Second-trimester genetic sonogram for detection of fetal chromosomal abnormalities in a community-based antenatal testing unit

OBJECTIVE

To evaluate the efficacy of the second-trimester genetic sonogram for the detection of Down syndrome and other chromosomal abnormalities in a community-based antenatal testing unit.

METHODS

This was a retrospective study using data from two community hospital antenatal ultrasound units. Six hundred and sixty fetal ultrasound examinations in both at-risk (n = 581) and low-risk (n = 79) pregnancies were performed from 15 + 0 to 22 + 6 weeks' gestation and all cases were verified for outcome data. The sonographic detection of a major congenital anomaly or a sonographic marker (increased nuchal skinfold, short humerus, short femur, echogenic bowel, pyelectasis, echogenic intracardiac focus, absence or hypoplasia of fifth mid phalanx or choroid plexus cyst) was recorded. The entire group of 660 ultrasound examinations as well as subgroups with and without non-ultrasound risk factors for a fetal chromosomal abnormality were analyzed to determine the sensitivity, specificity, positive and negative predictive values and positive likelihood ratio for the detection of Down syndrome and other fetal chromosomal abnormalities.

RESULTS

There were 32 (4.85%) chromosomal abnormalities in our study population. Twelve (3.75%) of these were Down syndrome, of which eight (66.6%) had a positive ultrasound examination in the second trimester. Six of seven (85.7%) of the trisomy 18 fetuses, 2/2 of the trisomy 13 fetuses and 2/3 of the non-mosaic 45,X fetuses had positive sonograms. The overall detection rate for chromosomal abnormalities was 20/32 (sensitivity, 62.5%; specificity, 80.7%; negative predictive value, 97.7%; positive predictive value, 14.2%; positive likelihood ratio, 3.24). Major structural defects and sonographic markers, excluding hypoplastic fifth digit and choroid plexus cyst, occurred significantly more frequently in Down syndrome cases compared with normal ones.

CONCLUSIONS

In a community-based antenatal testing unit we have demonstrated a detection rate for fetal Down syndrome with the second-trimester genetic sonogram that is comparable to the range of sensitivities reported by larger centers involving primarily high-risk patients. However, only 12 of the 32 fetal chromosomal abnormalities that we encountered were Down syndrome.

A report of two deaths from massive ibuprofen ingestion

INTRODUCTION

Ibuprofen is a commonly used non-steroidal anti-inflammatory drug. While the vast majority of exposures to the drug do not result in significant morbidity, we are reporting 2 fatalities that resulted from massive ibuprofen ingestion. CASE 1: A 17-year-old girl presented to the emergency department (ED) following an ibuprofen overdose; she was unresponsive with a metabolic acidosis and hypothermic. Her serum ibuprofen concentration was 352 microg/mL: the therapeutic range is 10-50 microg/mL. Despite intensive supportive care and continuous veno-venous hemofiltration, she expired. CASE 2: A 49-year-old man presents to the ED with a history of divalproex sodium and ibuprofen ingestion. He was unresponsive, hypotensive, and had a significant metabolic acidosis. His serum ibuprofen concentration was 260 microg/mL and serum valproate concentration was 560 microg/mL: the therapeutic range is 50-100 microg/mL. In spite of supportive care and hemodialysis, he expired.

DISCUSSION

We will describe 2 cases of ibuprofen overdose characterized by cardiovascular collapse, acidosis, and hypothermia despite the use of vasopressors and renal replacement therapy. Although rarely reported, massive ibuprofen overdose may result in refractory multisystem organ failure and death.

Plastic surgical options for HIV-associated lipodystrophy

With the reported prevalence of HIV-associated lipodystrophy approaching 80%, this patient group presents an increasing challenge to plastic surgeons. Based on a literature search conducted using OVID Medline, this review shall describe the various treatment options employed by plastic surgeons to deal with the problems of fat distribution in patients suffering from HIV-lipodystrophy, and examine the evidence for each treatment.

Experience in the treatment of HIV-associated lipodystrophy

AIM

To evaluate the outcome of patients with HIV-associated lipodystrophy treated within the Edinburgh unit to date.

METHODS

Information was collected from the medical case notes on the clinical features, method of treatment, postoperative complications, and length of follow up for each patient. A questionnaire was devised to assess patient satisfaction and facial volume was evaluated using three-dimensional imaging.

