Maternal obesity, gestational weight gain, and offspring asthma and atopy

BACKGROUND

Maternal obesity may affect offspring asthma and atopic disease risk by altering fetal immune system development. However, few studies evaluate gestational weight gain (GWG).

OBJECTIVE

To evaluate relationships between maternal body mass index (BMI), GWG, and persistent wheeze, eczema, allergy, and asthma risk in offspring through middle childhood.

METHODS

A total of 5939 children from Upstate KIDS, a population-based longitudinal cohort of children born in upstate New York (2008-2019) were included in the analysis. Persistent wheeze or asthma, eczema, and allergy were maternally reported at multiple study time points throughout early and middle childhood. Poisson regression models with robust SEs were used to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) for offspring atopic outcomes by maternal prepregnancy BMI and GWG.

RESULTS

Prepregnancy BMI was associated with increased risk of persistent wheeze by 3 years of age even after adjustments for maternal atopy (class I obesity: aRR, 1.58; 95% CI, 1.13-2.20; class II or III obesity: aRR, 1.69; 95% CI, 1.22-2.35). Associations with reported asthma in middle childhood did not reach statistical significance. Furthermore, no associations were found between prepregnancy BMI and atopic outcomes in either early or middle childhood. GWG was not associated with higher risk of early childhood persistent wheeze or middle childhood asthma.

CONCLUSION

Maternal prepregnancy BMI was associated with increased risk of offspring wheeze, whereas excessive GWG was generally not associated with childhood asthma or atopy.

Health facility management and primary health care performance in Uganda

Background

Primary health care is a critical foundation of high-quality health systems. Health facility management has been studied in high-income countries, but there are significant measurement gaps about facility management and primary health care performance in low and middle-income countries. A primary health care facility management evaluation tool (PRIME-Tool) was initially piloted in Ghana where better facility management was associated with higher performance on select primary health care outcomes such as essential drug availability, trust in providers, ease of following a provider’s advice, and overall patient-reported quality rating. In this study, we sought to understand health facility management within Uganda's decentralized primary health care system.

Methods

We administered and analyzed a cross-sectional household and health facility survey conducted in Uganda in 2019, assessing facility management using the PRIME-Tool.

Results

Better facility management was associated with better essential drug availability but not better performance on measures of stocking equipment. Facilities with better PRIME-Tool management scores trended towards better performance on a number of experiential quality measures. We found significant disparities in the management performance of primary health care facilities. In particular, patients with greater wealth and education and those living in urban areas sought care at facilities that performed better on management. Private facilities and hospitals performed better on the management index than public facilities and health centers and clinics.

Conclusions

These results suggest that investments in stronger facility management in Uganda may strengthen key aspects of facility readiness such as essential drug availability and potentially could affect experiential quality of care. Nevertheless, the stark disparities demonstrate that Uganda policymakers need to target investments strategically in order to improve primary health care equitably across socioeconomic status and geography. Moreover, other low and middle-income countries may benefit from the use of the PRIME-Tool to rapidly assess facility management with the goal of understanding and improving primary health care performance.

Predictors of patient-reported quality of care in low- and middle-income countries: a four-country survey of person-centered care

Background

Person-centeredness is a foundation of high-quality health systems but is poorly measured in low- and middle-income countries (LMICs). We piloted an online survey of four LMICs to identify the prevalence and correlates of excellent patient-reported quality of care (QOC).

Objective

The aims of this study were to investigate the examine people’s overall ratings of care quality in relation to their experiences seeking care in their respective health systems as well as individual-, provider- and facility-level predictors.

Methods

We administered a cross-sectional online survey using Random Domain Intercept Technology to collect a sample of random internet users across India, Kenya, Mexico and Nigeria in November 2016. The primary outcome was patient-reported QOC. Covariates included age, gender, level of education, urban/rural residence, person for whom care was sought, type of provider seen, public or private sector status of the health facility and type of facility. The exposure was an index of health system responsiveness based on a framework from the World Health Organization. We used descriptive statistics to determine the prevalence of excellent patient-reported QOC and multivariable Poisson regression to calculate adjusted prevalence ratios (aPRs) for predictors of excellent patient-reported quality.

Results

Fourteen thousand and eight people completed the survey (22.6% completion rate). Survey respondents tended to be young, male, well-educated and urban-dwelling, reflective of the demographic of the internet-using population. Four thousand one and ninety-one (29.9%) respondents sought care in the prior 6 months. Of those, 21.8% rated their QOC as excellent. The highest proportion of respondents gave the top rating for wait time (44.6%), while the lowest proportion gave the top rating for facility cleanliness (21.7%). In an adjusted analysis, people who experienced the highest level of health system responsiveness were significantly more likely to report excellent QOC compared to those who did not (aPR 8.61, 95% confidence interval [95% CI]: 7.50, 9.89). In the adjusted model, urban-dwelling individuals were less likely to report excellent quality compared to rural-dwelling individuals (aPR 0.88, 95% CI: 0.78, 0.99). People who saw community health workers (aPR 1.37, 95% CI: 1.12, 1.67) and specialists (aPR 1.30, 95% CI: 1.12, 1.50) were more likely to report excellent quality than those who saw primary care providers. High perceived respect from the provider or staff was most highly associated with excellent ratings of quality, while ratings of wait time corresponded the least.

Conclusion

Patient-reported QOC is low in four LMICs, even among a well-educated, young population of internet users. Better health system responsiveness may be associated with better ratings of care quality. Improving person-centered care will be an important component of building high-quality health systems in these LMICs.

