Stereotactic Radiosurgery for Trigeminal Neuralgia: A Comparison of Proximal and Distal Isocenter Outcomes

PURPOSE/OBJECTIVE(S)

Trigeminal neuralgia is a chronic pain condition of the trigeminal nerve affecting 12 per 100,000 people. Stereotactic radiosurgery (SRS) delivered by both a non-invasive stereotactic radiosurgery instrument and linear accelerators (LINAC) is a non-invasive alternative to surgical approaches. Although SRS in this setting is commonly performed, there lacks a consensus and comparative data on the optimal anatomical target with the two most common targets being the dorsal root entry zone (proximal) and retrogasserian zone (distal). This study aims to evaluate treatment outcomes in patients based on these two target locations.

MATERIALS/METHODS

This multi-center, retrospective analysis included patients treated for trigeminal neuralgia between 2017 and 2021 with GK and LINAC-based SRS who were followed for at least 1 year. All patients received a dose of 85 Gy prescribed to the isocenter, set at the dorsal root entry zone (proximal) or the retrogasserian zone (distal). Isocenter location was based on the preference of the radiation oncologist and neurosurgeon. Patient reported clinical pain relief was recorded as full, partial, or no pain relief after SRS. Among patients with full and partial pain relief duration of pain relief was recorded. Ability to achieve full or partial medication de-escalation was also recorded. Outcomes of patients in the proximal and distal target cohort were compared using time based univariate analyses using log rank hazards model.

RESULTS

We identified 86 eligible patients, of whom 54 patients (63%; median age 63, 72% female) were treated using a proximal target, and 32 (37%; median age 66, 71% female) were prescribed to a distal target. In the proximal and distal cohorts, patients experienced pain relief (either partial or full relief) at a rate of 74% and 90% and full pain relief at a rate of 46% and 31%, respectively (p = 0.011). The duration of pain relief was not significantly different amongst the two groups (p = 0.18). Partial medication de-escalation was more frequent in the distal target (75%) vs proximal (33%), while full medication de-escalation was more frequent with proximal (39%) vs distal (13%), p = 0.001.

CONCLUSION

This study contributes to the limited data evaluating the differences in outcomes between proximal and distal targeting for treatment of trigeminal neuralgia with stereotactic radiosurgery. Overall, this study confirms that both approaches achieve a high rate of response in a difficult to control disease process. Our study suggests that a distal isocenter may be associated with higher rates of any type of pain improvement while a proximal isocenter may be associated with higher rates of complete pain relief. This data is hypothesis-generating and warrants further investigation into the effectiveness/toxicity differences of two approaches.

Skin-interfaced biosensors for advanced wireless physiological monitoring in neonatal and pediatric intensive-care units

Standard of care management in neonatal and pediatric intensive care units (NICUs and PICUs) involve continuous monitoring of vital signs with hard-wired devices that adhere to the skin and, in certain instances, include catheter-loaded pressure sensors that insert into the arteries. These protocols involve risks for complications and impediments to clinical care and skin-to-skin contact between parent and child. Here we present a wireless, non-invasive technology that not only offers measurement equivalency to these management standards but also supports a range of important additional features (without limitations or shortcomings of existing approaches), supported by data from pilot clinical studies in the neonatal intensive care unit (NICU) and pediatric ICU (PICU). The combined capabilities of these platforms extend beyond clinical quality measurements of vital signs (heart rate, respiration rate, temperature and blood oxygenation) to include novel modalities for (1) tracking movements and changes in body orientation, (2) quantifying the physiological benefits of skin-to-skin care (e.g. Kangaroo care) for neonates, (3) capturing acoustic signatures of cardiac activity by directly measuring mechanical vibrations generated through the skin on the chest, (4) recording vocal biomarkers associated with tonality and temporal characteristics of crying impervious to confounding ambient noise, and (5) monitoring a reliable surrogate for systolic blood pressure. The results have potential to significantly enhance the quality of neonatal and pediatric critical care.

Baby swimming: exploring the effects of early intervention on subsequent motor abilities

AIM

The aim of the study was to explore the effects of baby swimming on subsequent motor abilities.

BACKGROUND

A range of motor abilities was examined in 4-year-old children who had previously participated in a programme of baby swimming (n= 19) and compared with a matched group of coevals who had not had this experience (n= 19).

RESULTS

As predicted from the nature of the exercises that comprise the programme, the effects of baby swimming were restricted to abilities associated with prehension and balance.

CONCLUSIONS

Suggestions are made as to how the theme of this hypothesis-generating, demonstration study can be pursued in the future with more rigorous experimental controls and applications to children with disabilities and impairments.

ADAMTS5-/- mice have less subchondral bone changes after induction of osteoarthritis through surgical instability: implications for a link between cartilage and subchondral bone changes

OBJECTIVE

Osteoarthritis (OA) is characterized by damaged articular cartilage and changes in subchondral bone. Previous work demonstrated aggrecanase-2 deficient (ADAMTS5-/-) mice to be protected from cartilage damage induced by joint instability. This study analyzed whether this protective effect on cartilage is also reflected in the subchondral bone structure.

METHODS

Right knee joints from 10-week old male wild type (WT) and ADAMTS5-/- mice received transection of the medial meniscotibial ligament to induce OA, whereas left knees were left unoperated. After 8 weeks knee joints were scanned by micro-CT. The proximal tibia was selected for further analysis. Histology was performed to evaluate cartilage damage and osteoclast presence.