RESULTS

Forty-six patients with HIV-associated lipodystrophy were treated over a 3-year period. Twenty-six patients received Coleman fat injections, 10 patients were treated with Newfill, eight patients were treated with Bio-alcamid, 21 patients received liposuction, and three patients had a minimal access cranial suspension facelift. Follow up ranged from 1 to 14 months. Patient and surgeon satisfaction was high with autologous fat injections although fat resorption occurred in nine patients. Aesthetic improvement with Newfill was moderate and required up to seven treatment sessions. The results of treatment with Bio-alcamid were good immediately postoperatively, although two patients required further corrective procedures. Two patients who had liposuction to the dorso-cervical fat pad reported recurrence at 5 and 9 months, respectively.

CONCLUSIONS

Based on our experience, a treatment algorithm has been devised to aid management decisions. We favour the use of autologous fat injections for facial lipoatrophy but have found fillers to be useful in patients with inadequate fat reserves.

Combination of enzyme analysis, allele-specific PCR and sequencing to detect mutations in the GALT gene

Newborn screening can identify patients with classical galactosaemia, and their diagnosis needs to be confirmed with assay of the activity of galactose-1-phosphate uridyltransferase (GALT). Unfortunately, in many cases the results can be ambiguous and further testing is required. Here we report a combination of biochemical analysis of GALT enzyme activity and mutation analysis of the most common mutations in the corresponding gene. Samples (n = 243) submitted for confirmatory testing for classical galactosaemia were analysed simultaneously for GALT enzyme activity and allele-specific PCR/fragment analysis for seven mutations and two polymorphisms in the GALT gene (mutations IVS2-2A>G, p.S135L, p.T138M, p.L195P, p.K285N, p.Q188R, p.Y209C; polymorphisms p.N314D, p.L218L). Mutation detection accorded with biochemical analysis in 93% of samples. Subsequently, a total of 34 samples with either discordant results between the above methods or low enzyme activity were fully sequenced, identifying previously reported pathogenic mutations and seven novel variations (p.P185H, p.R201C, p.E220K, p.R223S, p.I278N, p.L289F and p.L218X) in the GALT gene. This approach further increased concordance between genetic and biochemical analysis to 99% of all alleles tested. Our results indicate that DNA testing can help to verify biochemical enzymatic data and improve distinction of borderline enzyme activities where a patient may still benefit from treatment.

Identification of excited states in the T(z) = 1 nucleus (110)Xe: evidence for enhanced collectivity near the N=Z=50 double shell closure

Gamma-ray transitions have been identified for the first time in the extremely neutron-deficient (N=Z+2) nucleus (110)Xe, and the energies of the three lowest excited states in the ground-state band have been deduced. The results establish a breaking of the normal trend of increasing first excited 2(+) and 4(+) level energies as a function of the decreasing neutron number as the N=50 major shell gap is approached for the neutron-deficient Xe isotopes. This unusual feature is suggested to be an effect of enhanced collectivity, possibly arising from isoscalar n-p interactions becoming increasingly important close to the N=Z line.

Coping styles, psychological functioning and quality of life in children with asthma

BACKGROUND

Previous research suggests that children dealing with the asthma are at a greater risk for experiencing psychological maladjustment than children without asthma. Research also suggests that coping is a factor in psychological adaptation to chronic stressors such as physical illnesses. The question as to how coping relates to psychological functioning and quality of life in the paediatric asthma population has not yet been answered. The objective of the current study was to examine the relationships among coping, psychological functioning and quality of life in children diagnosed with asthma and to investigate the relationship that mothers' quality of life has with these variables.

METHODS

Forty-seven youths (aged 8-15 years) diagnosed with asthma completed measures of coping with asthma and quality of life. Each youth's mother completed measures of her child's coping, psychological functioning and her own quality of life.

RESULTS

Mothers and children with asthma both reported that children used significantly more approach coping than avoidant coping when dealing with asthma. Three regression analyses indicated that avoidant coping negatively predicted psychological functioning, child's quality of life and mother's quality of life. Bivariate analyses also indicated a positive relationship between child's quality of life and mother's quality of life.

CONCLUSIONS

Results indicate that, in children with asthma, coping style plays an important role in the child's psychological functioning and quality of life and mother's quality of life. Therefore, it is recommended that type of coping be assessed when developing comprehensive treatment plans for children with asthma. Further research is needed to determine the efficacy of focused coping interventions in improving quality of life and psychological functioning in children with asthma.

Placental abruption is more frequent in women with the angiotensinogen Thr235 mutation

OBJECTIVE

Obstetrical complications such as preeclampsia, fetal growth restriction, and placental abruption are associated with inadequate placental perfusion. Previous studies have shown that the angiotensinogen (AGT) Thr235 mutation is associated with abnormal remodeling of the uterine spiral arteries and occurs at higher frequencies in preeclampsia. This study was done to evaluate whether the AGT Thr235 mutation increases the risk of placental abruption.