The joint role of thyroid function and iodine concentration on gestational diabetes risk in a population-based study

INTRODUCTION

Iodine is essential for thyroid function, and iodine deficiency during pregnancy is common in Europe and the USA. However, no published studies have examined the role of iodine deficiency in the relation between thyroid function and gestational diabetes mellitus (GDM).

MATERIAL AND METHODS

We conducted a population-based, nested case-control study within the Finnish Maternity Cohort using pregnancy and perinatal outcome data from the Finnish Maternal Birth Register. We randomly selected 224 GDM cases with singleton pregnancies and 224 controls without GDM from all singleton births occurring in Finland during 2012-2013. Blood was drawn at 10-14 weeks' gestation and analyzed for serum iodide, thyroglobulin, and thyroid-stimulating hormone (TSH) concentrations. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CI) of GDM.

RESULTS

Very high thyroglobulin concentration (>95% percentile; >83 μg/L) was not associated with significantly altered odds of GDM compared to those with normal levels (OR 0.41; 95% CI: 0.12, 1.38). High concentrations of TSH were also not associated with increased odds of GDM compared to normal levels of TSH (OR 0.45; 95% CI: 0.06, 3.18). Women in the lowest 5th percentile (<1.58 ng/mL) of iodine did not have increased odds of GDM compared to those with iodide in the highest quartile (OR 0.39; 95% CI: 0.11, 1.35).

CONCLUSIONS

Low levels of iodide and thyroid function in early pregnancy are not associated with increased risk of GDM in this mildly iodine-deficient population.

Maternal polycystic ovarian syndrome and early offspring development

STUDY QUESTION

Is maternal polycystic ovarian syndrome (PCOS) associated with developmental delays in offspring?

SUMMARY ANSWER

Offspring of mothers with PCOS were at higher risk of failure on the Ages and Stages Questionnaire (ASQ).

WHAT IS KNOWN ALREADY

There is growing evidence that offspring of mothers with PCOS may be at higher risk for developmental disorders due to potential exposure to hyperandrogenism and insulin resistance. Few studies exist regarding maternal PCOS and early childhood development in the USA.

STUDY DESIGN, SIZE, DURATION

The Upstate KIDS Study is a population-based prospective cohort study of infants born between 2008 and 2010 in New York State (excluding New York City), originally designed to study-and finding no impact of-infertility treatment exposure on child development. Children were followed up to 36 months of age. In all, 4453 mothers completed one or more developmental screening instruments for 5388 children (35.5% twins) up to 36 months of age.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In our study, 458 mothers (10.3%) reported a healthcare provider's diagnosis of PCOS, as well as the related treatment received, on the baseline study questionnaire. Parents completed the ASQ on their child's development at 4, 8, 12, 18, 24, 30 and 36 months of age to assess fine motor, gross motor, communication, personal-social functioning and problem-solving cognitive domains. We used generalized linear mixed models to estimate odds ratios (OR) between PCOS diagnosis and failures in the ASQ adjusted for maternal age, race, BMI, education, marital status, smoking, alcohol consumption, diabetes, insurance and plurality.

MAIN RESULTS AND THE ROLE OF CHANCE

Diagnosis of PCOS was associated with increased risk of the offspring failing the fine motor domain (adjusted odds ratio (aOR) = 1.77; 95% CI: 1.09, 2.89), largely driven by higher risk in female singletons (aOR = 2.23; 1.16, 4.29). Twins of mothers with PCOS had higher risk of failing the communication (aOR = 1.94; 1.19, 3.18) and personal-social functioning (aOR = 1.76; 1.12, 2.77) domains compared to twins born to mothers without PCOS. Compared to offspring of women without PCOS, offspring of women who reported receiving no treatment for their PCOS had a stronger association with failing the ASQ (aOR = 1.68; 0.95, 2.75) than the association among offspring of women who reported PCOS treatment (aOR = 1.16; 0.79, 1.73).

LIMITATIONS, REASONS FOR CAUTION

Further study is needed to confirm the role of maternal PCOS in early offspring development with provider-validated diagnosis of PCOS.

WIDER IMPLICATIONS OF THE FINDINGS

If confirmed, these findings suggest that offspring of women with PCOS may be at increased risk for developmental delay.

STUDY FUNDING/COMPETING INTEREST(S)

Supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD; contracts HHSN275201200005C, #HHSN267200700019C). Authors have no competing interests to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Maternal polycystic ovarian syndrome and offspring growth: the Upstate KIDS Study

BACKGROUND

Polycystic ovarian syndrome (PCOS) is the most common cause of female infertility and is associated with higher levels of circulating androgens. Exposure to higher levels of androgens in utero may be a risk factor for obesity among children of women with PCOS.

METHODS

We examined whether maternal PCOS was associated with differences in offspring growth and obesity in the Upstate KIDS study, a prospective cohort study of infants born in New York State (excluding New York City) oversampled for fertility treatments and multiple births. Measurements of offspring length/height and weight were recorded at doctor's visits through 3 years of age. PCOS diagnosis was self-reported by mothers at baseline. We used linear mixed models with robust SEs to estimate differences in growth by maternal PCOS exposure. We used logistic regression to examine whether infants experienced rapid weight gain at 4, 9 and 12 months. Growth measures were reported by 4098 mothers for 4949 children (1745 twins). Of these, 435 mothers (10.6%) had a diagnosis of PCOS.