RESULTS

ADAMTS5-/- joints had a significantly thinner subchondral plate and less epiphyseal trabecular bone compared to WT joints. Histology confirmed previous findings that ADAMTS5-/- mice have significantly less cartilage damage than WT in the instability-induced OA model. Although the subchondral bone plate became significantly thicker at the medial tibial plateau in operated joints of both genotypes, the percentage increase was significantly smaller in ADAMTS5-/- mice (WT: 20.7+/-4.7%, ADAMTS5-/-: 8.3+/-1.2% compared to the left unoperated control joint). In ADAMTS5-/- animals a significant decrease was found in both Oc.N./BS and Oc.S./BS. Finally, in WT but not in ADAMTS5-/- mice a significant correlation was found between medial subchondral bone plate thickness and cartilage damage at the medial tibial plateau.

CONCLUSION

ADAMTS5-/- joints that were protected from cartilage damage showed minor changes in the subchondral bone structure, in contrast to WT mice where substantial changes were found. This finding suggests links between the process of cartilage damage and subchondral bone changes in instability-induced OA.

Osteoarthritis severity is sex dependent in a surgical mouse model

OBJECTIVE

To investigate the role of sex hormones in cartilage degradation and progression of osteoarthritis (OA) in a murine model induced by destabilization of the medial meniscus (DMM).

DESIGN

Accelerated OA development in mice was induced by transection of the menisco-tibial ligament, which anchors the medial meniscus to the tibial plateau. Intact male and female, and orchiectomized (ORX) male and ovariectomized (OVX) female mouse knee histology were compared for signs of OA following DMM. The effect of testosterone or estrogen addition in vivo was assessed in ORX males in the surgical OA model.

RESULTS

OA severity was markedly higher in males than females after DMM. OVX females developed significantly more severe OA than control females. ORX males developed significantly less severe OA than control males. When ORX male mice were supplemented with exogenous dihydrotestosterone (DHT), the severity of OA was restored to the level experienced by the control male mice. Hip cartilage from mice of both sexes demonstrated similar spontaneous and interleukin-1alpha (IL-1alpha) induced proteoglycan (PG) release in vitro. DHT and 17-beta estradiol (E2) did not significantly alter the PG release pattern when supplemented to cartilage cultures of either sex.

CONCLUSION

Sex hormones play a critical role in the progression of OA in the murine DMM surgical model, with males having more severe OA than females. Intact females had more OA than OVX females, indicating that ovarian hormones decrease the severity of OA in the female mice. Male hormones, such as testosterone, exacerbate OA in male mice as demonstrated by the fact that ORX mice experienced less OA than intact males, and that addition of DHT to ORX males was able to counteract the effect of castration and re-establish severe OA.

Do 'clumsy' children have visual recognition problems?

OBJECTIVE

Visual recognition by 8-year-old children with hand-eye co-ordination problems (HECP), and by a control group of children without such problems was tested using a task of visual closure.

DESIGN

The task required the children to identify common objects from an incomplete visual presentation.

RESULT

As predicted, it was found that the HECP children, who were designated as such solely on the basis of their motor difficulties, identified significantly fewer correct objects than their control counterparts.

CONCLUSIONS

This finding raises the possibility that the visual processing problems of clumsy children contribute to, or even strongly determine, not only their movement problems but also their learning difficulties.

Nanometal Surface Energy Transfer in Optical Rulers, Breaking the FRET Barrier

Optical-based distance measurements are essential for tracking biomolecular conformational changes, drug discovery, and cell biology. Traditional Forster resonance energy transfer (FRET) is efficient for separation distances up to 100 A. We report the first successful application of a dipole-surface type energy transfer from a molecular dipole to a nanometal surface that more than doubles the traditional Forster range (220 A) and follows a 1/R(4) distance dependence. We appended a 1.4 nm Au cluster to the 5' end of one DNA strand as the energy acceptor and a fluorescein (FAM) to the 5' end of the complementary strand as the energy donor. Analysis of the energy transfer on DNA lengths (15, 20, 30, 60bp), complemented by protein-induced DNA bending, provides the basis for fully mapping the extent of this dipole surface type mechanism over its entire usable range (50-250 A). Further, protein function is fully compatible with these nanometal-DNA constructs. Significantly extending the range of optical based methods in molecular rulers is an important leap forward for biophysics.

The DNA sequence and comparative analysis of human chromosome 10

The finished sequence of human chromosome 10 comprises a total of 131,666,441 base pairs. It represents 99.4% of the euchromatic DNA and includes one megabase of heterochromatic sequence within the pericentromeric region of the short and long arm of the chromosome. Sequence annotation revealed 1,357 genes, of which 816 are protein coding, and 430 are pseudogenes. We observed widespread occurrence of overlapping coding genes (either strand) and identified 67 antisense transcripts. Our analysis suggests that both inter- and intrachromosomal segmental duplications have impacted on the gene count on chromosome 10. Multispecies comparative analysis indicated that we can readily annotate the protein-coding genes with current resources. We estimate that over 95% of all coding exons were identified in this study. Assessment of single base changes between the human chromosome 10 and chimpanzee sequence revealed nonsense mutations in only 21 coding genes with respect to the human sequence.

Fetal handedness and head position preference: a developmental study

Hand-head contacts were observed by means of serial ultrasound recordings in 10 healthy fetuses from 12 to 38 weeks of gestational age. Contacts were distinguished as being unimanual or bimanual, and if unimanual, whether they were made with the right or left hand. Both types of contact and ones made unimanually with the right or left hand were identified at each age as to whether they were associated with a preferential head position. A strong unimanual bias was evident at each age except for Week 36. At this age, there was a bimanual bias. Unimanual contacts did not develop a lateralized preference, and neither type of contact established a stable relationship with head position. Furthermore, there was no evidence to support the suggestion that hand contact and head position codevelop to form a preferred ipsilateral synergy. Findings are discussed relative to contradictory evidence from other fetal and neonatal studies.

