Children with low muscle strength are at an increased risk of fracture with exposure to exercise

OBJECTIVES

To use objective measures of physical fitness and muscle function to assess the interplay between exercise, muscle and fractures during childhood.

METHODS

A cross-sectional analysis was performed using The Young Hearts Project, a population-based cohort recruited from Northern Ireland. Grip strength was assessed with a hand-held dynamometer. Aerobic fitness was assessed using the 20-metre endurance shuttle run. The outcome of interest was reported fractures. Data were also collected on other potential confounders.

RESULTS

There were 787 boys (49.5%) and 803 girls aged 13.9±1.5 years. 414 (26.0%) children reported a fracture at anytime since birth. There was a positive association between higher aerobic fitness and reported fracture (OR 1.23, 95%CI 1.05 to 1.45, P=0.012) greatest in those with lowest grip strength (OR 2.10, 95%CI 1.23 to 3.31, P=0.005). Conversely, in those with highest grip strength, no association was seen between aerobic fitness and reported fractures.

CONCLUSION

In children, higher levels of aerobic fitness are associated with an increased risk of fractures, with the greatest risk seen in those with low muscle strength. Our results suggest that there is the potential for exercise protocols that aim to strengthen forearm musculature to reduce upper limb fractures in adolescents.

Effect of intravenous sodium salicylate administration prior to castration on plasma cortisol and electroencephalography parameters in calves

Nociception is an unavoidable consequence of many routine management procedures such as castration in cattle. This study investigated electroencephalography (EEG) parameters and cortisol levels in calves receiving intravenous sodium salicylate in response to a castration model. Twelve Holstein calves were randomly assigned to the following groups: (i) castrated, untreated controls, (ii) 50 mg/kg sodium salicylate IV precastration, were blood sampled at 0, 5, 10, 20, 30, 45, 60, 90, 120, 150, 180, 240, 360, and 480 min postcastration. The EEG recording included baseline, castration, immediate recovery (0-5 min after castration), middle recovery (5-10 min after castration), and late recovery (10-20 min after castration). Samples were analyzed by competitive chemiluminescent immunoassay and fluorescence polarization immunoassay for cortisol and salicylate, respectively. EEG visual inspection and spectral analysis were performed. Statistical analyses included anova repeated measures and correlations between response variable. No treatment effect was noted between the two groups for cortisol and EEG measurements, namely an attenuation of acute cortisol response and EEG desynchronization in sodium salicylate group. Time effects were noted for EEG measurements, cortisol and salicylates levels. Significant correlations between cortisol and EEG parameters were noted. These findings have implications for designing effective analgesic regimens, and they suggest that EEG can be useful to monitor pain attributable to castration.

Clinical trial: prolonged beneficial effect of Helicobacter pylori eradication on dyspepsia consultations - the Bristol Helicobacter Project

BACKGROUND

Chronic infection of the stomach with Helicobacter pylori is widespread throughout the world and is the major cause of peptic ulcer disease and gastric cancer. Short-term benefit results from community programmes to eradicate the infection, but there is little information on cumulative long-term benefit.

AIM

To determine whether a community programme of screening for and eradication of H. pylori infection produces further benefit after an initial 2-year period, as judged by a reduction in GP consultations for dyspepsia.

METHODS

A total of 1517 people aged 20-59 years, who were registered with seven general practices in Frenchay Health District, Bristol, had a positive (13)C-urea breath test for H. pylori infection and were entered into a randomized double-blind trial of H. pylori eradication therapy. After 2 years, we found a 35% reduction in GP consultations for dyspepsia (previously reported). In this extension to the study, we analysed dyspepsia consultations between two and 7 years after treatment.

RESULTS

Between two and 7 years after treatment, 81/764 (10.6%) of participants randomized to receive active treatment consulted for dyspepsia, compared with 106/753 (14.1%) of those who received placebo, a 25% reduction, odds ratio 0.84 (0.71, 1.00), P = 0.042.

CONCLUSIONS

Eradication of H. pylori infection in the community gives cumulative long-term benefit, with a continued reduction in the development of dyspepsia severe enough to require a consultation with a general practitioner up to at least 7 years. The cost savings resulting from this aspect of a community H. pylori eradication programme, in addition to the other theoretical benefits, make such programmes worthy of serious consideration, particularly in populations with a high prevalence of H. pylori infection.

Effects of supplementing feedlot steers and heifers with zilpaterol hydrochloride on Warner-Bratzler shear force interrelationships of steer and heifer longissimus lumborum and heifer triceps brachii and gluteus medius muscles aged for 7, 14 and 21d

Longissimus lumborum (LL) muscles from 117 steers plus LL, gluteus medius (GM), and triceps brachii (TB) muscles from 132 heifers were evaluated for effects of feeding duration of zilpaterol hydrochloride (Zilmax(R); ZH; 7.56g/907kg on a dry matter basis) and aging time on tenderness. Both genders were blocked by initial weight into six blocks of four pens. Pens were assigned to treatments of control (C), or 20, 30 or 40days on ZH, with a 3day withdrawal. Steaks from each subprimal were vacuum aged individually for 7, 14 or 21days, frozen, thawed, and cooked to 71 degrees C for Warner-Bratzler shear force (WBSF). All muscles from steers and heifers from ZH30 and ZH40 treatments had higher (P<0.05) WBSF than those of C. The WBSF of steer LL and heifer TB from the ZH20 treatment was higher (P<0.05) than C. There was a treatment by aging interaction (P>0.05) for WBSF of GM steaks from heifers. Percentage of intramuscular fat had little effect on tenderness. Percentages of steer LL and heifer TB steaks with WBSF values below thresholds of either 5.0 or 4.6kg from the ZH20 treatment were quite high, whereas percentages of heifer LL and GM muscles below 5.0kg (67%) and 4.6kg (57%) were low. Feeding ZH20days generally increased WBSF values, but mean WBSF values for steer LL and heifer TB were below 4.6kg. Feeding ZH 20days resulted in>40% of GM steaks with WBSF values above 4.6kg.