RESULTS

Compared with children born to mothers without PCOS, children of mothers with PCOS did not have significant differences in weight (4.81 g, 95% CI -95.1 to 104.7), length/height (0.18 cm, 95% CI -0.16 to 0.52) and body mass index (-0.14 kg/m², 95% CI -0.30 to 0.01) through 3 years of age. We also observed no association between maternal PCOS and offspring rapid weight gain.

CONCLUSIONS

Overall, we found little evidence to suggest that maternal PCOS influences early childhood growth in this large, prospective cohort study.

Concentration of Smaller High-Density Lipoprotein Particle (HDL-P) Is Inversely Correlated With Carotid Intima Media Thickening After Confounder Adjustment: The Multi Ethnic Study of Atherosclerosis (MESA)

Background

Recent studies have failed to establish a causal relationship between high‐density lipoprotein cholesterol levels (HDL‐C) and cardiovascular disease (CVD), shifting focus to other HDL measures. We previously reported that smaller/denser HDL levels are protective against cerebrovascular disease. This study sought to determine which of small+medium HDL particle concentration (HDL‐P) or large HDL‐P was more strongly associated with carotid intima‐media thickening (cIMT) in an ethnically diverse cohort.

Methods and Results

In cross‐sectional analyses of participants from the Multi Ethnic Study of Atherosclerosis (MESA), we evaluated the associations of nuclear magnetic resonance spectroscopy–measured small+medium versus large HDL‐P with cIMT measured in the common and internal carotid arteries, through linear regression. After adjustment for CVD confounders, low‐density lipoprotein cholesterol (LDL‐C), HDL‐C, and small+medium HDL‐P remained significantly and inversely associated with common (coefficient=−1.46 μm; P=0.00037; n=6512) and internal cIMT (coefficient=−3.82 μm; P=0.0051; n=6418) after Bonferroni correction for 4 independent tests (threshold for significance=0.0125; α=0.05/4). Large HDL‐P was significantly and inversely associated with both cIMT outcomes before HDL‐C adjustment; however, after adjustment for HDL‐C, the association of large HDL‐P with both common (coefficient=1.55 μm; P=0.30; n=6512) and internal cIMT (coefficient=4.84 μm; P=0.33; n=6418) was attenuated. In a separate sample of 126 men, small/medium HDL‐P was more strongly correlated with paraoxonase 1 activity (r_p=0.32; P=0.00023) as compared to both total HDL‐P (r_p=0.27; P=0.0024) and large HDL‐P (r_p=0.02; P=0.41) measures.

Conclusions

Small+medium HDL‐P is significantly and inversely correlated with cIMT measurements. Correlation of small+medium HDL‐P with cardioprotective paraoxonase 1 activity may reflect a functional aspect of HDL responsible for this finding.

Intake of long-chain ω-3 fatty acids from diet and supplements in relation to mortality

Evidence from experimental studies suggests that the long-chain ω-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid have beneficial effects that may lead to reduced mortality from chronic diseases, but epidemiologic evidence is mixed. Our objective was to evaluate whether intake of long-chain ω-3 fatty acids from diet and supplements is associated with cause-specific and total mortality. Study participants (n = 70,495) were members of a cohort study (the Vitamins and Lifestyle Study) who were residents of Washington State aged 50-76 years at the start of the study (2000-2002). Participants were followed for mortality through 2006 (n = 3,051 deaths). Higher combined intake of eicosapentaenoic acid and docosahexaenoic acid from diet and supplements was associated with a decreased risk of total mortality (hazard ratio (HR) = 0.82, 95% confidence interval (CI): 0.73, 0.93) and mortality from cancer (HR = 0.77, 95% CI: 0.64, 0.92) but only a small reduction in risk of death from cardiovascular disease (HR = 0.87, 95% CI: 0.68, 1.10). These results suggest that intake of long-chain ω-3 fatty acids may reduce risk of total and cancer-specific mortality.

Use of glucosamine and chondroitin in relation to mortality

Glucosamine and chondroitin are products commonly used by older adults in the US and Europe. There is limited evidence that they have anti-inflammatory properties, which could provide risk reduction of several diseases. However, data on their long-term health effects is lacking. To evaluate whether use of glucosamine and chondroitin are associated with cause-specific and total mortality. Participants (n = 77,510) were members of a cohort study of Washington State (US) residents aged 50-76 years who entered the cohort in 2000-2002 by completing a baseline questionnaire that included questions on glucosamine and chondroitin use. Participants were followed for mortality through 2008 (n = 5,362 deaths). Hazard ratios (HR) for death adjusted for multiple covariates were estimated using Cox models. Current (baseline) glucosamine and chondroitin use were associated with a decreased risk of total mortality compared to never use. The adjusted HR associated with current use of glucosamine (with or without chondroitin) was 0.82 (95 % CI 0.75-0.90) and 0.86 (95 % CI 0.78-0.96) for chondroitin (included in two-thirds of glucosamine supplements). Current use of glucosamine was associated with a significant decreased risk of death from cancer (HR 0.87 95 % CI 0.76-0.98) and with a large risk reduction for death from respiratory diseases (HR 0.59 95 % CI 0.41-0.83). Use of glucosamine with or without chondroitin was associated with reduced total mortality and with reductions of several broad causes of death. Although bias cannot be ruled out, these results suggest that glucosamine may provide some mortality benefit.