Muscle power in "high-risk" preterm infants at 12 and 24 weeks corrected age: a measure for early detection

A group of 72 "high-risk" preterm infants was studied at the corrected ages of 12 and 24 wk. Only infants with a high risk for developmental deviance with gestational ages below 32 wk and/or birthweights of less than 1500 g were included in the study. In addition, the infants were categorized according to their medical history, as confirmed by the "Neonatal Medical Index" (NMI I to V), with category I describing infants with few medical problems and V characterizing those with the most serious complications. In this study we included only "high-risk" infants as categorized in NMI III to V, since infants with a "low risk" have been described earlier. Apart from the standard paediatric follow-up, an age-adequate neurological assessment was made, with special emphasis on the relationship between active and passive muscle power. When development is optimal, these two components of muscle power should be in balance in order to create a stable posture and fluent motility. We compared muscle power at the corrected ages of 12 and 24 wk to determine whether the method employed to assess muscle power could enhance early detection of deviant development. At 12 wk of age, only 5 infants showed overall optimal muscle power, while at 24 wk this figure had increased to 27. Significantly more infants in NMI III had optimal outcomes at 24 wk of age. When muscle power in the different parts of the body was studied separately at 24 wk, outcomes in shoulders and trunk still showed significant discrepancies in all NMI groups. At this age, fewer asymmetries were found compared to outcomes at 12 wk.

CONCLUSION

Our method of assessing muscle power is useful in detecting preterm infants at risk for pathological development.

Effect of ruminal protein degradability on growth and N metabolism in growing beef steers

The objective of two experiments was to correlate plasma levels of urea N (PUN) and the percentage of urine N in the form of urea (UUN) to weight gain in response to different dietary protein regimens for growing Angus steers. In Exp. 1, 60 steers (302 kg BW) were assigned to various levels of dietary N (control plus supplemental N to provide from 100 to 400 g more crude protein daily) within two sources of supplemental N (soybean meal [SBM] or a mixture of two parts corn gluten meal:one part blood meal [CGM:BM]). In Exp. 2, 27 steers (229 kg BW) were fed two levels of SBM, and half of the steers received growth-promoting implants. Steers were housed in groups of 12 and fed individually for 84 d in both experiments. Corn silage was fed at a restricted rate to minimize orts. Jugular blood and urine samples were collected during the experiments. In Exp. 1, maximal ADG of steers fed SBM (1.0 kg) was reached with 671 g/d total crude protein, or 531 g/d metabolizable protein. Maximal ADG of steers fed CGM:BM (0.91 kg) was reached with 589 g/d total crude protein, or 539 g/d metabolizable protein. The DMI was higher (P < 0.07) for steers fed SBM (6.37 kg/d) than for steers fed CGM:BM (6.14 kg/d). Increasing ruminal escape protein from 36% (SBM) to 65% (CGM:BM) of CP decreased (P < 0.05) endogenous production of urea, as evidenced by lower concentrations of urea in blood and lower UUN. In Exp. 2, increasing supplemental protein from 100 to 200 g/d increased (P < 0.05) ADG and PUN. Implants lowered (P < 0.05) UUN, particularly at the higher level of supplemental protein. Protein supplementation of growing steers can be managed to maintain acceptable ADG yet decrease excretion of urea in the urine.

Development of spontaneous leg movements in infants with and without periventricular leukomalacia

The main question asked in the present study was whether support could be found for the notion that supraspinal influences on the generation of spontaneous kicking movements become increasingly apparent in the first half-year after birth. In comparing groups of infants with and without damage in tracts connected with the cortex surrounding the central sulcus, such support would consist of the finding that similar patterns of spontaneous kicking are observed early in development, whereas differences between groups should occur with increasing age. Using 3-D registrations, the spontaneous kicking movements of 19 infants with differing degrees of periventricular, lobar, and subcortical leukomalacia based on white matter (WM) abnormalities on ultrasound were compared to those of 10 healthy control infants at 6, 12, 18, and 26 weeks of corrected age. Magnetic resonance imaging recordings were used to identify the location and severity of the brain lesions. Infants with extensive lesions in the periventricular and lobar WM with or without diffuse lesions in the subcortical WM showed a decreased variability on some spatial and temporal parameters of kicks. More importantly, these infants showed a different developmental course for intralimb couplings when compared to the other infants; they were unable to dissociate tight intralimb couplings at 18 and 26 weeks. As all of these infants had substantial damage of the corticospinal tracts, these findings suggest that these tracts are involved in the regulation of intralimb joint dissociations between 4 and 6 months of age. However, caution is needed as areas outside those in which the corticospinal tracts are located could be damaged as well and most of the infants with moderate to severe lesions in the corticospinal tract had additional psychomotor problems. For interlimb couplings and most of the spatial and temporal parameters of kicks, no differences were found between groups. This strengthens the claim that inter- and intralimb couplings are organized in fundamentally different ways.

Motor asymmetries in the human newborn are state dependent, but independent of position in space

Human newborns have a preference for turning and maintaining the head to one side of the body. Most studies confirm a right-sided preference in supine. Few have addressed the state dependency of this lateral bias, and even fewer have examined whether it is also expressed in the semi-upright position. We investigated whether it varies as a function of behavioural state and position in space. Kinematic recordings of head movements were made with the newborn secured on a platform in the supine or semi-upright position, which alleviated biomechanical and postural constraints imposed by gravity. Newborns differed as to whether they had a vertex, Caesarean or breech delivery. The majority of infants maintained a right-sided preference in both positions, but it was strongly mediated by state. Delivery type did not account for any lateral bias. These findings provide convincing evidence that a lateral bias in movement and positioning of the head are reflections of active neural processes rooted in the regulation of state.