MATERIALS AND METHODS

We compared 62 placentas from women who had placental abruption with 240 control patients of similar age and ethnicity. DNA was extracted from paraffin blocks from placentas. AGT Met235Thr mutation status was determined by single fluoresceine labeled probe real-time PCR using a LightCycler system.

RESULT

AGT genotypes were divided into three groups: MM (homozygous wild), TT (homozygous mutant), and MT (heterozygous). The constituent ratio of AGT genotype in abrupted placentas (MM 14.5%, MT 43.5%, TT 41.9%) was significantly different from in control group (MM42.5%, MT 39.6%, TT 17.9%) (p<0.001). AGT mutant allele frequency in placental abruption (0.637) was significantly higher than in the control group (0.377) (p<0.001).

CONCLUSION

The AGT Thr235 mutation was observed more frequently in placental abruption. AGT Thr235 mutation may be considered a risk factor for placental abruption.

Are burns photographs useful?

Routine photography of all patients admitted to the West of Scotland Regional Burns Unit was introduced in 2003. To date, there are few burns units to evaluate the usefulness of photographs taken.

AIM

To assess the usefulness of photographs of patients admitted to the burns unit to various members of the multidisciplinary team.

METHOD

A questionnaire was completed by hospital staff involved in the management of burns patients over a 3-month period. A total of 43 questionnaires were completed.

RESULTS

The majority of questionnaires were completed by nursing staff (55%) followed by medical staff (23%); physiotherapy (5%); anaesthetists (7%); theatre staff (5%); students (2%); dietician (2%). About 98% of respondents agreed that photographs were useful overall, particularly for teaching purposes. About 9% disagreed that photographs were useful for assessment due to difficulty in assessing depth of burn. About 72% agreed that the photographs were useful for patient management and improve patient care. About 88% agreed that all patients should have photographs available in future. Advantages of photographs include; moving and handling of patients; patient positioning in theatre; reviewing wound healing and complications. They are useful for assessing site, size and type of burn. Disadvantages include difficulty in assessing depth of burn, technical factors, and unavailability out of hours.

CONCLUSIONS

Photographs of burns patients are useful overall to all members of the multidisciplinary team.

Laparoscopic versus open colposuspension--results of a prospective randomised controlled trial

OBJECTIVE

To compare the effectiveness and cost effectiveness of open and laparoscopic colposuspension in the treatment of stress urinary incontinence.

DESIGN

A randomised controlled trial. Women were randomised between March 1999 and February 2002 and were seen for assessment at 6, 12 and 24 months, postoperatively.

SETTING

Women were recruited from six gynaecology units in the UK.

POPULATION

Women with proven stress urinary incontinence requiring surgery.

METHODS

Open abdominal retropubic colposuspension or laparoscopic colposuspension.

MAIN OUTCOME MEASURES

Primary outcomes were subjective (satisfaction with outcome) and objective (negative 1-hour pad test). Secondary outcomes were operative and postoperative morbidity and quality of life. The study was powered to demonstrate noninferiority, i.e. that the absolute cure rate of laparoscopic colposuspension was no more than 15% below that of open colposuspension.

RESULTS

A total of 291 women were randomised, with 24-month data on subjective and objective outcomes in 88 and 82.5%, respectively. The intention-to-treat analysis indicated no significant difference in cure rates between open and laparoscopic surgery. The objective cure rates for open and laparoscopic were 70.1 and 79.7%, respectively. Subjective cure rates by satisfaction were lower than objective cure; 54.6 and 54.9%, respectively, and there was considerable nonconcordance both ways.

CONCLUSIONS

Laparoscopic colposuspension is not inferior to open colposuspension in terms of curing stress urinary incontinence.

Cost-effectiveness analysis of open colposuspension versus laparoscopic colposuspension in the treatment of urodynamic stress incontinence

OBJECTIVES

To compare the cost effectiveness of laparoscopic versus open colposuspension for the treatment of female urinary stress incontinence.

DESIGN

Cost utility analysis alongside a randomised controlled trial.

SETTING

Six gynaecological surgical centres within the UK.

POPULATION/SAMPLE

Women with proven stress urinary incontinence requiring surgery.

METHODS

Open abdominal retropubic colposuspension or laparoscopic colposuspension carried out by experienced surgeons.

MAIN OUTCOME MEASURES

Cost, measured in pounds sterling and generic health-related quality of life, measured using the EQ-5D. The latter was used to estimate patient-specific quality-adjusted life years (QALYs).

