Defining the fetal cardiac axis between 11 + 0 and 14 + 6 weeks of gestation: experience with 100 consecutive pregnancies

OBJECTIVE

The purpose of this study was to establish normal fetal cardiac axis values during the first and early second trimesters of pregnancy.

METHODS

This was a prospective observational cohort study in which the fetal cardiac axis was assessed during ultrasound examinations in 100 consecutive fetuses between 11 + 0 and 14 + 6 weeks of gestation. Transabdominal, and, when indicated, transvaginal, approaches were used. Intraobserver and interobserver reproducibility were calculated.

RESULTS

The cardiac axis ranged from 34.5 to 56.8° (mean (SD) 47.6 ± 5.6°) in 94 fetuses with normal cardiac anatomy. The fetal cardiac axis tended to be significantly higher in fetuses at 11 + 0 to 11 + 6 weeks of gestation than in fetuses at 12 + 0 to 14 + 6 weeks of gestation. Congenital heart defects were found in six out of 100 fetuses, four of which had abnormal cardiac axis values at 11 + 0 to 14 + 6 weeks of gestation.

CONCLUSION

Cardiac axis measurement is possible in the first and early second trimesters of pregnancy. The assessment of cardiac axis at an early gestational age may help to identify pregnancies at high risk for congenital heart defects. Copyright

Iodine Status and Availability of Iodized Salt: An Across-Country Analysis

Background

Iodine deficiency has serious consequences, and the Universal Salt Iodization initiative has attempted to reduce the extent of deficiency.

Objective

We aim to see how far across-country variations in urinary iodine in school-age children can be explained by environmental factors, particularly soil iodine and the availability of iodized salt.

Methods

We use simple multivariate regression for two separate datasets, one for 30 developing countries, and one for 13 developed countries, using data on availability of iodized salt and soil iodine levels.

Results

Median urinary iodine excretion is significantly and positively related to household availability of iodized salt (elasticity, 0.73) for developing countries, but the soil coefficient is not significant, probably because the dummy variable is not well measured. For the developed countries, there is a positive and significant effect of salt penetration rates (elasticity, 0.83) and a positive and significant effect of soil iodine (elasticity, 0.77). There is also a suggestion that countries with more serious soil deficits are more likely to iodize salt, so that univariate regressions of urinary iodine excretion on salt availability or penetration rates underestimate the beneficial effects of iodized salt availability on iodine nutrition.

Conclusions

There are limitations to cross-sectional (ecologic) studies such as this, and the data are not perfect. Nevertheless, the results provide support for policies to iodize salt, given the widespread deficiency of iodine in diets worldwide.

Cross-contamination in the Molecular Detection of Bartonella from Paraffin-embedded Tissues

The genus Bartonella comprises a group of gram-negative, fastidious bacteria. Because of diagnostic limitations of culture and serologic testing, polymerase chain reaction (PCR) has become a powerful tool for the detection of Bartonella spp. in blood and tissue samples. However, because many wild and domestic animals harbor Bartonella spp., transfer of Bartonella DNA during sample collection or histologic processing could result in false-positive PCR test results. In this study, we describe evidence of Bartonella DNA dissemination and transfer in the necropsy room and during the subsequent processing of formalin-fixed paraffin-embedded tissues. Bartonella DNA was amplified from different areas of the necropsy room, from the liquid paraffin in the tissue processor, and from different parts of the microtome. Unless stringent procedures are established and followed to avoid cross-contamination, the molecular detection of Bartonella spp. from tissue samples obtained at necropsy or processed in a multispecies histopathology laboratory will not be reliable.

The costs and cost-effectiveness of mass treatment for intestinal nematode worm infections using different treatment thresholds

Background

It is estimated that almost a half of all of people living in developing countries today are infected with roundworms, hookworms, or whipworms or combinations of these types of intestinal nematode worms. They can all be treated using safe, effective, and inexpensive single-dose generic drugs costing as little as USD 0.03 per person treated when bought in bulk. The disease caused by intestinal nematodes is strongly related to the number of worms in the gut, and it is typical to find that worms tend to be aggregated or clumped in their distribution so that <20% of people may harbour >80% of all worms. This clumping of worms is greatest when the prevalence is low. When the prevalence rises above 50%, the mean worm burden increases exponentially, worms are less clumped, and more people are likely to have moderate to heavy infections and may be diseased. Children are most at risk. For these reasons, the World Health Organization (WHO) currently recommends mass treatment of children ≥1 year old without prior diagnosis when the prevalence is ≥20% and treatment twice a year when the prevalence is ≥50%.