Vision of the hand and environmental context in human prehension

Previous findings on the role of visual contact with the hand in the control of reaching and grasping have been contradictory. Some studies have shown that such contact is largely irrelevant, while more recent ones have emphasised its importance. In contrast, information arising from the surrounding environment has received relatively little attention in the study of prehensile actions. In order to identify the roles of both sources of information, we made kinematic comparisons between three conditions. In the first, reaching was performed in a dimly lit room and compared with a second condition in which reaches in the dark, but with the thumb and first finger illuminated, were made to a luminous object. This contrast allows the effects of environmental context to be identified. A comparison between the second and a third condition, in which both vision of the hand and the environment was removed, but the object was still visually available, enabled the assessment of how and when vision of the hand plays a role. Removing environmental cues had effects both early and late in the reach, while vision of the hand was only crucial in the period after peak deceleration. In addition, removal of both sources of information resulted in larger grip apertures. Differences and similarities between our findings and those of other studies are discussed, as is the ongoing debate about the relative importance of visual feedback of the hand in the control and co-ordination of prehensile actions. We conclude with suggestions for further research based on the set-up used in the present study.

Prenatal active or passive tobacco smoke exposure and the risk of preterm delivery or low birth weight

We examined the association of exposure to environmental tobacco smoke with birth weight and gestational age in a large, prospective study. We also compared these endpoints between infants of active maternal smokers and those of non-smoking, non-ETS exposed women. Pregnant women were interviewed by telephone during the first trimester, and pregnancy outcome was determined for 99%. Among the 4,454 singleton live births that could be linked to their birth certificate, we confirmed increased risks of low birth weight and small for gestational age with heavier maternal smoking (> 10 cigarettes/day), as well as noting an increased risk for "very preterm" birth (< 35 weeks). These associations were generally stronger among infants of older (> or = 30 years) than those of younger mothers, as well as among non-whites. High environmental tobacco smoke exposure (> or = 7 hours/day in non-smokers) was moderately associated with low birth weight (adjusted odds ratio (AOR) 1.8, 95% confidence limits (95% CL) = 0.82, 4.1), preterm birth (AOR 1.6, 95% CL = 0.87, 2.9), and most strongly with very preterm birth (AOR 2.4, 95% CL = 1.0, 5.3). These associations were generally greater among non-whites than whites. The data support earlier studies suggesting that prenatal environmental tobacco smoke exposure, in addition to maternal smoking, affects infant health.

Reducing nosocomial pressure ulcers in an acute care facility

In 1996, a nursing committee at an acute care facility organized the first pressure ulcer point prevalence survey for that hospital. In 1996, hospital-acquired pressure ulcers were 90 percent of the predicted prevalence rate; in 1997, the rate dropped to 59 percent of the predicted prevalence and in 1998, to 53 percent of the predicted prevalence. The severity index decreased markedly from 291 (1996) to 98 (1997) then to 62 (1998). These improvements are attributed to the purposeful addition of multidimensional interventions, including best practices and research-based protocols, to prevent and treat nosocomial pressure ulcers.

Spontaneous kicking behavior in infants: age-related effects of unilateral weighting

The age-related effects of unilateral weighting on spontaneously generated kicks in 18 healthy, full-term infants were investigated. The main question was whether infants during the first half-year after birth reveal changes in how they adjust to unilateral weighting. At 6 weeks, infants reduced the frequency of the weighted leg and increased that of the unweighted leg whereas at 12 weeks the frequency of kicking increased in both legs. At both ages, unilateral weighting also resulted in differences on a number of kinematic parameters. By 18 and 26 weeks, such frequency and kinematic effects were no longer present. With regard to interlimb couplings, a clear pattern of bilateral coordination was only present at 26 weeks; these results suggest that the effects of unilateral weighting are not directly related to the tightness of interlimb couplings. The implications of these age-related differences for understanding developmental changes in the control of leg movements are discussed. It is suggested that the infants' improved ability to act in a task-specific manner as well as nonlinear changes in the musculo-skeletal system and fine-tuning processes at a neural level might be factors of importance.

The coordination of two-effector actions: spoon-feeding and intermanual prehension

The aim of this study was to assess whether kinematic characteristics of unimanual (one-effector) prehension movements can also be found in tasks where the transport and grasp components are distributed across separate effectors. Expt 1 compared prehension with spoon-feeding and showed that a number of kinematic landmarks, such as time to peak aperture, were similar. An unexpected difference between the tasks was that the onsets of the transport and grasp components in the two-effector task were not always synchronized. To control for a number of differences between the tasks used in Expt 1, such as the role of haptic and visual information, Expt 2 compared unimanual with intermanual prehension, which involved passing an object from one hand to the other. The results were consistent with those found in Expt 1. In particular, time to peak aperture was similar over the different tasks, despite a lack of consistent coupling between the components at movement onset. We conclude that the one- and two-effector tasks pose largely the same task constraints and are coordinated in a similar way. Intermanual prehension tasks thus provide a useful experimental tool for manipulations that are difficult or impossible to perform with unimanual reaching and grasping.

Characterisation of the 5-HT receptor binding profile of eletriptan and kinetics of [3H]eletriptan binding at human 5-HT1B and 5-HT1D receptors

The affinity of eletriptan ((R)-3-(1-methyl-2-pyrrolidinylmethyl)-5-[2-(phenylsulphonyl )ethyl]-1H-indole) for a range of 5-HT receptors was compared to values obtained for other 5-HT1B/1D receptor agonists known to be effective in the treatment of migraine. Eletriptan, like sumatriptan, zolmitriptan, naratriptan and rizatriptan had highest affinity for the human 5-HT1B, 5-HT1D and putative 5-ht1f receptor. Kinetic studies comparing the binding of [3H]eletriptan and [3H]sumatriptan to the human recombinant 5-HT1B and 5-HT1D receptors expressed in HeLa cells revealed that both radioligands bound with high specificity (>90%) and reached equilibrium within 10-15 min. However, [3H]eletriptan had over 6-fold higher affinity than [3H]sumatriptan at the 5-HT1D receptor (K(D)): 0.92 and 6.58 nM, respectively) and over 3-fold higher affinity than [3H]sumatriptan at the 5-HT1B receptor (K(D): 3.14 and 11.07 nM, respectively). Association and dissociation rates for both radioligands could only be accurately determined at the 5-HT1D receptor and then only at 4 degrees C. At this temperature, [3H]eletriptan had a significantly (P<0.05) faster association rate (K(on) 0.249 min(-1) nM(-1)) than [3H]sumatriptan (K(on) 0.024 min(-1) nM(-1)) and a significantly (P<0.05) slower off-rate (K(off) 0.027 min(-1) compared to 0.037 min(-1) for [3H]sumatriptan). These data indicate that eletriptan is a potent ligand at the human 5-HT1B, 5-HT1D, and 5-ht1f receptors and are consistent with its potent vasoconstrictor activity and use as a drug for the acute treatment of migraine headache.