Detection and discrimination of propionic acid after removal of its 2-DG identified major focus in the olfactory bulb: a psychophysical analysis

Prior 2-deoxyglucose and c-fos studies have demonstrated increased metabolic activity in a rostral dorsomedial area of the olfactory bulb in response to the vapor of propionic acid. We used psychophysical tests to assess the effect of removing this area of the bulb on odor sensitivity and discrimination. Normal rats, those with lesions of the rostral dorsomedial bulb or with control lesions of the lateral olfactory bulb were tested for propionic acid absolute detection and intensity difference thresholds and ability to discriminate propionic acid from other odors. There were no differences among groups for absolute or intensity difference threshold or on simple 2-odor discrimination tests but both groups with bulbar lesions made more errors than controls on a relatively difficult odor-mixture task. The results demonstrate that removal of an area of the bulb identified as responsive to propionic acid is essentially without effect on sensitivity to that odor or ability to discriminate it from other odors.

Changes in metabolic activity in the hyperstriatum of the chick before and after hatching

Changes in metabolic activity in the hyperstriatal regions of the chick forebrain have been assessed just prior to and after hatching using [14C] 2-deoxyglucose (2-DG) autoradiography. Embryos were injected on day E19, followed by either exposure to light for 30 min or being held in darkness. Other embryos were injected on day E20, after pipping of the egg shell had occurred, and chicks were injected on day 1 (D1) after hatching, followed by light exposure. In the E19 groups metabolic activity in visual regions of the hyperstriatum accessorium (HA) was significantly higher than that in the hyperstriatum dorsale (HD), the region which receives the thalamofugal visual projections. The result was the same in both the light and dark exposed embryos, indicating that the high level of activity in HA on day E19 is not visually driven and that HA may be processing inputs from other sensory modalities. At stage E20 the activities of HA and HD did not differ and by day 1 post-hatching HD activity exceeded that of HA. Activity in HA fell between E19 and E20, while in HD activity rose between E20 and D1. The developmental sequence of metabolic activity levels in the intermediate medial hyperstriatum ventrale (IMHV), a region involved with imprinting memory formation, was higher on E19 and D1 than on E20. E20 is thus a quiescent period of neural activity in the hyperstriatum prior to hatching. Although a small number of the embryos showed distinct hemispheric asymmetries in metabolic activity, overall there was no significant asymmetry in the embryo groups. The implications of these results for imprinting and early perceptual processing are discussed: it appears that HA activity may be inhibited or limited during the sensitive period for visual imprinting, thereby temporarily diminishing the importance of the thalamofugal visual pathway relative to the tectofugal pathway in the imprinting process.

Metabolic activity in the hyperstriatum of 2-day-old chicks during optomotor and contrasting visual stimulation

Our earlier report of differences in metabolic activity within the visual regions of the hyperstriatum and ectostriatum, in 2-day-old chicks compared with 23-day-old chicks, suggested that two visual pathways within the visual system develop at different rates. Here we have investigated whether the demands of varying visual environments will increase the activity of the hyperstriatum accessorium (HA) in 2-day-olds. Metabolic activity in the HA was monitored in 2-day-old chicks by the radioactive 2-deoxyglucose technique during monocular stimulation with three different visual environments: moving stripes in a rotating drum, which induced eye and head movements, a featureless white environment, and the complex visual environment of the home cage with other chicks. Although a small but significant level of activity was found in HA in the hemisphere opposite the open eye, the activity did not vary with the visual treatment. On the other hand, a raised level of activity in the hyperstriatum dorsale (HD) appeared in chicks viewing the rotating stripes, indicating that at this age the thalamo-hyperstriatal pathway may be involved in processing whole-field visual movement. The optomoter environment also produced high activity in the medial hyperstriatum ventrale (MHV), a region that has been implicated in memory formation of imprinting. We suggest that during the sensitive period for imprinting, HA may either have not developed its fully functional capacity, or that following or during imprinting it is actively shut down to protect itself and associated regions from interfering visual input. In contrast to the 2-day-olds, 17-day-old chicks in a visually rich cage environment, had high levels of activity in HA, demonstrating that the functional maturation of the HA, related to performance in the cage environment, is complete at least 6 days earlier than previously observed.

Two- and three-dimensional image reconstructions from stained and autoradiographed histological sections

A complete system has been developed to utilize histological serial sections for two- and three-dimensional image reconstructions. Eighty to 120 sections are digitized using a personal computing system augmented with a imaging board and CCD camera. The image files are transmitted to a VAX computer for processing and image reconstruction, and the processed images are transmitted back to the personal computer for display and recording using a film recorder or PostScript printer. The software developed for the system allows serial sections to be placed into proper registration in a 256(3) array, 256 grey levels. Autoradiographs of the sections are obtained in the presence of appropriate standards which are used to recalibrate grey levels to represent linearly the radioactivity of each pixel in the sections and scale the values to allow maximum use of the grey scale. Starting from coronally sectioned material the system has been used to analyse and reconstruct rat nasal turbinates. In two dimensions horizontal and sagittal sections have been obtained while in three dimensions back-to-front and surface-rendered images have been constructed. Useful rendering of differential metabolic activity within an organ of complex geometry has been obtained, and there appears to be no reason why the system cannot be used for any material for which serial sectioning is appropriate.