RESULTS

Healthcare resource use over 6-month follow up translated into costs of pound 1805 for the laparoscopic arm and pound 1433 for the open arm (differential mean cost pound 372; 95% credibility interval [CrI]: 274-471). At 6 months, QALYs were slightly higher in the laparoscopic arm relative to the open arm (0.005; 95% CrI: -0.012 to 0.023). Therefore, the cost of each extra QALY in the laparoscopic group (the incremental cost-effectiveness ratio [ICER]) was pound 74,400 at 6 months. At 24 months, the laparoscopic arm again had a higher mean QALY score compared to the open surgery group. Thus, assuming that beyond 6 months the laparoscopic colposuspension would not lead to any significant additional costs compared with open colposuspension, the ICER was reduced to pound 9300 at 24 months. Extensive sensitivity analyses were carried out to test assumptions made in the base case scenario.

CONCLUSIONS

Laparoscopic colposuspension is not cost effective when compared with open colposuspension during the first 6 months following surgery, but it may be cost effective over 24 months.

Tetramethylenedisulfotetramine: old agent and new terror

Tetramethylenedisulfotetramine has accounted for numerous intentional and unintentional poisonings in China. In May 2002, the first known case of human illness in the United States caused by tetramethylenedisulfotetramine, a banned neurotoxic rodenticide from China, occurred in New York City. The clinical presentation after tetramethylenedisulfotetramine exposure is dose dependent, and the most recognized complication is status epilepticus. Poisonings may be fatal within hours. No known antidote exists, and treatment is mainly supportive. Anecdotal reports, case reports, and 2 animal studies suggest possible success with certain pharmacologic interventions, including pyridoxine and chelation therapy. Pesticide and rodenticide poisonings, whether intentional or unintentional, pose a serious threat to populations, and the availability of a banned rodenticide such as tetramethylenedisulfotetramine, with its associated morbidity and lethality, is a serious public health concern. Given the recent case report that confirms the presence of tetramethylenedisulfotetramine in the United States, the toxicity of the compound, its unique physical properties, the absence of an antidote, and the history of its use as an agent of intentional mass poisoning, public health entities have undertaken educational efforts to inform the public, health care providers, and emergency personnel of this potentially lethal rodenticide.

Botulinum toxin type B: a new therapy for axillary hyperhidrosis

Primary axillary hyperhidrosis is a disorder affecting mainly adolescents with significant adverse effects on quality of life. No ideal treatment exists, although recent data has demonstrated Botulinum toxin type A (Botox) as a treatment option. However, antibody formation may lead to loss of clinical benefit over time. Botulinum toxin type B (Neurobloc) has recently been introduced and may induce less immunogenic response.

OBJECTIVE

To investigate the efficacy of Neurobloc for axillary hyperhidrosis.

METHOD

Thirteen patients (22 axillae) were recruited to the study. The hyperhidrotic area was defined using the iodine-starch test then measured and photographed. 5000 MU of Neurobloc was administered subdermally. Patients were reviewed at 4, 8 and 12 weeks to assess outcome objectively (hyperhidrotic area measurements and photographs) and subjectively (sweat production and patient satisfaction).

RESULTS

There was a significant reduction in hyperhidrotic area at follow-up compared to baseline. Mean percentage reduction in hyperhidrotic area was 84, 87 and 81% at 4, 8 and 12 weeks (p=0.001, paired t test). Patient satisfaction was 100% throughout. Subjective mean percentage reduction in sweat production was 98, 96 and 90 at 4, 8 and 12 weeks. Side effects were minimal.

CONCLUSION

Neurobloc is an effective treatment for axillary hyperhidrosis.

Capacity building for international tuberculosis control through operations research training

SETTING

In resource-poor countries, few tuberculosis (TB) program staff at the national, provincial, and even district levels have the basic analytical and epidemiological skills necessary for collecting and analyzing quality data pertaining to national TB control program (NTP) improvements. This includes setting program priorities, operations planning, and implementing and evaluating program activities.

OBJECTIVES

To present a model course for building capacity in basic epidemiology and operations research (OR).

DESIGN

A combination of didactic lectures and applied field exercises were used to achieve the main objectives of the 6-day OR course. These were to increase the understanding of quantitative and qualitative research concepts, study design, and analytic methods, and to increase awareness of how these methods apply to the epidemiology and control of TB; and to demonstrate the potential uses of OR in answering practical questions on NTP effectiveness. As a final outcome, course participants develop OR proposals that are funded and later implemented.

RESULTS

Since 1997, this OR course has been conducted nine times in five countries; 149 key NTP and laboratory staff have been trained in OR methods, and 44 OR protocols have been completed or are underway.

CONCLUSION

This low-cost model course can be adapted to a wide range of public health issues.