Vitamin D status and parathyroid hormone relationship in adolescents and its association with bone health parameters: analysis of the Northern Ireland Young Heart's Project

In girls, a plateau in parathyroid hormone (PTH) was observed at a 25-hydroxyvitamin D (25(OH)D) concentration of approximately 60 nmol/l. In boys, there was no plateau in PTH concentrations as 25(OH)D concentration increased. A 25(OH)D threshold of 60 nmol/l appears to have implications for bone health outcomes in both girls and boys.

INTRODUCTION

Our objective was to investigate if there is a threshold 25(OH)D concentration where a plateau in PTH concentration is evident and to examine the impact of this relationship on bone mineral density (BMD) and bone turnover in a representative sample of adolescents.

METHODS

We conducted a cross-sectional analysis among 1,015 Northern Irish adolescents aged 12 and 15 years. Serum 25(OH)D, PTH, osteocalcin, type 1 collagen cross-linked C-telopeptide (CTx), and BMD of the nondominant forearm and heel were measured. Nonlinear regression analysis was used to model the association between 25(OH)D and PTH.

RESULTS

In girls, a plateau in PTH was observed at a 25(OH)D concentration of approximately 60 nmol/l (PTH = 47.146 + 370.314 x exp((-0.092 x 25(OH)D))) while no plateau in PTH was observed in boys (PTH = 42.144 + 56.366 x exp((-0.022 x 25(OH)D))). Subjects with 25(OH)D levels <60 nmol/l had significantly higher osteocalcin concentrations (P < 0.05) compared with those who had >or=60 nmol/l, while no significant (P > 0.05) differences were noted for CTx concentrations. In girls only, nondominant forearm BMD but not heel BMD was significantly higher (P = 0.046) in those with 25(OH)D concentrations >or= 60 nmol/l.

CONCLUSIONS

Serum 25(OH)D levels above 60 nmol/l in Northern Irish adolescent girls prevent an increase in serum PTH levels and maintaining 25(OH)D >60 nmol/l in both girls and boys may lead to improved bone health outcomes.

Development and content validity of a gastroparesis cardinal symptom index daily diary

BACKGROUND

The Gastroparesis Cardinal Symptom Index (GCSI) is a patient-reported outcome for gastroparesis using a two-week recall period. To minimize potential patient recall effects, a daily diary version of the GCSI (GCSI-DD) was developed.

AIMS

To evaluate the content validity of GCSI-DD for the symptoms in patients with documented gastroparesis, to capture symptom variability over time and to compare responses of this GCSI-DD to the original GCSI.

METHODS

In gastroparesis adults with delayed gastric emptying, cognitive debriefing interviews were conducted to elicit their perspective on relevant symptoms of gastroparesis and relevant recall periods and to evaluate patient understanding of GCSI-DD. Patients completed the GCSI-DD daily over a 2-week period and completed the GCSI at baseline and the 2-week follow-up visit.

RESULTS

Twelve gastroparesis patients, of whom five were diabetic and nine women, reported nausea (100%), vomiting (100%), stomach fullness (75%), bloating (58%) and loss of appetite (50%) were important symptoms. All patients understood diary instructions and item content and reported that the diary captured their gastroparesis symptom experience; 83% considered response scales adequate. There was significant daily variability in GCSI-DD scores. Mean GCSI-DD subscale and total scores over 2 weeks correlated strongly (all r > 0.90) with GCSI scores at 2-week follow-up.

CONCLUSIONS

The GCSI-DD includes symptoms relevant to patients with gastroparesis, captures daily variability of those symptoms and has psychometric properties consistent with a good patient-reported outcome endpoint for gastroparesis clinical trials.

The development of anxiety disorders in childhood: an integrative review

We present an integrative review of the development of child anxiety, drawing on a number of strands of research. Family aggregation and genetic studies indicate raised vulnerability to anxiety in offspring of adults with the disorder (e.g. the temperamental style of behavioural inhibition, or information processing biases). Environmental factors are also important; these include adverse life events and exposure to negative information or modelling. Parents are likely to be key, although not unique, sources of such influences, particularly if they are anxious themselves. Some parenting behaviours associated with child anxiety, such as overprotection, may be elicited by child characteristics, especially in the context of parental anxiety, and these may serve to maintain child disorder. Emerging evidence emphasizes the importance of taking the nature of child and parental anxiety into account, of constructing assessments and interventions that are both disorder specific, and of considering bidirectional influences.

Effects of dry-rolled or steam-flaked corn finishing diets with or without twenty-five percent dried distillers grains on ruminal fermentation and apparent total tract digestion

A metabolism study was conducted to evaluate ruminal fermentation and apparent total tract digestibilities of cattle finishing diets. Holstein steers (n = 16, 351 kg of BW) with ruminal cannulas were fed diets consisting of 0 or 25% dried corn distillers grains (DDG), using dry-rolled corn (DRC) or steam-flaked corn (SFC) as the principal energy source (2 x 2 factorial arrangement). The study was conducted in 2 periods, with 4 steers per treatment in each period. Periods consisted of a 12-d adaptation phase and a 3-d collection phase. Compared with DRC, feeding SFC decreased intakes of DM, OM, starch, NDF, and ether extract (P < 0.01), and steers fed SFC excreted less DM, OM, starch, NDF, and ether extract (P < 0.01). Compared with SFC, feeding DRC decreased ruminal concentrations of acetate, butyrate, isobutyrate, and isovalerate, and decreased the acetate-to-propionate ratio (P < 0.01). Compared with SFC, DRC decreased ruminal propionate, valerate, and lactate concentrations (P < 0.01). When compared with cattle fed SFC, ruminal pH of cattle fed DRC was less at 0 h and greater at 6 h postfeeding (P < 0.01). Ruminal ammonia concentrations were greater for DRC vs. SFC at h 0, 6, 10, 12, 14, 16, 18, 20, and 22 postfeeding (P < 0.05). Feeding DDG decreased consumption of starch and ether extract, but increased NDF intake (P < 0.01). Fecal excretion of ether extract was increased by adding DDG compared with diets without DDG (P < 0.05), resulting in less apparent total tract digestibility of ether extract for cattle fed DDG (P < 0.01). Ruminal lactate concentrations were increased with addition of DDG compared with diets without DDG (P = 0.01). Ruminal ammonia concentrations were less for steers fed 25 vs. 0% DDG at 2, 4, 6, 8, and 10 h postfeeding (P < 0.05). We conclude, based on these results, that ruminal fermentation and apparent total tract digestibility of DDG are affected by grain processing.