Evaluation of analytical techniques for measurement of denture-base acrylic resin glass-transition temperature

The glass-transition temperature of a range of acrylic resin materials used in prosthetic dentistry was determined. The techniques used to make the measurement included: thermal mechanical analysis, dynamic mechanical thermal analysis, and differential scanning calorimetry. It was found that the measuring techniques used yielded very similar results, and as a consequence it was concluded that: familiarity and easy availability of thermal mechanical analysis lead to the recommendation that this technique should be employed as the standard glass-transition evaluation technique for denture-base acrylic resins.

Budd-Chiari syndrome and Crohn's disease. An unreported association

Hepatic vein thrombosis (Budd-Chiari syndrome) is a rare complication of ulcerative colitis and has not previously been reported in association with Crohn's disease. We here report the first known case of Crohn's disease presenting as the Budd-Chiari syndrome.

Odor-induced metabolic activity in the olfactory bulb of rats trained to detect propionic acid vapor

The pattern of glucose metabolism in the glomerular layer of the main olfactory bulb was studied in rats trained to sample brief odor stimuli. After injection with [14C]2-deoxyglucose (2-DG). 5 rats were tested for discrimination of propionic acid from air. Over the 45 min test period rats sampled the stimulus for 0.5-0.8s during each trial and their total exposure to the stimulus was 53-147 s. A discrete focus of increased glucose metabolism was found in the central dorsomedial sector of the glomerular layer in each animal. The position of this focus and the overall pattern of glomerular layer activity was essentially identical to that obtained in 4 control rats which were exposed passively to alternating 5 min periods of the odor and clean air for 45 min. The size of the primary focus was only slightly smaller in the trained rats, despite the large difference in total exposure time. The absence of olfactory adaptation during the behavioral tests and the similar pattern of 2-DG uptake in controls and trained animals indicate that adaptation does not play a significant role in the patterns of glucose metabolism induced in the glomeruli of the olfactory bulb by extended exposure to an odor.

Different rates of functional development in the two visual systems of the chicken revealed by [14C]2-deoxyglucose

Age-dependent changes in neuronal metabolic activity in the visual systems of the male chicken were assessed using [14C]2-deoxyglucose (2-DG) autoradiography. Groups of 3 and 4 chicks aged either 2 or 23 days posthatching were injected with 2 DG and exposed for 30 min to a variety of visual stimuli in either the monocular or binocular condition. Control birds had both eyes occluded. All groups were subjected to the same auditory background. In the 2-day-old chicks high levels of metabolic activity occurred in the rotundal-ectostriatal system in a manner consistent with eye use and known neuro-anatomical connections, but very low levels of activity occurred in the thalamo-hyperstriatal visual system. In the 23-day-old chicks eye use resulted in high levels of metabolic activity in both visual systems. The distribution of higher activity within the rostral regions of the anterior hyperstriatum at this age was consistent with eye use and the known distribution of ipsilateral and contralateral projections to the region. Different rates of functional development in the hyperstriatal and ectostriatal systems may reflect a requirement for different visual information processing in young versus older chickens. This study indicates that the ectostriatal system subserves the majority of early visual behavior. Age-dependent changes in the regional arrangement of activity in the Field L auditory region were also noted.

Function and quality of life results after ileal pouch surgery for chronic ulcerative colitis and familial polyposis

The aim of this study was to assess gastrointestinal function and quality of life, including occupational, social, and sexual function, in 75 patients who underwent pelvic pouch construction between November 1984 and May 1988 at our institution. Complications occurred in 45 percent of patients after pouch construction and in 17 percent after ileostomy closure. One patient died from sepsis caused by an anastomotic leak after ileostomy closure. The most common complication was a pouch-anal anastomotic stricture (22 percent), and the complication with the greatest potential morbidity was pouch-anal dehiscence (8 percent), which was highly predictive of pouch failure. Functional results were assessed by questionnaire during the 3-month period after ileostomy closure in all 58 patients who successfully attained intestinal continuity. A second assessment was performed at 15 +/- 11 months after ileostomy closure in 52 patients whose continuity had been restored for longer than 3 months. In an overall assessment, 94 percent of all patients with restored intestinal continuity (73 percent of entire patient group) rated the pouch as being superior to a permanent ileostomy and 92 percent (71 percent of entire group) would go through another pouch procedure. These results support the continued recommendation of this procedure as an acceptable alternative to proctocolectomy and permanent ileostomy in patients with ulcerative colitis or familial polyposis.

Metabolic activity in rat tectal grafts is influenced by host sensory innervation

It has been shown previously that fetal tectal tissue grafted to the midbrain of newborn host rats grows, differentiates, and receives input from the host brain. In the present study, 4 neuroanatomical techniques have been combined to examine how metabolic activity in tectal transplants is influenced by an identified host sensory pathway. Tectal tissue from E15 pigmented rat embryos was transplanted to the midbrain region of anesthetized newborn rats of the same strain. Six to 22 weeks later, the functional relationship between tectal transplants and the visual system of the host animal was examined by mapping metabolic activity in the grafts and relating this activity to the presence or absence of host retinal innervation. Metabolic activity in tectal grafts was assessed using the radioactive 2-deoxy-glucose (2-DG) method and cytochrome oxidase (CO) histochemistry. Graft regions receiving input from host retinal axons were demonstrated by anterograde labeling after bilateral intraocular injections of HRP or WGA-HRP; all areas in grafts that were homologous to the superficial layers of normal superior colliculus (SC) were identified using AChE histochemistry. The levels of metabolic activity demonstrated with 2-DG and CO varied between animals and within individual grafts. Grafts that did not connect with the host showed only low metabolic activity. In grafts that received host input, localized areas of high metabolic activity were seen with both 2-DG and CO. Highest levels of activity were consistently found in area containing both intense AChE activity and a high density of host retinal innervation.

