L).

CONCLUSIONS

Veterans with diabetes but no recently coded heart disease, older individuals, and African Americans could benefit from programs targeted to introduce LLMs. Up to one third of individuals given LLMs remained above the target level of 130 mg/dL for low-density lipoprotein cholesterol.

Health status of harp seals (Phoca groenlandica) and hooded seals (Cystophora cristata) on Sable Island, Nova Scotia, Canada, concurrent with their expanding range

Beach surveys for harp (Phoca groenlaandica) and hooded (Cystophora cristata) seals documented a dramatic increase in their numbers on Sable Island in mid 1990s. In the 1980s, no more than five animals of both species were observed on this island each year, however, during late 1994 to 1998, 1,191 harp and 870 hooded seals, mostly young animals, were recorded. Although some of these seals had been killed by sharks, most (roughly 75%) were found alive or as intact carcasses on the beach, and some of the live seals were later found dead. Emaciation/starvation was considered the primary cause of death in seals that were not obviously killed by sharks. Factors that may have compounded this poor body condition included gastric impaction with abnormal ingesta, hemorrhagic diathesis possibly induced by parasitic migration and secondary vasculitis, and stomatitis (in hooded seals only). Some harp and hooded seals expanding their range in recent years may be unable to feed successfully, although the reasons for this are unclear.

Immunological variables mediate cognitive dysfunction in gulf war veterans but not civilians with chronic fatigue syndrome

We explored the relationship between a set of immunological variables and a set of cognitive and functional status measures and a diagnosis of chronic fatigue syndrome (CFS) in civilians and veterans using various regression and factor analytic methods. Our approach emphasized the extraction of a few distinct factors in order to limit statistical problems associated with doing large numbers of multiple comparisons. This approach led to our finding cytokine data grouping into type 1 and type 2 clusters. A type 2 cluster plus a T and B cell factor predicted CFS caseness for Gulf War veterans but not for civilians with CFS. When a cognitive variable, reaction time, was added into the model, both immunological factors lost statistical significance; this indicates that the cognitive variable reaction time moderated the effects of the immunological factors in predicting patient status. We did a similar analysis on the roles of the immunological and cognitive variables in functional status using SF-36 data. Higher levels of these same two immunological factors predicted poorer general health as well as poorer physical and social functioning in Gulf War veterans but not in civilians with CFS. When the reaction time factor was added, only the lymphocyte factor remained significant. This implies that lymphocytes are directly related to functional status in Gulf War veterans with CFS, but the Th2 factor produces its effect on functional status via changes in cognitive abilities.

Empowering parents through asthma education

Asthma is the most common chronic illness in children and has a significant impact on children and their families. Asthma management requires a multi-faceted approach, including an effective educational component. The purpose of this pilot study was to compare outcomes for parents who participated in empowering and traditional approaches to asthma education. Specific outcomes that were examined included (a) knowledge, (b) sense of control, (c) ability to make decisions, and (d) ability to provide care. The sample consisted of 57 families who participated in a multi-session educational intervention. Twenty-nine families participated in the empowering approach; the remaining 28 families received the traditional approach. Data were collected before, immediately after, and 6 months following the educational intervention. Significant differences were found regarding sense of control, ability to make decisions, and ability to provide care for parents who participated in the empowering approach. Both approaches resulted in increased knowledge. These findings have implications for asthma education and for the education of health professionals.