Levels of agreement on the grading, analysis and reporting of significant events by general practitioners: a cross-sectional study

BACKGROUND AND AIMS

There is variation in the identification, analysis and reporting of significant events in general practice. Consistency is desired to optimise learning from, and reporting of, patient safety incidents. We examined levels of agreement among different groups of general practitioners (GPs) on the grading, analysis and reporting of selected significant event scenarios.

METHOD

Cross-sectional postal questionnaire survey of 162 GPs split into five professional groups in the west of Scotland. Differences in grading severity and willingness to formally analyse and report seven significant event scenarios were examined using analysis of variance (ANOVA). Differences in proportions were calculated together with 95% confidence intervals.

RESULTS

122 GPs responded (77%). No difference was found in the grading severity of significant events by GP groups. Increased grading severity was linked to the willingness of GP groups to analyse and report that event (p<0.05). A preference to anonymously report all event scenarios to a national educational body was reported (p<0.05). The majority of respondents were not willing to involve patients in relevant event analyses (83-100%).

CONCLUSIONS

The strong levels of agreement suggest that GPs can prioritise relevant significant events for formal analysis and reporting. Focused guidance should be developed to encourage their engagement with the patient safety agenda, optimise learning from safety-relevant events and increase reporting opportunities. Exploration is required of the reasons why GPs may prefer an educational body as a potential reporting source or may be unwilling to include patients in relevant event analyses.

Serum brain-derived neurotrophic factor is associated with reduced appetite in healthy older adults

OBJECTIVE

Loss of appetite and body mass are common in older adults and are associated with negative consequences. Research indicates that these processes likely involve increases in serum brain-derived neurotrophic factor (BDNF). Animal and human models demonstrate that BDNF may serve a regulatory function in food intake, but no study has addressed the possibility that BDNF may be involved in appetite reduction and loss of body mass in older adults.

DESIGN AND PARTICIPANTS

34 older adults without significant neurological or psychiatric history underwent fasting blood draw and measurement of body composition. Appetite and eating behavior were assessed by questionnaire and related to serum BDNF levels.

RESULTS

Partial correlations showed serum BDNF levels were inversely related to appetite (r = -.38, p = .02). No significant correlations emerged between serum BDNF and age, diet, or body composition.

CONCLUSIONS

The current study extends past work and shows that BDNF is associated with appetite in healthy older adults. Further work is needed to clarify mechanisms for these findings, particularly prospective studies.

Chyle leakage and early enteral feeding following pancreatico-duodenectomy: management options

BACKGROUND

Chyle leaks are a rare complication following abdominal surgery. The aim of this study is to describe the management of chyle leaks following surgery for pancreatico-duodenal malignancy.

METHODS

Data were collated from a consecutive series of 105 patients who had undergone a pancreatico-duodenectomy for malignancy. From this cohort, patients who developed significant chyle leaks, defined as drainage of more than 600 ml of amylase-poor chylous fluid per day, were identified and their management reviewed.

RESULTS

A total of 7 (6.7%) patients with significant chyle leaks were identified. All but one of the chyle leaks were identified between the 5th and 9th post-operative day. Early restoration of enteral feeding appeared to increase the incidence of chyle leak. Six of the 7 patients were successfully treated conservatively with total parenteral nutrition and after a median of 7.5 days the chyle leak had resolved. One patient required a peritoneovenous shunt for chylous ascites.

CONCLUSION

This study has described a high incidence of chyle leak among patients undergoing surgery for pancreatico-duodenal malignancy. Early introduction of enteral feed may encourage development. However, patients who develop an abdominal chyle leak remain clinically well and the leak can be managed relatively easily with parenteral nutrition.

Skin cancer trends in Northern Ireland and consequences for provision of dermatology services

BACKGROUND

The incidence of skin cancer, both melanoma and nonmelanoma skin cancer (NMSC), is rising throughout the world. The evaluation of trends in skin cancer will allow better planning of the future development of skin cancer services.

OBJECTIVES

Using data collected from the Northern Ireland Cancer Registry (NICR), the incidence of the three major cutaneous cancers, basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and malignant melanoma (MM), was determined and the workload associated with their management assessed.

METHODS

The records of patients with a first diagnosis of BCC, SCC or MM occurring between 1993 and 2002 were retrieved from the NICR database. The annual age- and sex-adjusted incidence rates of all three skin cancers were computed per 100 000 person-years by direct standardization according to the European Standard Population. Trends in incidence were estimated by calculating the estimated annual percentage change using Microsoft Excel. For patients registered with the NICR as having BCC, SCC or MM, the number of pathological reports where malignant samples had been examined was counted and then summed to provide the number of specimens examined each year between 1993 and 2004.

RESULTS

For all three cancers the age-specific rates for both males and females increased with age, except for MM in men aged 75 years and over, where the rates were seen to decrease. Over the 12-year period there was a 62% increase in the overall number of skin cancer samples processed by local pathology laboratories and a 20% increase in the number of patients. These data highlight the fact that many patients will have more than one skin cancer, which reinforces the benefit in collecting data for both patient and sample numbers in order to obtain a true reflection of the workload. The data have also shown that more affluent men and women have higher rates of BCC and MM than their less affluent counterparts.