Odour mixture suppression: evidence for a peripheral mechanism in human and rat

Rarely do we encounter a single odorant in our environment. Perception of odours, therefore, usually depends on the reception and neural processing of many components. However, little is known about how and where odour mixtures are processed. Evidence is presented here that suppression of one odour by another, a common result of mixing odours, is primarily a peripheral event. Having demonstrated with human subjects that perception of one or both odorants in two-component mixtures is dependent on the polarity and perceived intensity of the odorants, the same mixtures were presented to rats that had been injected with a metabolic marker, [3H]2-deoxyglucose (2-DG). By measuring the metabolic activity in the glomeruli of the rat olfactory bulb, where the axons of the receptor cells terminate, it was found that in a mixture where humans had perceived only one odour, there is a dramatic reduction in metabolic activity of glomeruli specific to the suppressed odour. In mixtures where both odorants were perceived, metabolic activity characteristic of both components was observed. These findings indicate that similar mechanisms underlie the perception of odour mixtures in the two species. Since metabolic activity revealed by 2-DG in glomeruli occurs predominantly in presynaptic receptor axons, the reduced activity seen after stimulation with odour mixtures indicates that a mechanism for mixture suppression begins at the receptor cells. Therefore, the ability of one odorant to suppress another in a mixture is probably determined by their relative chemical polarities, which effects access to and competition for membrane receptor sites in the olfactory epithelium.

Detection of propionic acid vapor by rats with lesions of olfactory bulb areas associated with high 2-DG uptake

This study tested the functional significance of recent 2-deoxyglucose (2-DG) results demonstrating a discrete focus of activity in the olfactory bulb of rats exposed to the vapor of propionic acid. Rats with lesions that destroyed this area of the olfactory bulb performed as well as did sham operated and lesioned controls in detection of amyl acetate, butanol, geraniol, propionic acid, and on a test for propionic acid threshold. Our results demonstrate that an area of the olfactory bulb containing a major focus of metabolic activity induced by exposure to an odor can be removed without producing a deficit in the detection of that odor.

Investigations of the anal sphincter before and after restorative proctocolectomy

Twenty-eight patients who underwent sphincter-saving proctocolectomy and formation of an ileoanal reservoir had clinical evaluation of resting and maximal anal sphincter pressures and perfused catheter manometry. The clinical estimate of resting tone, heretofore believe to be a good predictive parameter of postoperative function, was inaccurate. This suggests the advisability of manometric evaluation. There were significant changes in sphincter pressures postoperatively. Operation did not effect the preoperative electromyographic findings of the puborectalis muscle and external sphincter in our small postoperative population. The mechanism by which operation might influence these parameters has been discussed. Factors such as parity and the descending perineum syndrome may effect continence. Due to the length of time the sphincter is required to function in these patients and the multiplicity of factors involved, we believe that long-term studies are needed.

The incidence of wound infection after stapled or sutured bowel anastomosis and stapled or sutured skin closure in humans and guinea pigs

In a study of antimicrobial prophylaxis in colorectal surgery, a higher incidence of wound sepsis was noted in patients who underwent stapled rather than sutured anastomoses and skin closures. There were six wound infections in 69 patients (8.7%) who underwent nonstapled anastomoses compared with seven in 28 (25%) in whom GIA or EEA staplers were used (p = 0.003). Excluding the EEA-stapled cases, the infection rate was 29% (p = 0.022). In patients who underwent sutured anastomoses, there were no wound infections in 21 whose skin was closed with sutures compared with five in 38 patients (13%) with stapled skin closure (p = 0.082). In an experimental guinea pig model dual incisions were infected with Bacteroides fragilis and Escherichia coli. One incision was then closed with staples, the other with sutures. There was a statistically significant (p = 0.016) advantage to the use of staplers. The possible significance of these results is discussed.

Quality of use of parenteral metronidazole therapy in a teaching hospital

The recent release, relatively high cost and potential adverse effects of parenterally administered metronidazole prompted a quality-of-use audit at a 1000-bed teaching hospital. Ninety-two courses of treatment in 81 inpatients during a 6-week period were studied. Appropriateness of therapy was assessed on the basis of published indications. Parenterally administered metronidazole was prescribed primarily in anaerobic and anaerobic-aerobic infections. It was used as frequently for prophylaxis as for therapy. Surgical services accounted for 95% of the treatment courses. Inappropriate use was noted in 27 (29%) of the courses: agents other than parenterally administered metronidazole were indicated in 12 (13%), while the dose, dosing interval or duration of treatment was suboptimal in 15 (16%). Substantial savings would be achieved if oral or rectal metronidazole therapy were substituted for intravenous therapy for perioperative prophylaxis in elective colorectal surgery. Written justification for use and automatic stop orders are recommended to improve the cost effectiveness of both prophylactic and therapeutic use of selected antimicrobial agents.