Methods and Findings

The risk of moderate to heavy infections with intestinal nematodes was estimated by applying the negative binomial probability distribution, then the drug cost of treating diseased individuals was calculated based on different threshold numbers of worms. Based on this cost analysis, a new three-tier treatment regime is proposed: if the combined prevalence is >40%, treat all children once a year; >60% treat twice a year; and >80% treat three times a year. Using average data on drug and delivery costs of USD 0.15 to treat a school-age child and USD 0.25 to treat a pre-school child (with provisos) the cost of treating children aged 2–14 years was calculated for 105 low- and low-middle-income countries and for constituent regions of India and China based on estimates of the combined prevalence of intestinal nematode worms therein. The annual cost of the three-tier threshold was estimated to be USD 224 million compared with USD 276 million when the current WHO recommendations for mass treatment were applied.

Conclusion

The three-tier treatment thresholds were less expensive and more effective as they allocated a greater proportion of expenditures to treating infected individuals when compared with the WHO thresholds (73% compared with 61%) and treated a larger proportion of individuals with moderate to heavy worm burdens, arbitrarily defined as more than 10 worms per person (31% compared with 21%).

Almost one in every two people in the developing world is infected with one or more types of intestinal nematode worms. When fewer than 50% of people are infected, most carry only a few worms; but when more than 50% are infected, the number carrying moderate to heavy numbers increases markedly, as does the risk of disease. The WHO recommends annual mass deworming of children when 20% or more are infected and twice a year if 50% or more are infected. We estimated the cost of this to treat children with 10+ worms, an arbitrary moderate to heavy infection. We concluded that it is not cost-effective to mass treat children when fewer than 40% are infected because the majority are uninfected and few are likely be diseased. We propose annual treatment when 40% or more children are infected, twice a year at 60%, and three times a year at 80% or more. This would cost USD 224 million annually to treat all children aged 2–14 years in 107 developing countries compared with USD 276 million using current WHO guidelines. The new three-tier guidelines also treat a larger proportion of infected children and treat children with moderate to heavy worm burdens more often.

Clinical investigation of the novel iron-chelating agent, CP94, to enhance topical photodynamic therapy of nodular basal cell carcinoma

BACKGROUND

Photodynamic therapy (PDT) involves the activation of a photosensitizer by visible light to produce activated oxygen species within target cells, resulting in their destruction. Evidence-based guidelines support the efficacy of PDT using topical 5-aminolaevulinic acid (ALA-PDT) in actinic keratoses, Bowen disease and basal cell carcinoma (BCC). Efficacy for nodular BCC appears inferior to that for superficial BCC unless prior debulking or repeat treatments are performed. Objectives The aim of this study was to assess the safety and efficacy of adding a novel iron-chelating agent, CP94 (1,2-diethyl-3-hydroxypyridin-4-one hydrochloride), to topical ALA, to temporarily increase the accumulation of the photosensitizer in the tumour.

METHODS

A mixed topical formulation of ALA + increasing concentrations of CP94 was used to carry out PDT on previously biopsied nodular BCC with no prior lesion preparation using standard light delivery. The area was assessed clinically and surgically excised 6 weeks later for histological examination.

RESULTS

Enhanced PDT using 40% CP94 resulted in significantly greater clearance rates in nodular BCC than with ALA-PDT alone, in our protocol of single-treatment PDT with no lesion preparation.

CONCLUSIONS

The results of this study demonstrate the safe and effective use of an enhanced ALA-PDT protocol for nodular BCC using CP94, with no adverse reactions to this modification. This is the first time this formulation has been used in patients. This formulation is now the focus of further study.

The economics of food fortification

This paper summarizes some of the literature on the cost effectiveness and cost benefit of food fortification with selected micronutrients most relevant for developing countries. Micronutrients covered include iron, iodine, vitamin A, and zinc. The main focus is on commercial fortification, although home fortification and biofortification are mentioned. Fortification with iron, vitamin A, and zinc averts significant numbers of infant and child deaths and is a very attractive preventive health-care intervention. Fortification with iron, iodine, and potentially zinc provides significant economic benefits and the low unit cost of food fortification ensures large benefit:cost ratios, with effects via cognition being very important for iron and iodine. Fortification will not reach all individuals and is most attractive as an investment where there is a convenient food vehicle, where processing is more centralized, and where either the deficiency is widespread or the adverse effects are very costly even though only a small group is affected.