CONCLUSIONS

In view of the data presented it is clear that management of NMSC and MM will impose significant demands on services in the years ahead. This will impact on the entire multidisciplinary team. Future planning, in terms of manpower and resources, will prove essential if we are to remain in a position to manage our patients with these malignant tumours appropriately.

A local nutritional screening tool compared to malnutrition universal screening tool

OBJECTIVE

The aim of the study was to compare the Glasgow Nutritional Screening Tool with the Malnutrition Universal Screening Tool (MUST) recently recommended for use by the British Association for Parenteral and Enteral Nutrition.

DESIGN

Comparison-validation study.

SETTING

Four adult acute hospitals in Glasgow, UK.

SUBJECTS

All 242 in-patients from a variety of specialties.

METHODS

Two investigators independently interviewed 202 in-patients for the comparison-validation study. Each used a single tool with each patient, using each tool in turn. Investigators were not aware of each other's assessments. Forty other patients were interviewed by both raters separately using the local tool to evaluate inter-rater reliability.

RESULTS

When compared with MUST as a 'gold standard', the local tool had a sensitivity of 95.3% and a specificity of 64.9%, with moderate agreement between the two tools using kappa test (kappa=0.57). Agreement between the raters was substantial (kappa=0.69) with 85% of patients classified the same by both raters.

CONCLUSION

The Glasgow Nutritional Screening Tool is a valid and reliable tool that can be used on admission for nutritional screening.

Toxicology case of the month: Carbamazepine overdose

A 29-year-old woman presents shortly after a massive overdose of carbamazepine controlled-release tablets. In anticipation of coma, she is electively intubated to safely enable gastrointestinal decontamination with nasogastric activated charcoal. She is admitted to the intensive care unit for ongoing supportive care, and further doses of activated charcoal are prescribed to enhance elimination of carbamazepine. Carbamazepine levels remain high and haemodialysis is carried out to further enhance elimination. Her coma resolves as levels fall, but clinical progress is complicated by anticholinergic delirium, ileus and bowel obstruction from charcoal concretions. She survives to medical discharge on day 12.

No evidence for the presence of apolipoprotein epsilon4, interleukin-lalpha allele 2 and interleukin-1beta allele 2 cause an increase in programmed cell death following traumatic brain injury in humans

BACKGROUND

Brain injury after trauma is an important cause of mortality and morbidity in society. There is evidence in both man and laboratory animals that in addition to necrosis, cell loss may occur as a result of programmed cell death (PCD). The cellular and molecular responses after head injury are partly influenced by genetic polymorphisms of apolipoprotein E and the pro-inflammatory cytokine IL-I.

AIM

The principal aim of this study was to determine whether the presence of the ApoE epsilon4, IL- 1 alpha2 or IL- 1beta2 allele types influenced the amounts of PCD after head injury compared with controls.

METHODS

Paraffin sections from the hippocampus of 38 patients (32 M : 6 F, aged 15 - 75, mean 38 years, survival 7- 576 hours; mean 36 hours) who died after a head injury were stained by Tunel histochemistry and quantified, and genotyping was undertaken by PCR "blind" to clinical detail.

RESULTS

There were more Tunel+ cells (neurons and glia) after head injury than in controls with statistically increased numbers in all sectors of the hippocampus including the dentate fascia. However, there was no correlation between ApoEepsilon4, IL- 1 alpha allele 2 and IL- 1beta allele 2 and the amount of Tunel positivity.

CONCLUSION

Given that both the ApoE and IL-1 influence outcome after various forms of acute brain injury, further work will be required to determine the mechanism underlying this relationship.

TP53 and progression from Barrett's metaplasia to oesophageal adenocarcinoma in a UK population cohort

BACKGROUND AND AIMS

Oesophageal adenocarcinoma frequently develops on a background of metaplastic Barrett's epithelium. The development of malignancy is accompanied by genetic alterations, which may be promising biomarkers of disease progression.

METHODS

A case control study was conducted nested within a large unselected population based cohort of Barrett's patients. Incident oesophageal malignancies and high grade dysplasias were identified. For each case up to five controls were matched on age, sex, and year of diagnosis. Biopsies from the time of diagnosis of Barrett's epithelium were stained immunohistochemically for TP53, cyclin D1, cyclooxygenase 2 (COX-2), and beta-catenin proteins.

RESULTS

Twenty nine incident oesophageal malignancies and six cases of high grade dysplasia were identified. The odds of diffuse or intense TP53 staining were substantially elevated in biopsies from patients who developed oesophageal adenocarcinoma compared with controls (odds ratio (OR) 11.7 (95% confidence interval (CI) 1.93, 71.4)). This difference was also present when all cases were considered (OR 8.42 (95% CI 2.37, 30.0). Despite the association with TP53 staining, only 32.4% of cases had an initial biopsy showing diffuse/intense TP53 staining. There were no significant associations between cyclin D1, COX-2, or beta-catenin staining and case control status. The OR for positive staining for both TP53 and COX-2 was markedly increased in cases compared with controls (OR 27.3 (95% CI 2.89, 257.0)) although only 15% of cases had positive staining for both markers.

CONCLUSIONS

Immunohistochemical detection of TP53 expression is a biomarker of malignant progression in Barrett's oesophagus but sensitivity is too low to act as a criterion to inform endoscopic surveillance strategies. Additional biomarkers are required which when combined with TP53 will identify, with adequate sensitivity and specificity, Barrett's patients who are at risk of developing cancer.

Toxicology case of the month: ingestion of two unidentified tablets by a toddler

An asymptomatic 18 month old child presents to the emergency department of a small district hospital shortly after ingesting two unidentified tablets. A small number of pharmaceuticals and illicit drugs may produce life threatening toxicity in a small child if ingested even in one or two dose units and the onset of toxicity may be delayed for some agents. Following risk assessment, a rational management plan is devised and the child is carefully monitored. The patient is observed overnight and discharged home the following day.