Evaluation of the use of a protocol in the antimicrobial treatment of intra-abdominal sepsis

A protocol was established aimed at limiting the duration of antimicrobial therapy in two patient groups with peritonitis. One group had perforated or gangrenous appendicitis and the other non-appendiceal disease. The duration of treatment given to patients treated according to the protocol was compared retrospectively to that of similar patients treated without the protocol. Patients with perforated or gangrenous appendicitis required significantly less antimicrobial therapy than those with peritonitis due to non-appendiceal disease. In non-appendiceal intra-abdominal sepsis the use of the protocol was associated with a significantly reduced duration of antimicrobial therapy, compared with that observed without the protocol.

Olfactory mitral cell integrity after freeze-fixation

The condition of freeze-fixed mitral cells from the main olfactory bulb of the rat brain was found to depend on the rat at which the tissue is frozen: at very slow rates, mitral cells swell and rupture; at faster rates, cell integrity is preserved. Cooling the tissue to just above its freezing point before rapid freeze-fixation helps to maintain cell integrity at depths well below the surface. When freeze-fixation must be used, as in the 2-deoxyglucose technique, rapid freezing rates should be used to minimize diffusion of isotope and increase autoradiographic resolution. After rapid freezing, better cell integrity was produced by freeze-drying and plastic embedding than by cryostat sectioning and thaw-mounting.

Hartmann resection for perforated sigmoid diverticulitis. A retrospective study of the Vancouver General Hospital experience

The results of management of perforated sigmoid diverticulitis were studied retrospectively at Vancouver General Hospital over a 15-year period. The Hartmann resection (or a modification) was the surgical procedure used. A classic Hartmann resection was performed in 63 of 78 patients, i.e., following removal of the distal segment, the rectal stump was closed. A modified Hartmann resection was performed in 15 patients (19.2 per cent), where a distal mucous fistula was created to facilitate subsequent colostomy closure. Hemorrhage was a common problem during the procedure (37.2 per cent) and other organ injury was uncommon. The wound infection rate was 24.4 per cent. Nine per cent of patients required a second operation for treating postoperative complications. Two of the patients died; the mortality was 2.6 per cent. Recommendations include the creation of a distal mucous fistula when possible. Minimal resection of the distal segment may often permit this and will allow easier closure of the colostomy.

Adenocarcinoma of the vermiform appendix: retrospective study and literature review

Adenocarcinoma of the vermiform appendix is a rare clinical entity, fewer than 200 cases having been reported. The authors carried out a retrospective review over a 25-year period and found five patients admitted to the Vancouver General Hospital with primary appendiceal adenocarcinoma. Four other patients, initially reported as having appendiceal adenocarcinoma, were found after critical microscopic review to have had either benign disease or mucinous carcinoid. Primary epithelial neoplasms of the appendix demonstrate a wide variety of histologic types and because of the different clinical behaviour, an accurate diagnosis must be made. For the benign tumours, appendectomy alone will suffice but for adenocarcinoma of the appendix, right hemicolectomy is recommended.

Intravenous prophylactic antimicrobial drugs in elective colorectal operations

In a prospective, randomized, double blind study of 123 patients undergoing elective colorectal surgery, 61 received intravenously erythromycin gluceptate, and 62 received intravenously metronidazole perioperatively together with tobramycin. Three dosages of each drug were given. Eight patients in each treatment group had wound infections. Of these, only three in each treatment group were severe enough to require antibiotic therapy and to cause prolongation of hospitalization. Antibiotic levels in the serums of patients, in skin samples and in intestinal walls showed that metronidazole was most frequently detected at satisfactory concentrations in serum and that skin and the intestinal wall did not contain any detectable antibiotic.

Metronidazole in the treatment of intra-abdominal sepsis

A study of antibiotic treatment of intra-abdominal sepsis was conducted between May 1978 and May 1981. In the first phase, clindamycin (C) was compared with metronidazole (M), each combined with tobramycin (T), in a prospective, double-blind, randomized study. Twenty-three patients received C + T and 34 patients received M + T. The two groups were similar with respect to age, gender, underlying disease, presence of abscess, clinical condition, severity of illness, duration of illness before treatment and bacteriology. Anaerobic organisms outnumbered facultative and aerobic organisms. Bacteroides fragilis and Escherichia coli predominated. In the C + T group of patients, 74% had a good response. In the M + T group, 83% had good results. Adverse effects were few and minor in the two treatment groups. Three patients on C + T and one who received M + T followed by C + T died of infections; two patients died of underlying disease. In the second, open phase of the study, M + T was used to treat 45 patients with 46 courses. Twenty patients had intra-abdominal abscesses, which represented all grades of severity of illness. Five patients received long-term corticosteroid therapy. Almost half the patients had peritonitis complicating appendicitis. Good results were obtained in 81%. One patient died of the underlying disease and one died of infection complicating severe trauma and hypovolemic shock.

Prophylactic antibiotics in elective colon surgery

A double-blind, randomized, prospective study comparing the efficacy of two intravenously administered antibiotics was conducted at Vancouver General Hospital on 98 patients undergoing elective colon surgery. The test drugs, erythromycin gluceptate and metronidazole, were each administered intravenously in 500 mg doses. The first dose was administered with the premedication 1 hour before surgery and the subsequent two doses were administered at 8-hour intervals. All patients received three doses of tobramycin intravenously, 1.5 mg/kg body weight, at the same time as the study drug. Fourteen patients developed wound infections, of which seven were classified as major and seven as minor infections. A major infection was diagnosed when the patient had a fever, required antibiotics, or had a prolonged hospital stay because of the wound infection. Three patients with major infections had received metronidazole and four had received erythromycin. Four patients with minor infections had received metronidazole and three patients had received erythromycin. The two treatment populations were similar with respect to type of surgery, age, gender, weight, and nutritional status. Both drugs were equally well tolerated. The overall wound infection was 14.4%, with no difference between erythromycin and metronidazole.