Birth order and its association with the onset of chronic fatigue syndrome

Chronic fatigue syndrome (CFS) is a medically unexplained illness that is diagnosed on the basis of a clinical case definition; so it probably is an illness with multiple causes producing the same clinical picture. One way of dealing with this heterogeneity is to stratify patients based on illness onset. We hypothesized that either the whole group of CFS patients or that group which developed CFS gradually would show a relation with birth order, while patients who developed CFS suddenly, probably due to a viral illness, would not show such a relation. We hypothesized the birth order effect in the gradual onset group because those patients have more psychological problems, and birth order effects have been shown for psychological characteristics. We compared birth order in our CFS patients to that in a comparison group derived from U.S. demographic data. We found a tendency that did not reach formal statistical significance for a birth order effect in the gradual onset group, but not in either the sudden onset or combined total group. However, the birth order effect we found was due to relatively increased rates of CFS in second-born children; prior birth order studies of personality characteristics have found such effects to be skewed toward first-born children. Thus, our data do support a birth order effect in a subset of patients with CFS. The results of this study should encourage a larger multicenter study to further explore and understand this relation.

Stakeholder evaluation of a high-risk prenatal nutrition intervention program in Prince Edward Island

Since 1971, a Prince Edward Island prenatal program has provided nutrition support to pregnant women at high risk for poor birth outcomes. Provincial changes in the delivery of health care services since 1986 have caused concern that the program is becoming less effective. The current research was designed to evaluate stakeholders satisfaction with the program; it was part of a larger study conducted in 1998 and 1999 to evaluate overall program effectiveness. Nutritionists (n=9), referring health professionals (n=57), and clients (n=50) completed a survey. The results indicated that program satisfaction was high for all stakeholders. Perceived program strengths included the counselling approach, program quality, food and income supplements, and accessibility. Perceived program weaknesses included inadequate staff/time, administrative requirements, limited communication/awareness, the counselling approach, and difficulty contacting clients. Recommendations for improvement fall into four key areas: staff services, program delivery, the counselling approach, and communication. The findings suggest that the components of prenatal education considered important vary among clients and staff, and that the relationship developed between staff and clients during counselling is an important contributor to program success.

What determines health? To where should we shift resources? Attitudes towards the determinants of health among multiple stakeholder groups in Prince Edward Island, Canada

The population health perspective has become significant in academic and policy discourse. The purpose of this paper is to assess its significance among health care practitioners and administrators as well as the general public. Respondents in Prince Edward Island, Canada were asked to rank the broad determinants of health and comment on to where resources should be shifted to improve the health of the population. Important variations are noted between the groups with family physicians and front-line staff being similar in perceptions to the general public on most determinants than other groups. The paper concludes with discussion on the relevance of the findings for population health research and health policy.

Cytologic and biochemical changes associated with inoculation of amniotic fluid and meconium into lungs of neonatal rats

OBJECTIVE

To evaluate the effect of homologous amniotic fluid and meconium inoculated intratracheally into the lungs of neonatal rats.

ANIMALS

153 male 7-day-old Fischer-344 rats.

PROCEDURE

Amniotic fluid was obtained by cesarean section from the uterus of pregnant rats and meconium was collected at the time of birth from the gastrointestinal tract of neonatal rats. Neonatal rats were randomly allocated into 5 treatment groups. Two groups received 0.05 ml of saline (0.9% NaCl) solution; the third and fourth groups received 0.05 ml of 50% or 100% amniotic fluid, respectively; the fifth group was inoculated with 0.05 ml of a 20% suspension of meconium. Six or 7 rat pups/group were euthanatized by exsanguination under halothane anesthesia at postinoculation days 1, 3, 7, and 14. The magnitude of injury and inflammatory response was determined by biochemical and cytologic analyses of bronchoalveolar lavage fluid.

RESULTS

Inoculation with saline solution and amniotic fluid did not induce pulmonary injury or inflammatory response. Inoculation with meconium induced significant (P < 0.01) injury and inflammatory response, characterized by the release of cytosolic enzymes and recruitment of neutrophils in the lung.

CONCLUSIONS

Saline solution is an innocuous vehicle that can be safely used in intratracheal inoculations in neonatal rats. Homologous amniotic fluid, despite containing keratin and epidermal cells, does not cause acute injury or inflammation in the lung. In contrast, meconium acts as a toxic substance injuring respiratory cells and causing a vigorous but transient leukocytic inflammatory reaction in the lungs.