Toxicology case of the month: oral hypoglycaemic overdose

A teenager ingests 375 mg of glipizide and 14.5 g of melformin intentionally in a small country town. She presents to the local medical facility with symptoms and signs of hypoglycaemia. Using a risk assessment based approach, the management of suiphonylurea and metformin overdose is discussed. Sulphonylurea overdose invariably results in profound hypoglycaemia that requires resuscitation with IV dextrose and the use of octreotide as an antidote. Metfonnin overdose rarely causes problems.

A risk assessment based approach to the management of acute poisoning

Early assessment and management of poisoning constitutes a core emergency medicine competency. Medical and psychiatric emergencies coexist; the acute poisoning is a dynamic medical illness that represents an acute exacerbation of a chronic underlying psychosocial disorder. The emergency physician must use an approach that ensures early decisions address potentially time critical interventions, while allowing management to be tailored to the individual patient's needs in that particular medical setting. This article outlines a rationale approach to the management of the poisoned patient that emphasises the importance of early risk assessment. Ideally, this approach should be used in the setting of a health system designed to optimise the medical and psychosocial care of the poisoned patient.

Establishing guidelines to improve identification of fire ants Solenopsis xyloni and Solenopsis invicta

As red imported fire ant, Solenopsis invicta Buren, continues to expand its range into the southwestern United States, it can be easily confused with the native southern fire ant, Solenopsis xyloni McCook. Variability in the morphological characteristics commonly used to differentiate these ant species was quantified by examining the length of the clypeal tooth, striations of the mesopleuron, length of antennal scape, area of the petiolar process, number and size of mandibular teeth, and color by using both scanning electron and light microscopy. Given enough samples, the average values of each of these characteristics is different between the two species; however, significant morphological variability occurs in both S. xyloni and S. invicta populations, creating an area of overlap where either of the two species could exhibit similar characteristics. Better differentiation of these two species is achieved using a combination of characteristics, but morphological techniques are not dependable unless numerous ants from each population are analyzed by a taxonomist familiar with Solenopsis. For situations requiring a more accurate identification, such as before quarantining a county or a portion of a county, a molecular technique using mitochondrial DNA and polymerase chain reaction techniques was developed.

Collett's snake (Pseudechis colletti) envenoming in snake handlers

BACKGROUND

Collett's snake (Pseudechis colletti) is a member of the black snake genus and occurs in a warm temperate to sub-tropical region of central Queensland, Australia. There are no reports of bites occurring in the wild, and bites were previously thought to cause only minor effects. They are a popular snake among zoos and exotic snake keepers.

AIM

To investigate the clinical effects of severe envenoming by Collett's snake, and possible treatment options.

DESIGN

Case series.

METHODS

Clinical and laboratory features are described for six bites, all in snake handlers.

RESULTS

All six bites were from captive snakes, resulting in severe envenoming in four. Two patients were treated early with black snake antivenom, and only developed an anticoagulant coagulopathy and mild myolysis. Two developed anticoagulant coagulopathy and severe rhabdomyolysis associated with acute renal failure, requiring haemodialysis; both received antivenom >10 h after the bite, and initially received minimal fluid replacement. Other effects included thrombocytopenia, non-immune haemolytic anaemia and a marked leukocytosis.

DISCUSSION

Collett's snake envenoming is characterized by early generalized systemic effects (nausea, vomiting, abdominal pain, diarrhoea and headache) and an anticoagulant coagulopathy, followed in some cases by rhabdomyolysis and acute renal failure in untreated patients within 24 h. Early initiation of fluid therapy and treatment with black snake antivenom should be undertaken in all envenomed patients.

Secular trends in heart rate in young adults, 1949 to 2004: analyses of cross sectional studies

OBJECTIVE

To investigate secular trends in resting heart rate in young adults.

DESIGN, SETTING, AND PARTICIPANTS

A series of cross sectional cohorts of first year undergraduates (5562) aged 16-24 years who attended Queen's University Belfast from 1949 to 2004 and underwent health checks at the university health centre.

MAIN OUTCOME MEASURE

Resting heart rate.

RESULTS

Crude aggregate data for 1949-59 showed a secular decline in heart rate in male and female students. Both unadjusted and fully adjusted analyses of data from 1975 onwards-controlled for age, body mass index, height, and smoking-showed a U shaped association between heart rate and year of entry to university in both sexes (p < 0.001): heart rate initially declined and then increased from the mid 1980s. Trends were similar in smokers and non-smokers and in students with normal body size and those who were overweight. However, heart rate in the 693 (28%) male students reporting the most physical activity remained stable and lower than that of men who participated in less physical activity over the period of the study. Similarly in female students, heart rate was generally lower in the 210 (10%) who participated in the most physical activity than in those who engaged in less physical activity.

CONCLUSIONS

The decline in heart rate in young adults occurring at least 50 years ago and continuing until the 1980s is consistent with other favourable findings on cardiovascular health in this age group and with observed long term declines in cardiovascular mortality. The more recent rise in heart rate, not accounted for by increases in overweight, prompts concern that recent favourable trends in cardiovascular disease risk may not be maintained. Among students who took part in the highest levels of physical activity the finding of low and stable heart rates points to the importance of exercise in maintaining cardiovascular health. Measurement of heart rate in population surveys would provide a simple tool to assist monitoring cardiovascular health.

Weight changes after vertical banded gastroplication

AIMS

This study assessed the patterns of weight change in response to surgical treatment for obesity.

METHODS

Vertical Banded Gastroplication (VBG) was performed during the period 1994-2000. Patients were required to follow a liquid diet (800 kcals)for 12 weeks before surgery. The same diet plus a multivitamin capsule (Forceval) was followed for 12 weeks postoperatively, after which normal foods were introduced. Data from 23 patients, 16 women and 7 men, aged 33-63 years (mean, SD; 42 +/- 8 yrs), with BMI from 38 to 69 kg/m2 (52.5 +/- 8.1 kg/m2) at the time of the surgery were available for analysis. Follow up was 3 to 7 years (mean 4 years).