Evaluation of four maternal smoking questions

OBJECTIVE

The authors evaluated four questions about maternal smoking during pregnancy for use on birth certificates.

METHODS

Question 1 (yes/no format) and Question 2 (trimester-specific design) were tested among 1171 women who delivered at two Kaiser Permanente medical centers in northern California. Responses to Questions 1 and 2 were compared with smoking information provided by participants in telephone interviews conducted during pregnancy. Question 3 (multiple choice format) and Question 4 (month- and grouped month-specific design) were tested among 900 women who enrolled in a statewide prenatal screening program and who delivered in 20 hospitals in four Central Valley counties. Responses to Questions 3 and 4 were compared with mid-pregnancy serum cotinine levels. The authors evaluated the four questions in terms of conciseness, response rate, data accuracy, and type of data requested.

RESULTS

Questions 1 and 2 were the most concise. Response rates could not be calculated for Questions 1 and 2. Response rates were 86.0% for Question 3 and 74.2% for Question 4. Sensitivity was 47.3% for Question 1, 62.1% for Question 2, 83.8% for Question 3, and 86.7% for Question 4. The types of data requested by Questions 2 and 4 seem to best satisfy the needs of the broad audience of birth certificate users.

CONCLUSIONS

No single question was clearly superior. The authors propose a combination of Questions 2 and 4, which asks about average number of cigarettes smoked per day in the three months before pregnancy and in each trimester of pregnancy.

Evidence for an association between environmental tobacco smoke exposure and birthweight: a meta-analysis and new data

Because of the strong association of active smoking with fetal growth retardation, increasing interest has focused on whether there is also an association with exposure to environmental tobacco smoke (ETS). We examined this issue in a retrospective study and by conducting a review of the literature and data pooling. In our study, nonsmoking women with singleton livebirths born in 1986-87 (n = 992) provided information on exposure to ETS for 1 h or more per day and paternal smoking. The risk of low birthweight (LBW, < 2500 g) was not increased in infants of ETS-exposed women, but there was a somewhat increased risk for LBW at term (adjusted odds ratio [OR] 1.8, 95% confidence interval [CI] 0.6, 4.8) and small-for-gestational-age (< 10th percentile of weight; OR = 1.4, 95% CI = 0.8, 2.5). These results were in the range of 16 other studies in the literature that had odds ratios from 1.0 to 2.2. A weighted average of the results of all studies on LBW at term or small-for-gestational-age yielded a pooled estimate of 1.2 [95% CI = 1.1, 1.3] in nonsmoking women. The pooled estimate of mean birthweight indicated a decrement of 28 g with ETS exposure of nonsmoking women [95% CI = -41, -16], with a greater decrement (about 40 g) seen among more homogeneous studies.

Lateral biases in head turning and the Moro response in the human newborn: are they both vestibular in origin?

Head turning after release from the midline and the Moro response to a full-body drop in 15 full-term newborns lying supine on a custom-built platform was studied. While the lateral bias for head turning was not as pronounced as for the Moro response, it was still assumed in the ratio of 2 (right):1 (left) as predicted by Previc (1991). Onset latency and time-to-peak acceleration were both significantly shorter in the right arm during the initial phase of the Moro response. For both measures, this right arm bias persisted over four consecutive elicitations in most infants. Vaginally delivered infants and those born by Caesarean section did not differ in terms of head preference and the two measures of arm advantage. Our main finding was that infants with a right-sided head preference had a consistently shorter onset latency for the right arm. We interpret this association as stemming from a common labyrinthine asymmetry that involves different vestibulospinal pathways for the neck and arm muscles. In general, our findings are discussed in the context of Previc's (1991) left-otolithic dominance hypothesis and Grattan, De Vos, Levy, and McClintock's (1992) model of newborn functional asymmetries.

Muscle power and medical history in high risk preterm infants at 3 months of corrected age

A group of 73 "high risk" preterm infants was studied at the corrected age of 12 weeks. The infants were categorized according to their medical history in 5 classes conform with the "Neonatal Medical Index" (NMI). Only infants with high-risk for developmental discrepancies with a score of NMI > or = III were included in the study. Apart from pediatric follow-up and an age-adequate neurological examination, special emphasis was put on measuring a specific feature in the development of preterm infants: the relationship between active muscle power and passive tone. These two components of muscle power should be in balance with each other to create stable posture and fluent motility and later co-ordination. Discrepancy between active and passive muscle tone was found in all NMI groups studied and was most outspoken in the legs. Infants in NMI IV and V showed a significantly higher incidence of increased passive tone than the infants in NMI III. When the different regions of the body were studied separately, the infants in NMI IV and V showed significantly increased passive tone in the trunk and shoulders (p 0.009) compared to infants in NMI III, which may constitute an alarm signal of deviant development. The main aim of the study was to provide a clinical method for early detection, subtle enough to select infants most at risk for later functional and neurological problems.