Teaching and learning speech and language therapy skills: the effectiveness of classroom as clinic in speech and language therapy student education

BACKGROUND

Terms such as 'clinical intuition' have often been applied to the practice of speech and language therapy. Various authors have aimed to make the process of therapy practice more explicit, and it is argued that recently developed descriptive/analytic frameworks have the potential to engender the critical mindset necessary for student speech and language therapists to become good reflective practitioners, with the potential for enhancing clinical education.

AIMS

To investigate whether and how aspects of clinical skills education could be usefully addressed in an academic, as opposed to a clinical, setting. The study aimed to address the question of whether use of an interaction analysis system, in conjunction with video observation, and 'practice simulation' in a teaching-learning programme could be shown to have a positive impact on: (1) students' perceptions of their own understanding and practice of therapy, and their perceptions of themselves as self-reflective practitioners; and whether (2) this was borne out by students' ability to observe and interpret therapeutic interaction, as measured by (i) an objective written assessment; (ii) an objective video observation assessment; and (iii) assessment of their abilities in clinical practice.

METHODS & PROCEDURES

Thirty-six students from City University took part in an experimental, placebo-controlled study using a deferred intervention design. Assessments designed to reflect changes resulting from the teaching-learning curriculum were carried out pre- and post-intervention with experimental and control groups. Quantitative and qualitative results were obtained.

OUTCOMES & RESULTS

The intervention programme was found to have had a significant impact on students' perceptions of their understanding of therapy, but not on their perceptions of their practice of therapy. The experimental group scored significantly better on a written assessment of 'interpretation of therapy interaction', but were no better than the control group on a 'Video observation' assessment. Owing to attrition and the poor quality of videos submitted for assessment, it was not possible to measure changes in actual clinical practice. Qualitative feedback from the teaching-learning programme suggests that students generally found the approach to be beneficial.

CONCLUSIONS

While there were some encouraging results, it is still uncertain whether addressing the actual practice of therapy in an academic setting gives 'added value' to the work carried out on clinical placements. However, there is no doubt that bringing this type of programme under the umbrella of an academic institution would greatly increase the consistency of teaching and the range of experiences available to students.

East African running dominance revisited: a role for stereotype threat?

Regardless of the possible existence of physiological advantages in East African runners, belief that such differences exist creates a psychological atmosphere that can have significant consequences on performance. This is known as stereotype threat and can feature in many sports.

Trends in diet, nutritional status, and diet-related noncommunicable diseases in China and India: the economic costs of the nutrition transition

Undernutrition is being rapidly reduced in India and China. In both countries the diet is shifting toward higher fat and lower carbohydrate content. Distinct features are high intakes of foods from animal sources and edible oils in China, and high intakes of dairy and added sugar in India. The proportion of overweight is increasing very rapidly in China among all adults; in India the shift is most pronounced among urban residents and high-income rural residents. Hypertension and stroke are relatively higher in China and adult-onset diabetes is relatively higher in India. Established economic techniques were used to measure and project the costs of undernutrition and diet-related noncommunicable diseases in 1995 and 2025. Current WHO mortality projections of diet-related noncommunicable diseases, dietary and body composition survey data, and national data sets of hospital costs for healthcare, are used for the economic analyses. In 1995, China's costs of undernutrition and costs of diet-related noncommunicable diseases were of similar magnitude, but there will be a rapid increase in the costs and prevalence of diet-related noncommunicable diseases by 2025. By contrast with China, India's costs of undernutrition will continue to decline, but undernutrition costs did surpass overnutrition diet-related noncommunicable disease costs in 1995. India's rapid increase in diet-related noncommunicable diseases and their costs projects similar economic costs of undernutrition and overnutrition by 2025.

Commentary on "evidence that iron deficiency anemia causes reduced work capacity"

This commentary assesses the strength of the causal evidence presented by Haas and Brownlie in this supplement and examines the potential magnitude of iron-deficiency anemia on welfare. From both the laboratory and field experiments, the evidence is strong and suggests that the potential magnitude of the effect of iron-deficiency anemia on work productivity is substantial. This commentary briefly discusses some of the limitations of using the estimates of effects on physiological capacity for measuring the effect on the social and economic well-being of individuals and society. Biological data are relevant to social and economic development, but additional field studies may be as important as the laboratory experiments to answer questions that also affect work productivity, household maintenance and child raising activities, and hence affect social and economic development. We extend the critical evidence review of human field studies that received disproportionately less attention than the laboratory studies in Haas and Brownlie. We provide some estimates of the magnitude of effects on well-being based on how this information has been used. Future field studies that examine the effect of iron-deficiency anemia and work output in an economic sense should measure increases in productivity but should complement this information with data on wages, income or some measure of profits to derive a money metric measure of increased productivity. Additional information on individual time allocation in household work, child care and leisure may also be required to capture social benefits deriving from improved work capacity.