RESULTS

An initial weight loss of 44.4 +/- 24.3 kg (min 11.5, max 110.5 kg) was reached during the first two years (mean BMI decrease 15.8 kg/m2). However a regain in weight (36% of the initial weight loss = 5.6 kg/m2) up to 3 to 7 years after surgery was usual. Average annual regain was 13.6 kg (n=17), 9.45 kg (n=11) and 0.8 kg (n=8) during the 3rd, 4th and 5th year after surgery). Five participants reached a BMI below 30 but only one, BMI < 25, has maintained all the weight loss after 5years.

CONCLUSIONS

Weight lossfollowing VBG ceased after twoyears with a subsequent substantial weight regain. Auxiliary therapies to counteract weight regain are necessary after VBG.

A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis

BACKGROUND

After 50 yr in which nasoenteric feeding was considered contraindicated in acute pancreatitis (AP), several clinical studies have shown that early nasojejunal (NJ) feeding can be achieved in most patients. A pilot study of early nasogastric (NG) feeding in patients with objectively graded severe AP proved that this approach was also feasible. A randomized study comparing NG versus NJ feeding has been performed.

METHODS

A total of 50 consecutive patients with objectively graded severe AP were randomized to receive either NG or NJ feeding via a fine bore feeding tube. The end points were markers of the acute phase response APACHE II scores and C-reactive protein (CRP) measurements, and pain patterns by visual analogue score (VAS) and analgesic requirements. Complications were monitored and comparisons made of both total hospital and intensive-care stays.

RESULTS

A total of 27 patients were randomized to NG feeding and 23 to NJ. One of those in the NJ group had a false diagnosis, thereby reducing the number to 22. Demographics were similar between the groups and no significant differences were found between the groups in APACHE II score, CRP measurement, VAS, or analgesic requirement. Clinical differences between the two groups were not significant. Overall mortality was 24.5% with five deaths in the NG group and seven in the NJ group.

CONCLUSIONS

The simpler, cheaper, and more easily used NG feeding is as good as NJ feeding in patients with objectively graded severe AP. This appears to be a useful and practical therapeutic approach to enteral feeding in the early management of patients with severe AP.

There is no evidence of an association in children and teenagers between the apolipoprotein E epsilon4 allele and post-traumatic brain swelling

Traumatic brain injury (TBI) is an important cause of mortality and disability in children and teenagers. A particular feature of the neuropathology at post-mortem is brain swelling. The cause of the swelling in some cases is not known, while in others it is associated with traumatic axonal injury or hypoxia. Apolipoprotein E (APOE) epsilon4 allele is known to be an important genetic determinant of outcome in children after TBI. We hypothesized a relationship between possession of APOEepsilon4 and diffuse traumatic brain swelling. A total of 165 cases aged between 2 and 19 years were identified from the department's tissue archive. APOE genotype was determined by polymerase chain reaction (PCR) in 106 cases. Bilateral swelling was present in 44 cases (11 with APOEepsilon4), unilateral swelling in 25 cases (7 with APOEepsilon4) and in 36 cases (9 with APOEepsilon4) there was no evidence of brain swelling. There was no significant relationship between possession of APOEepsilon4 and the presence of cerebral swelling (chi(2) = 0.09, df = 2, P = 0.96). The 95% confidence interval for difference in proportions with swelling in those with and without the APOE epsilon4 is -19% to 22%. Thus, a significant relationship was not found between diffuse brain swelling and possession of APOEepsilon4, and in this cohort of patients there was an identifying cause of the brain swelling in all cases.

The effects of maternal depression and parental conflict on children's peer play

BACKGROUND

Little is known about the relative effects of exposure to postnatal depression and parental conflict on the social functioning of school-aged children. This is, in part, because of a lack of specificity in the measurement of child and parental behaviour and a reliance on children's reports of their hypothetical responses to conflict in play.

METHODS

In the course of a prospective longitudinal study of children of postnatally depressed and well women, 5-year-old children were videotaped at home with a friend in a naturalistic dressing-up play setting. As well as examining possible associations between the occurrence of postnatal depression and the quality of the children's interactions, we investigated the influence of parental conflict and co-operation, and the continuity of maternal depression. The quality of the current mother-child relationship was considered as a possible mediating factor.

RESULTS

Exposure to postnatal depression was associated with increased likelihood, among boys, of displaying physical aggression in play with their friend. However, parental conflict mediated the effects of postnatal depression on active aggression during play, and was also associated with displays of autonomy and intense conflict. While there were no gender effects in terms of the degree or intensity of aggressive behaviours, girls were more likely to express aggression verbally using denigration and gloating whereas boys were more likely to display physical aggression via interpersonal and object struggles.

CONCLUSIONS

The study provided evidence for the specificity of effects, with strong links between parental and child peer conflict. These effects appear to arise from direct exposure to parental conflict, rather than indirectly, through mother-child interactions.

Carbonated soft drink consumption and bone mineral density in adolescence: the Northern Ireland Young Hearts project

In an observational study of 1335 boys and girls aged 12 and 15 years, higher intakes of carbonated soft drinks (CSDs) were significantly associated with lower bone mineral density at the heel, but only in girls. Owing to the upward trend in CSD intake in adolescence, this finding may be of concern.

INTRODUCTION

High consumption of carbonated soft drinks (CSD) during adolescence may reduce bone mineral accrual and increase fracture risk. The aim of this study was to examine the relationship between CSD consumption and bone mineral density (BMD) in a representative sample of adolescents.

MATERIALS AND METHODS

This was a cross-sectional observational study in 36 postprimary schools in Northern Ireland. Participants included 591 boys and 744 girls either 12 or 15 years old. BMD was measured by DXA, and usual beverage consumption was assessed by the diet history method. Adjusted regression modeling was used to investigate the influence of CSD on BMD.