Repeated low-level formaldehyde exposure produces cross-sensitization to cocaine: possible relevance to chemical sensitivity in humans

Sensitivity to chemicals in humans has been proposed to be an acquired disorder in which individuals become increasingly sensitive to chemicals in the environment. A possible link between the manifestation of psychiatric symptoms in individuals claiming sensitivity to chemicals was investigated based on a leading hypothesis put forth by Bell and co-workers (1992) to explain the amplification of symptoms after chemical exposure. The hypothesis is that chemical sensitivities may be akin to sensitization observed in rodents after repeated psychostimulants. Repeated exposure to psychostimulants enhances behavioral activity and the underlying neurochemical responses in specific limbic pathways; a similar sensitization of limbic pathways has been proposed to occur in individuals who become sensitive to chemicals. To test this hypothesis, female Sprague-Dawley rats were exposed to either air or formaldehyde (Form) for 1 h/day for 7 days or 20 days (5 days/week x 4 weeks). Two to 4 days after the last exposure, rats were given a cocaine challenge (= early withdrawal) followed by an additional cocaine challenge 4-6 weeks later (= late withdrawal). No differences in cocaine-induced locomotor activity were noted between groups after 7 days of exposure. However, after 20 days of exposure to Form, vertical activity was significantly elevated at both early and late withdrawal times. These studies demonstrate that behavioral sensitization occurs after long-term, but not short-term, low-level exposure to Form, and lends support to the limbic system sensitization hypothesis of sensitivity to chemicals in humans.

Prenatal development of arm posture

Fetal arm posture was studied longitudinally in 10 uncomplicated pregnancies using real-time ultrasound. Observation were performed at four weekly intervals from 12 to 36 weeks, and at 38 weeks. The percentage of assessments with optimal visualization of elbow, wrist and fingers was 84% at 12 weeks and more than 90% thereafter (range 92-98%). There was a clear developmental trend towards increased flexion. Flexion of the elbow occurred frequently from 12 weeks onwards with an increased incidence at 16 weeks, that in the fingers from 20 weeks onwards and from 28 weeks to term age in the wrist. All three trends were statistically significant. There was considerable intra-individual consistency in terms of the ages at which flexion increased. In fact the increase of flexion occurred one session later in only 6/30 registrations. The combined data of the elbow, wrist and fingers revealed preferential arm posture at 12 weeks with the elbow flexed and the wrist and fingers extended. From 16 to 28 weeks, the predominant posture consisted of elbow flexion, wrist extension and finger flexion and complete flexion thereafter. The development of fetal arm posture does not comply with a proximo-distal trend in that there was first an increase in flexion at the elbow, followed by the fingers and finally the wrist. The implications of our findings for understanding the prenatal development of the central nervous system and subsequent postural adjustments to extrauterine life are discussed.

Adrenal cortical carcinoma associated with a splenic vein tumor thrombus

A unique case is reported of a left adrenal cortical carcinoma with a splenic vein tumor thrombus. En bloc radical nephroadrenalectomy, distal pancreatectomy, splenectomy and splenic vein tumor thrombectomy were performed. Reconstruction of the proximal portal vein was required, incorporating a segment of the left renal vein (harvested from the surgical specimen) as a free interposition graft, bridging the defect between the superior mesenteric vein and portal vein. To our knowledge, this is the first reported case of an adrenal cortical carcinoma associated with a splenic vein tumor thrombus. In addition, the described technique used to reconstruct the proximal portion of the portal vein has not been previously reported.

Evidence for a phase transition in the early development of prehension

A longitudinal study was conducted to examine the hypothesis that the development of prehension during the first 5 months of life is characterized by the presence of a discontinuous phase transition. Ten infants were observed weekly from 8 to 24 weeks of age. Video recordings were made of movements toward an attractive object which were classified according to two behavioral categories: reaching without grasping and reaching with grasping. The time evolution of the relative incidence of these behavioral categories was analyzed statistically. Evidence was found for a sudden jump from a (developmental) state in which reaching without grasping is predominant to a state in which reaching with grasping is predominant. Evidence was also found for bimodality, inaccessibility, and anomalous variance. In combination, these findings support the hypothesis that the investigated behavioral change constitutes a discontinuous phase transition. The behavioral change in question occurred at the moment in developmental time at which the attractor strength of reaching for objects as such relative to that of other behavioral activities appeared to be increased.

A prospective study of spontaneous abortion: relation to amount and source of drinking water consumed in early pregnancy

In 1992, we published four retrospective studies, conducted primarily within a single California county, which found higher spontaneous abortion rates among women who drank more tapwater than bottled water in early pregnancy. The current prospective study extends that investigation to other water systems. Pregnant women from three regions in California were interviewed during their first trimester. Multivariate analyses modeled the amount and type of water consumed at 8 weeks' gestation in each region in relation to spontaneous abortion rate. In Region I, which was within the previous study area, the adjusted odds ratio (OR) comparing high (> or = 6 glasses per day) consumption of cold tapwater with none was 2.17 [95% confidence interval (CI) = 1.22-3.87]. Furthermore, when women with high cold tapwater and no bottled water consumption were compared with those with high bottled water and no cold tapwater consumption, the adjusted odds ratio was 4.58 (95% CI = 1.97-10.64). Conversely, women with high bottled water consumption and no tapwater had a reduced rate of spontaneous abortion compared with those drinking tapwater and no bottled water (adjusted OR = 0.22; 95% CI = 0.09-0.51). Neither tap nor bottled water consumption altered the risk of spontaneous abortion in Regions II and III. Although controlling for age, prior spontaneous abortion, race, gestational age at interview, and weight somewhat strengthened the association in Region I, the distribution of these confounders did not vary appreciably across regions. This study confirms the association between cold tapwater and spontaneous abortion first seen in this county in 1980. If causal, the agent(s) is not ubiquitous but is likely to have been present in Region I for some time.