Neurogenin2 expression in ventral and dorsal spinal neural tube progenitor cells is regulated by distinct enhancers

The basic helix-loop-helix transcription factor Neurogenin2 (NGN2) is expressed in distinct populations of neural progenitor cells within the developing central and peripheral nervous systems. Transgenic mice containing ngn2/lacZ reporter constructs were used to study the regulation of ngn2 in the developing spinal cord. ngn2/lacZ transgenic embryos containing sequence found 5' or 3' to the ngn2 coding region express lacZ in domains that reflect the spatial and temporal expression profile of endogenous ngn2. A 4.4-kb fragment 5' of ngn2 was sufficient to drive lacZ expression in the ventral neural tube, whereas a 1.0-kb fragment located 3' of ngn2 directed expression to both dorsal and ventral domains. Persistent -gal activity revealed that the NGN2 progenitor cells in the dorsal domain give rise to a subset of interneurons that send their axons to the floor plate, and the NGN2 progenitors in the ventral domain give rise to a subset of motor neurons. We identified a discrete element that is required for the activity of the ngn2 enhancer specifically in the ventral neural tube. Thus, separable regulatory elements that direct ngn2 expression to distinct neural progenitor populations have been defined.

Examining interaction in language therapy

Discussions around a 'theory of therapy' have prompted attempts to delineate the components of therapy for language impairment in aphasia. Here it is suggested that the therapy components associated with how language therapy is enacted need more precise specification, especially in relation to what is entailed by interaction between therapist and person with aphasia. Presented too is a system used for the analysis of interaction in language impairment therapy for aphasia and its possible applications are discussed. Components of the system are described and a sample analysis presented. The methodological difficulties entailed in making comparisons of therapy enactment are discussed. It is suggested furthermore that unless more is known about precisely defined interactions in therapy, it will be difficult to answer basic questions not only about how language therapy is being carried out, but also, subsequently, whether the ways in which therapy tasks are enacted have a significant impact on the outcome.

Preoperative and postoperative considerations for carbon dioxide laser resurfacing

Cutaneous laser resurfacing is a tremendous advance in the treatment of photoaged skin. With the recent developments in laser technology, the procedure has become widely utilized among many physician subspecialists. The latest laser systems permit controlled vaporization of skin so that most novice operators feel comfortable with the technique in a short period of time. Nevertheless, there are many issues that need to be addressed before performing the procedure. First, not every person is an appropriate candidate for laser resurfacing. Second, both the physician and the patient must be aware of the preoperative preparation and prolonged postoperative care involved with the procedure. Finally, the physician must be able to identify and treat, and the patient must be educated about, the side effects and potential complications associated with the procedure. It is only by addressing these issues that the clinical results obtained by CO2 laser resurfacing can be maximized.

Safety and toxicity of nonoxynol-9 gel as a rectal microbicide

BACKGROUND AND OBJECTIVES

Methods of HIV and STD prevention, which can be controlled by the receptive partner, are a high priority for research and development. Studies on the safety of Nonoxynol-9 (N-9) on the vaginal mucosa have yielded conflicting results. No Phase I study has evaluated the effect of N-9 on the rectal mucosa.

GOALS

To assess the safety of 52.5 mg of N-9 in a 1.5-g gel when applied one to four applicators per day to the rectum and penis.

STUDY DESIGN

The study included 25 HIV-negative and 10 HIV-positive, monogamous gay male couples in which each partner was exclusively insertive or receptive while using N-9 gel. Each participant served as his own control during placebo gel use compared to during N-9 gel use. Receptive partners underwent anoscopic examination after 1 week of placebo use and after 2, 5, and 6 weeks of N-9 gel use, with rectal biopsies obtained after 1 week of placebo use and after 5 and 6 weeks of N-9 gel use. Insertive partners had safety monitoring after 1 week of placebo use and after 2, 5, and 6 weeks of N-9.

RESULTS

No rectal ulcers were detected; superficial rectal erosions were noted in two HIV-negative participants. Abnormal or slightly abnormal histologic abnormalities of rectal biopsies were detected in 31 (89%) receptive participants after N-9 gel use compared to 24 (69%) participants after 1 week of placebo gel use. Meatal ulceration, not caused by herpes simplex virus, was detected in one HIV-negative participant.

CONCLUSION

Low-dose N-9 gel was not associated with macroscopic rectal and penile epithelial disruption or inflammation, but histologic abnormalities were commonly observed during N-9 gel as well as during placebo gel use.