RESULTS

A significant inverse relationship between total CSD intake and BMD was observed in girls at the dominant heel (beta, -0.099; 95% CI, -0.173 to -0.025). Non-cola consumption was inversely associated with dominant heel BMD in girls (beta, -0.121; 95% CI, -0.194 to -0.048), and diet drinks were also inversely associated with heel BMD in girls (beta, -0.087; 95% CI, -0.158 to -0.016). However, no consistent relationships were observed between CSD intake and BMD in boys. Cola consumption and nondiet drinks were not significantly related to BMD in either sex.

CONCLUSION

CSD consumption seems to be inversely related to BMD at the dominant heel in girls. It is possible that the apparent association results from the displacement of more nutritious beverages from the diet. Although the inverse association observed between CSD consumption and BMD is modest and confined to girls, this finding may have important public health implications given the widespread use and current upward trend in CSD consumption in Western populations.

Mental health of parents caring for infants

The postpartum period is a sensitive time due to the presence and demands of the developing infant. The care provided by a mother to her infant during this period may be compromised if she is suffering from postnatal depression or postpartum psychosis. Evidence has been emerging which suggests that postnatal depression and postpartum psychoses have adverse effects on the quality of the mother-infant relationship and also on the infant's subsequent cognitive and emotional development. Presented is a review of the literature relating to how these conditions impact on parenting and infant outcomes, what measures are in place to detect these conditions and evidence-based models of best clinical practice are proposed.

What level of physical activity protects against premature cardiovascular death? The Caerphilly study

OBJECTIVE

To examine the optimal intensity of leisure time physical activity (LTPA) to decrease the risk of all cause, cardiovascular disease (CVD), and coronary heart disease (CHD) mortality in a population sample of middle aged British men.

DESIGN

Prospective study of middle aged men with an 11 year follow up.

SETTING

A whole population sample of men from Caerphilly, South Wales, UK.

SUBJECTS

1975 men aged 49-64 years without historical or clinical evidence of CHD at baseline examination.

MAIN OUTCOME MEASURES

All cause, CVD, and CHD mortality.

RESULTS

Total (cumulative) LTPA had a graded, significant relation with all cause, CVD, and CHD mortality but no trend with cancer deaths. When different intensities of activity were considered, light and moderate intensity LTPA had inconsistent and non-significant relations with all cause, CVD, or CHD mortality whether adjusted only for age or for other cardiovascular risk factors. In contrast a significant dose-response relation was found for heavy intensity LTPA for all cause, CVD, and CHD mortality fully adjusted for other risk factors.

CONCLUSIONS

These data suggest that, in a population of men without evidence of CHD at baseline, only leisure exercise classified as heavy or vigorous was independently associated with reduced risk of premature death from CVD.

Children's representation of family mealtime in the context of maternal eating disorders

BACKGROUND

Recent research provides evidence for specific disturbance in feeding and growth in children of mothers with eating disorders.

AIM

To investigate the impact of maternal eating disorders during the post-natal year on the internal world of children, as expressed in children's representations of self and their mother in pretend mealtime play at 5 years of age.

METHODS

Children of mothers with eating disorders (n = 33) and a comparison group (n = 24) were videotaped enacting a family mealtime in pretend play. Specific classes of children's play representations were coded blind to group membership. Univariate analyses compared the groups on representations of mother and self. Logistic regression explored factors predicting pretend play representations.

RESULTS

Positive representations of the mother expressed as feeding, eating or body shape themes were more frequent in the index group. There were no other significant group differences in representations. In a logistic regression analysis, current maternal eating psychopathology was the principal predictor of these positive maternal representations. Marital criticism was associated with negative representations of the mother.

CONCLUSIONS

These findings suggest that maternal eating disorders may influence the development of a child's internal world, such that they are more preoccupied with maternal eating concerns. However, more extensive research on larger samples is required to replicate these preliminary findings.

Repeatability of long and short echo-time in vivo proton chemical-shift imaging

We carried out long (145 ms) and short (25 ms) echo time spectroscopic imaging of the brain (chemical-shift imaging, CSI) on two occasions 1 week apart on 15 healthy individuals. We found coefficients of variation (CVs) generally in the range 10-25% for long and 15-30% for short echo-time measurements. The CVs of metabolite ratios were higher by about 5-10%. Limits of agreement (defined as mean+/-2 SD of the week 1-week 2 differences) were wider at the shorter echo time. The modest repeatability may be due in part to the difficulty of repositioning spectroscopic voxels at a scale of 1 mm. The generally higher CVs and wider limits of agreement at TE25 ms suggest that the increased spectral complexity more than offsets the theoretical advantage of increased signal at short echo-times. Analysis of variance general linear modelling of metabolites and metabolite ratios showed that, in general, the subject, region of the brain and hemisphere were more important than the occasion in explaining the variability of results. Unless information on short-T2 metabolites is specifically required, better results can probably be achieved with longer echo-times. The magnitude of the CVs needs to be taken into account in the calculation of sample size for cross-sectional or linear studies.

Investigation into an engraftment defect induced by culturing primitive hematopoietic cells with cytokines

BACKGROUND

Strategies for transplanting primitive hematopoietic progenitor (PHP) cells are under development that require in vitro manipulation of cells for several hours to several days prior to transplantation. This applies to gene-therapy protocols involving transduction with adenoviral or lentiviral vectors (typically 1 day of ex vivo culture) or retroviral vectors (up to 3 days of culture).

METHODS

Human mobilized peripheral blood (MPB) CD34(+) cells were cultured with the cytokines thrombopoietin mimetic peptide (mTPO), flt3 ligand (FL), and c-kit ligand (KL). Equal numbers of CD34(+) cells, either uncultured or cultured for various time periods up to 5 days, were tested for engraftment in sublethally irradiated 8-10 week-old NOD/SCID mice. Cells were also compared for expression and function of several key surface molecules.