Metronidazole and tobramycin in intra-abdominal sepsis

In an open study of 49 episodes of intra-abdominal sepsis in 48 patients, metronidazole was used in combination with tobramycin, and each was given by intravenous infusion. All patients were also treated by appropriate surgical operation. The ages of the patients ranged from 21 to 89 years, and both sexes were equally represented. Twenty-two patients had abscesses drained. Thirty-eight of 49 treatment courses gave good results. Eight patients recovered, although slowly, and three were classified as failures. Of the failures, one instance was attributed to infection with Staphylococcus aureus, and recovery was satisfactory when cloxacillin sodium was given. The other two failures were due, in part, to shock caused by trauma and blood loss in one instance and disseminated anaplastic lymphoma in the other. No significant adverse effects were attributable to the antibiotics.

The effects of colchicine and vinblastine on memory in chicks

Colchicine, injected bilaterally into the forebrain of day-old chicks at times before and after one-trial avoidance learning, produced transient amnesia for one to three hours after learning, that could not be accounted for as a perceptual or attentional defect. The amnesia was dose dependent and was produced only when injections occurred within a limited period before and after learning. No amnesia occurred when injections were given 120 min before or 60 min later than the learning trial, nor at times prior to the retrieval test. During the amnesic period, new learning could occur and be retrieved 15 min later. The amnesia could be overcome by retention-testing or by a new, related, learning experience before or up to 30 min after onset of amnesia. Control birds injected with saline or lumicolchicine, a biologically inactive derivative of colchicine, showed normal retention. Vinblastine sulphate, which also interrupts microtubular networks and hence axonal flow, had no amnesic properties. Colchicine injections had no effect on the levels of acetylcholinesterase, choline acetyltransferase, glutamic acid decarboxylase, and muscarinic acetylcholine receptors in the whole forebrain or in forebrain synaptosomes during the amnesic period. Nor did colchicine injections affect amino acid uptake and protein or glycoprotein synthesis before or during the amnesic period, although there was 10-20% inhibition of protein synthesis 5 h after injection. Thus over the amnesic period, there was no evidence of gross perturbation of brain function. Electron microscopy showed microtubules intact within 1 mm of the injection site 2.5 after injection. Oedema was found at this time in chicks injected with a high dose (100 micrograms) shown to disturb behaviour grossly, but not with a low dose (5 micrograms) which caused amnesia. Transient amnesia for one-trial avoidance learning is most probably caused by secondary effects of colchicine on nerve cell function. We suggest that the amnesic episode represents destruction of one of the stages of a multiple independent parallel process of memory consolidation.

Lateral internal sphincterotomy in chronic anal fissure--a surgical technique

Lateral internal sphincterotoy provides a simple and safe operative procedure which can be performed under local or general anesthesia on an outpatient basis. There is very little postoperative discomfort, the results of treatment are superb, and patient acceptance is excellent.

Closure of colostomy following sigmoid colon resection for perforated diverticulitis

Hartmann resection has been the treatment of choice for perforated diverticulitis of the sigmoid colon at the Vancouver General Hospital for nearly 20 years. A retrospective analysis of 70 patients who had the colonic stomas closed following the Hartmann resection was done. A modified Hartmann resection for the initial procedure has been recommended on the basis of fewer complication and shorter hospital stay when the closure operation is performed. The modification consists of the creation of a distal mucus fistula rather than suturing the rectum closed. To facilitate the creation of a distal mucus fistula, it is suggested that less sigmoid colon be resected at the time of the initial operation. The colon can be assessed for residual diverticular disease later and more resected at the later closure operation if required.

Interhemispheric engram transfer in chick

Monocular training on a one-trial passive avoidance task in the young chick has been shown to establish an engram in the forebrain hemisphere contralateral to the trained eye, and hence interocular transfer of this task must involve the naive hemisphere making access to the engram in the opposite hemisphere. We have studied the consequences for the untrained hemisphere of accessing a unilateral engram during two short term stages of its consolidation, by conducting interocular transfer tests at 7.5 min and 30 min after learning, prior to onset of amnesia induced by intracranial injection of ouabain or cycloheximide. Testing the naive hemisphere 24 h later indicated that engram transfer had occurred in chicks receiving one access trial at 7.5 min, during the first stage of consolidation of the unilateral engram. At 30 min, during second consolidation stage, five access trials were required to achieve engram transfer. These experiments confirm the findings from the rat that engram transfer can follow from making access to the unilateral engram. However, it has not previously been recognised that interhemispheric memory transfer depends on the recency of formation of the unilateral engram.

Unilateral storage of monocular engram in day-old chick

Efficient interocular transfer of a one-trial passive avoidance task by the day-old domestic chicken, for whom the optic nerves decussate completely, raised the question of whether memory for the task was held in one or both sides of the forebrain. Intracranial injection of ouabain or cycloheximide to the trained hemisphere immediately after learning suppressed avoidance behaviour learned monocularly, while injection to the untrained side did not. Memory for the task was established in the side of the brain served by the eye used in learning. Interocular transfer was therefore achieved by the untrained hemisphere borrowing information from the other side's store. The presence of memories in the trained side was not sufficient to establish memory in the naive side.

Dysentery organisms and immigrants

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