Trihalomethanes in drinking water and spontaneous abortion

Trihalomethanes (chloroform, bromoform, bromodichloromethane, and chlorodibromomethane) are common contaminants of chlorinated drinking water. Although animal data indicate that these compounds may be reproductive toxicants, little information exists on their relation to spontaneous abortion in humans. We examined exposure to trihalomethanes and spontaneous abortion in a prospective study of 5,144 pregnant women in a prepaid health plan. Seventy-eight drinking water utilities provided concurrent trihalomethane sampling data. We calculated total trihalomethane levels by averaging all measurements taken by the subject's utility during her first trimester. We calculated exposures to individual trihalomethanes in an analogous manner. Women who drank > or = 5 glasses per day of cold tapwater containing > or = 75 micrograms per liter total trihalomethanes had an adjusted odds ratio (OR) of 1.8 for spontaneous abortion [95% confidence interval (CI) = 1.1-3.0]. Of the four individual trihalomethanes, only high bromodichloromethane exposure (consumption of > or = 5 glasses per day of cold tapwater containing > or = 18 micrograms per liter bromodichloromethane) was associated with spontaneous abortion both alone (adjusted OR = 2.0; 95% CI = 1.2-3.5) and after adjustment for the other trihalomethanes (adjusted OR = 3.0; 95% CI = 1.4-6.6).

Head position preference in the human newborn: a new look

Head position preference was studied in 20 awake newborns who differed in terms of delivery and sex. They were placed supine on a custom-built platform to reduce the effects of gravity and asymmetries in trunk posture and skull shape. A global and a specific scoring method were used, the infants being in State 3 (quiet wakefulness) or 4 (active wakefulness, excluding crying). Delivery and sex did not account for differences in head position. The head turned more often to the right and was maintained longer in this position during State 3, regardless of scoring method. The maintenance of the head in midline was comparable in duration to that reported for infants at 2-3 months when using the global scoring method. This suggests that the neural mechanisms responsible for attaining and maintaining a midline position are present at birth, but are not functionally expressed due to a lack of adequate power in the antigravity muscles of the neck.

Locomoting through apertures of different width: a study of children with cerebral palsy

Whether children with cerebral palsy (CP) differ from non-handicapped (NH) children was studied, using body-scaled information about the passability of a doorway-like opening. There were 55 children of whom 23 were NH and 32 had CP, the latter consisting of 12 who could stand and walk unaided (CP-Walk) and 20 confined to a wheelchair (CP-Wheel). All groups were divided into two age ranges (5-8 and 9-13 year) and were tested on two occasions separated by an interval of 12 months. On both occasions, testing involved three consecutive tasks: making perceptual (pre)judgments about the passability of an opening varying in width, actually attempting to locomote through the openings (performance), and another round of (post)judgments. Judgments and performance were expressed in terms of absolute and relative outcomes, the latter differing from the former in accounting for differences in body width relative to aperture width. There were two main findings. Firstly, the younger CP-Walk children were the least able to employ body-scaled information in judging aperture width and the older CP-Wheel and NH the most able. Secondly, when performances in passing through the openings were adjusted for differences in body width, all groups had similar outcomes. This findings lends credence to the notion that when action is used in the service of perception, this is beneficial for the visual-spatial abilities of both NH and CP children. The study concludes by pointing out future directions in this type of research as well as some of the clinical implications of the findings.

Winnicott and the capacity to believe

Like Freud's, Winnicott's writing displays an enormous interest in words, in their histories as well as their current usage. The author discusses his use of two words, 'capacity' and 'belief' combined in the phrase 'capacity to believe'. What Winnicott has to say about this capacity sheds light on the nature of both religious and cultural experience generally. The paper's argument has two strands that are woven together throughout. The first is Winnicott's concern for words and how a knowledge of their roots can enrich their current meaning. The second is his concern for the nature of belief, the 'capacity to believe', and his conviction that in exploring this capacity psychoanalysis might have something to teach religion. These concerns are interrelated in a number of ways in Winnicott's writing and are ultimately connected with his notion of a 'cultural field', a place to grow, where 'inventiveness', even verbal inventiveness, is 'just one more example ... of the interplay between separateness and union', that is the separateness of individual language users but also their union through the language they share.

Motor asymmetries in preterm infants at 18 weeks corrected age and outcomes at 1 year

Persisting asymmetries in the motility and posture of preterm infants after term age is a common finding, but their diagnostic and prognostic significance has proved to be difficult to interpret. It has been claimed that if an asymmetry is of central origin, then it should be most prominently detectable in infantile reactions that persist beyond the age when they should have disappeared. We hypothesis that motor asymmetries in preterm infants without a major risk for neurological problems may stem from a high degree of active muscle power in the trunk that continues to be present after 12 weeks corrected age. In order to test this hypothesis, 34 preterm infants with a low risk for neurological complications were compared to a group of 17 fullterm infants at 18 weeks of (corrected) age for the presence or absence of motor asymmetries. None of the full-term infants showed asymmetrical motor behaviour, while within the preterm group a significant number did, in particular those who were small for gestational age. A significant relationship between motor asymmetries and a high degree of muscle power in the trunk at this age was found in the preterm group. Asymmetrical active muscle power at 18 weeks had a good predictive value for asymmetrical locomotor, hand and eye functions at 52 weeks.

An instrument to measure independent walking: are there differences between preterm and fullterm infants?

In clinical practice walking independently has always been considered a major milestone in development. Nevertheless, little attention has been paid to the quality of movement expressed in the first attempts at walking free. Even when children achieve walking within a normal time range, some of them show features that are deviant. Early walking is difficult to judge, but at the same time may provide a sensitive means for detecting possible developmental impairments. The main aim of this paper is to provide a standardized clinical instrument for the qualitative assessment of early walking in a structured free field situation and to compare preterm and fullterm infants. All subjects were assessed 14 days after being able to walk 5 meters independently. The study group consisted of 52 children, of whom 33 were born prematurely (further distinguished in terms of being small- or appropriate-for-gestational age), and 19 were born fullterm. Judgments of walking performance were made in terms of optimal, near-optimal, near-poor, or poor. After correction for age, the preterm group was still later in the onset of walking, but more importantly, showed a qualitatively different pattern of locomotion. Those who were the youngest and small-for-gestational age were overrepresented in the near-poor and poor categories of walking.