RESULTS

At a limiting dose of 1 million cells, mice receiving uncultured cells had a mean of 20% CD45(+) (human) cells in their BM 6 weeks post-transplantation, versus 3% for mice receiving 3-5 day cultured cells. Analysis of 10 surface molecules, CD11a, CD18, CD29, CD49d, CD49e, CXCR-4, CD62L, CD31, CD43, and CD44 over a 5-day culture period showed that their expression levels were either maintained or up-regulated on CD34(+) cells and the primitive Thy-1(+) subset. Similar percentages of uncultured and 3-day cultured MPB CD34(+) cells bound to plates coated with vascular cell adhesion molecule-1 (VCAM-1) under both static and physiological flow conditions, and chemotaxis of cultured cells towards stromal-derived factor-1 (SDF-1) was not impaired, suggesting that VLA-4 and CXCR-4 were functional on cultured cells. CD34(+) Thy-1(+) MPB cells cultured with cytokines expressed increasing levels of Fas receptor beginning at 20 h in culture, with peak expression levels after 3 days (mean Day 0 expression, 39%; mean Day 3 expression, 86%), without increased apoptosis. Including inhibitors of caspases in the media of cells cultured for 24-48 h significantly improved their engraftment in a SCID-hu bone-engraftment model.

DISCUSSION

Increased susceptibility to apoptosis upon in vivo injection may contribute to impaired engraftment of in vitro manipulated cells. Inhibitors of apoptosis may increase their engrafting capacity in clinical settings.

Associations between physical fitness and activity patterns during adolescence and cardiovascular risk factors in young adulthood: the Northern Ireland Young Hearts Project

The aim of the present study was to examine relationships between cardiovascular disease (CVD) risk factor status in young adulthood (mean age = 22.5 yrs) and antecedent physical fitness and physical activity at ages 12 and 15 years. The data were obtained from the Young Hearts Project, a longitudinal observational study of CVD risk factors in a representative sample of young people from Northern Ireland. Physical fitness was measured by the 20-metre endurance shuttle run, and physical activity and sports participation by a self-report recall questionnaire. CVD risk factors examined included serum total cholesterol (TC) and HDL cholesterol concentrations, the TC:HDL ratio, systolic and diastolic blood pressure and body fatness (sum of four skinfolds). Linear regression analyses showed modest relationships between physical fitness in adolescence and both TC:HDL ratio and body fatness in young adulthood. No such relationships were apparent for adolescent physical activity. The promotion of physical fitness during adolescence may reduce exposure to other risk factors lasting into early adulthood.

Association of early life factors and acute lymphoblastic leukaemia in childhood: historical cohort study

In a historical cohort study of all singleton live births in Northern Ireland from 1971-86 (n=434,933) associations between early life factors and childhood acute lymphoblastic leukaemia were investigated. Multivariable analyses showed a positive association between high paternal age (> or =35 years) and acute lymphoblastic leukaemia (relative risk=1.49; 95% confidence interval (CI)=0.96--2.31) but no association with maternal age. High birth weight (> or =3500 g) was positively associated with acute lymphoblastic leukaemia (relative risk=1.66; 95% CI=1.18--2.33). Children of mothers with a previous miscarriage or increased gestation (> or =40 weeks) had reduced risks of ALL (respective relative risks=0.49; 95% CI=0.29--0.80, and 0.67; 95% CI=0.48--0.94). Children born into more crowded households (> or =1 person per room) had substantially lower risks than children born into less crowded homes with also some evidence of a lower risk for children born into homes with three adults (relative risks=0.56; 95% CI=0.35-0.91 and 0.58; 95% CI=0.21-1.61 respectively). These findings indicate that several early life factors, including living conditions in childhood and maternal miscarriage history, influence risk of acute lymphoblastic leukaemia in childhood.

A selective impairment in the processing of sad and fearful expressions in children with psychopathic tendencies

The processing of emotional expressions is fundamental for normal socialisation and interaction. Reduced responsiveness to the expressions of sadness and fear has been implicated in the development of psychopathy (R. J. R. Blair, 1995). The current study investigates the sensitivity of children with psychopathic tendencies to facial expressions. Children with psychopathic tendencies and a comparison group, as defined by the Psychopathy Screening Device (PSD; P. J. Frick & R. D. Hare, in press), were presented with a cinematic display of a standardised set of facial expressions that depicted sadness, happiness, anger, disgust, fear, and surprise. Participants observed as these facial expressions slowly evolved through 20 successive frames of increasing intensity. The children with psychopathic tendencies presented with selective impairments; they needed significantly more stages before they could successfully recognise the sad expressions and even when the fearful expressions were at full intensity were significantly more likely to mistake them for another expression. These results are interpreted with reference to an amygdala and empathy impairment explanation of psychopathy.

Birthweight and aerobic fitness in adolescents: the Northern Ireland Young Hearts Project

The purpose of this study was to examine relationships between aerobic fitness and birthweight in adolescents. A representative cohort of 1015 males and females aged 12 and 15 y was studied, at baseline, with 89% of the 12-y-olds being re-examined 3 y later. The main outcome measures were an index of aerobic fitness, measured in laps completed at voluntary exhaustion by a twenty-metre shuttle run test, and recorded birthweight. Multiple linear regression, with and without adjustment for known and potential confounding variables, was performed to examine associations between fitness and birthweight. Birthweight and aerobic fitness were positively related so that for each kg decrease in birthweight, there was a mean (95% confidence interval) decrease in fitness score of 4.84 (0.35 to 9.33) laps and 3.21 (0.32 to 6.10) laps, in 12-y-old boys and girls respectively. This relationship is of a similar order to the strength of association between birthweight and adult blood pressure previously reported. Associations between birthweight and physical fitness at the age of 15 were weaker and were not significant. Our findings suggest that aerobic fitness may be involved in mediating the association between birthweight and cardiovascular disease risk later in life. The weakening of the association between birthweight and fitness between the ages of 12 and 15 y is similar to the weaker associations between birthweight and blood pressure seen among adolescents compared to younger children. We are currently re-examining this cohort to see if, as with blood pressure, the association with fitness re-emerges at an older age.