Thoracic radiographic appearance in the normal llama

The goal of this study was to collect quantitative and qualitative radiographic information of the normal adult llama thorax. Standing right-left lateral radiographs of the thorax of 16 normal llamas were made. Normal ratios of cardiac height, width, and height plus width to thoracic vertebrae 3-5 and thoracic height were calculated. Normal values determined for tracheal angle of divergence from the thoracic spine, cardiophrenic and cardiosternal contact are additional potential indicators of cardiac enlargement. Ratios of normal pulmonary artery and vein, caudal vena cava and trachea to the height of the fourth thoracic vertebra should allow identification of pathology of these structures. Observations regarding pulmonary vessels and airways, thoracic spine, sternebrae and portions of the gastrointestinal tract observed on thoracic radiographs are also included. It is proposed that these normal values and observations can be used to better evaluate diseases of the cardiovascular and respiratory systems of adult llamas.

Effects of environmental management on seasonal decrease in milk production in dairy cattle

OBJECTIVE

To describe effects of season on milk production in Holstein dairy cows and to determine the location and effectiveness of fans and sprinklers in the management of stress attributable to season.

DESIGN

Longitudinal observational study.

ANIMALS

141 dairy herds for which owners used the Dairy Herd Improvement Association's database for production and reproduction record keeping.

PROCEDURE

Owners were interviewed to identify location of fans, shade structures, and sprinklers. Production and reproduction data were retrieved from the database, and a mixed model ANOVA was used to estimate effects of season, parity, and use of sprinklers, and fans on milk production.

RESULTS

Daily peak milk production decreased for all parity groups in the summer, but the effect decreased with increasing days in lactation. Use of sprinklers increased peak milk production in parity-1 and -3 or higher cows, but use of fans did not significantly alter effects of season. After calving in the summer, 305-day milk production decreased in parity-2 and -3 cows. This decrease was not significantly modified by the presence of sprinklers or fans.

CLINICAL IMPLICATIONS

Use of sprinklers may increase peak milk production in high-producing cows and could be recommended for reducing heat and total stress during this time. Production-oriented veterinarians should be cautious when recommending use of sprinklers and fans to increase production because of the wide confidence intervals describing their effectiveness. Management of parity-2 or higher cows so that they calve from October to June could increase 305-day milk production.

Results of bone scintigraphy in horses used for show jumping, hunting, or eventing: 141 cases (1988-1994)

OBJECTIVE

To determine anatomic patterns and clinical importance of increased radiopharmaceutical uptake in bones of horses used for show jumping, hunting, and eventing.

DESIGN

Retrospective study.

ANIMALS

141 horses evaluated because of lameness.

PROCEDURE

Medical records were reviewed, and information on results of physical examination, radiography, and scintigraphy were obtained. Scintigrams were evaluated to identify areas of increased radio-pharmaceutical uptake.

RESULTS

834 areas of increased radiopharmaceutical uptake were identified. Scintigraphy of the vertebral column was performed in 78 horses, and 50 had areas of increased radiopharmaceutical uptake involving the spinous processes. Scintigraphy of the proximal phalanx of the forelimb was performed in 88 horses. Similarly, scintigraphy of the proximal phalanx of the hind limb was performed in 99 horses, and scintigrams of 374 proximal phalanges were available for review. One hundred fifty-five scintigrams had areas of increased radiopharmaceutical uptake. Scintigraphy of the tarsal joint was performed in 99 horses, and scintigrams of 198 joints were available for review. Eighty-five had areas of increased radiopharmaceutical uptake. Overall, 214 of 834 areas of increased radiopharmaceutical uptake were definitively associated with lameness.

CLINICAL IMPLICATIONS

Results of this study suggest that jumping creates unique stresses on the bones of horses. The distinctive patterns of increased radiopharmaceutical uptake identified in this study suggest that horses used for jumping may have a predilection to develop orthopedic disease at specific sites distinct from those in racehorses.