The organization of leg movements in preterm and full-term infants after term age

In a sample of 13 full-term and 10 preterm infants, the development of kicking movements was studied at 6, 12, and 18 weeks (corrected) age. In healthy full-term infants some characteristics are strikingly stable, such as the duration of the flexion and extension phase and the within-joint organization. These parameters did not differ in preterm compared to full-term infants. For other features, however, developmental changes and differences were observed. Full-term infants tended to decrease their kick frequencies slightly with age. In preterm infants much higher initial kick rates were found, followed by a steep decrease, which resulted in kick frequencies comparable to the full-term levels after the (corrected) age of 12 weeks. There is a tight coupling between the movements in the different joints of the leg in full-term newborns. Preterm infants, in contrast, initially show much lower cross-correlations between hip and ankle and between knee and ankle. This is particularly the case for those preterm infants who were born before 32 weeks gestation. Again, the differences resolved after the age of 12 weeks, which might be related to a transformation in neural functions reported previously around this age. The initial differences in the characteristics of kicking appeared to be more readily explainable by differences in neurological condition than by contrasts in leg volume or postural control.

Crying patterns in preterm infants

Healthy infants born at term cry most in the first three months of life, with a peak and increased crying in the evening during the second month. To determine whether the crying of preterm infants manifests similar features, the pattern of crying from 40 weeks gestational age through 24 weeks corrected age was described for 35 relatively healthy preterm infants born between 28 and 34 weeks gestational age. Despite their additional extra-uterine experience, they still cried significantly more after 40 weeks gestational age, with a peak and evening clustering at 6 weeks corrected age. The age of peak crying was not related to gestational age at birth, weight for gestational age, or a variety of perinatal and neurological indices. The results support the argument that the early-peak pattern is a robust maturational feature of early development and may be universal to human infancy.

The association of moderate maternal and paternal alcohol consumption with birthweight and gestational age

Heavy maternal alcohol consumption during pregnancy has been associated with fetal growth retardation, but whether more moderate consumption also is associated remains a controversial issue. We examined moderate consumption in 1233 women with singleton livebirths, by calculating a weighted average of weekly consumption in the first 20 weeks from questions that asked about alcohol consumption before pregnancy, as well as any changes during the first half of pregnancy. The adjusted odds ratio for ("moderate") consumption of three or more drinks per week for low birthweight was 2.6 [95% confidence limits (CL) = 1.2, 5.7], and that for intrauterine growth retardation was 2.3 (95% CL = 1.2, 4.6). Examining the joint effect of smoking with alcohol consumption revealed associations that differed by outcome; we found a synergistic effect for low birthweight, but not for intrauterine growth retardation. Moderate alcohol consumers had an average birthweight decrement of 143 gm, which varied by smoking. There was little association of alcohol consumption with preterm delivery (< 37 weeks). Paternal alcohol consumption was not associated with any of the fetal growth measures after adjustment for other variables.

Muscle power, sitting unsupported and trunk rotation in pre-term infants

Discrepancies between active and passive muscle power are often seen in pre-term infants over the first year. Generally of a transient nature, they are most obvious in the extensor muscles of the trunk where there is a high active muscle power relative to the passive component. While high active muscle power may not be a sign of cerebral palsy, it is our contention that it will impair functions such as unsupported sitting and the ability to rotate in this position. In this study, 20 full-term and 37 healthy pre-term infants were assessed at the (corrected) ages of 39 and 52 weeks for muscle power in the trunk, sitting unsupported and rotation around the body axis while seated. At the age of 39 weeks, all full-term infants could sit without support. In contrast half of the pre-term infants could not sit without support and the majority of them could not rotate the trunk in this position. At 52 weeks the majority of pre-term infants could sit without support, despite having higher active muscle power in the trunk. However this deviant muscle power prevented rotatory movements of the trunk during sitting. The origin of this deviance may reside in the positioning to which pre-term infants are subjected after birth and thus postural management should be directed towards avoidance of extensor positions.

Prenatal head position from 12-38 weeks. I. Developmental aspects

Fetal head position relative to the fetal body was studied longitudinally in 10 uncomplicated pregnancies by means of real-time ultrasound. Registrations were made at 4 weekly intervals from 12 to 36 weeks, and at 38 weeks. The percentage of assessments with optimal visualization of head position for analysis increased with age. The development of head position involved a change from a midline to a lateralized preference. It was only at 38 weeks that a clear lateralized head position was found with the head being held mainly to the right. The degree of intra- and inter-individual variability was considerable, a finding typical of motor behaviour in the healthy fetus. It is hypothesized that this bias is due to neural maturation. The implications of our findings for the subsequent development of hand preference are discussed.

Prenatal head position from 12-38 weeks. II. The effects of fetal orientation and placental localization

The possible influence of placental localization and fetal orientation on a predominant fetal head position was studied longitudinally in 10 uncomplicated pregnancies from 12 to 38 weeks by means of real-time ultrasound. Throughout gestation, when the fetal vertebral column was oriented to the left side of the mother, head positions to the right and in midline were seen most frequently, whereas a vertebral column to the right was more often associated with a head left position and a head position in midline. These findings support the suggestion that when the fetal vertebral column is in a lateral orientation relative to the mother, one side of the fetal head is more likely to be restricted by the pelvis and backbone of the mother. However, the orientation of the fetal vertebral column does not seem to be a determining factor as the incidence of lateralized head positions increased with age, while the incidence of a vertebral column to the right or left side of the mother remained unchanged. No associations were found between the localization of the placenta and either head position or fetal lie.