The role of preterm birth in stress-induced sodium excretion in young adults

BACKGROUND

Early-life programming due to prematurity and very low birth weight (VLBW, <1500 g) is believed to contribute to development of hypertension, but the mechanisms remain unclear. Experimental data suggest that altered pressure natriuresis (increased renal perfusion pressure promoting sodium excretion) may be a contributing mechanism. We hypothesize that young adults born preterm will have a blunted pressure natriuresis response to mental stress compared with those born term.

METHODS

In this prospective cohort study of 190 individuals aged 18-23 years, 156 born preterm with VLBW and 34 controls born term with birth weight at least 2500 g, we measured urine sodium/creatinine before and after a mental stress test and continuous blood pressure before and during the stress test. Participants were stratified into groups by the trajectory at which mean arterial pressure (MAP) increased following the test. The group with the lowest MAP trajectory was the reference group. We used generalized linear models to assess poststress urine sodium/creatinine relative to the change in MAP trajectory and assessed the difference between groups by preterm birth status.

RESULTS

Participants' mean age was 19.8 years and 57% were women. Change in urine sodium/creatinine per unit increase in MAP when comparing middle trajectory group against the reference group was greater in those born preterm [β 5.4%, 95% confidence interval (95% CI) -11.4 to 5.3] than those born term (β 38.5%, 95% CI -0.04 to 92.0), interaction term P = 0.002.

CONCLUSION

We observed that, as blood pressure increased following mental stress, young adults born preterm exhibited decreased sodium excretion relative to term-born individuals.

Diabetic Osteomyelitis: Oral versus Intravenous Antibiotics at a Single Level 1 Academic Medical Trauma Center

Residual osteomyelitis is a frequent problem following surgical intervention for diabetic foot infection. The Infectious Disease Society of America guidelines recommend a prolonged course of antibiotics for treatment of residual osteomyelitis. Recent literature suggests oral antibiotic therapy is not inferior to IV therapy. The primary aim of this study was to evaluate treatment success in 128 patients receiving oral versus IV antibiotics for residual osteomyelitis in the diabetic foot after amputation at a Level 1 academic medical trauma center. Treatment success was defined as completion of at least 4 weeks of antibiotic therapy, complete surgical wound healing, and no residual infection requiring further debridement or amputation within 1 year of the initial surgery. Patients with peripheral arterial disease were excluded. A retrospective chart review was performed, and we found no statistically significant difference in treatment success between these two groups (p = .2766). The median time to healing for oral antibiotic treatment was 3.17 months compared to 4.06 months for IV treatment (p = .1045). Furthermore, there was no significant difference in group demographics or comorbidities, aside from more patients in the IV group having coronary artery disease (p = .0416). The type of closure and whether the infection was single or polymicrobial were also not associated with a difference in outcomes between the two treatment arms. The results of the present study suggest oral antibiotics for treatment of residual osteomyelitis are not inferior to IV therapy and may be more efficacious for certain patients regarding cost and ease of administration.

A Comparison of Functional Luminal Imaging Probe With High-resolution Manometry, Timed Barium Esophagram, and pH Impedance Testing to Evaluate Functional Luminal Imaging Probe's Diagnostic Capabilities

OBJECTIVE

The aims of this study are to determine the functional luminal imaging probe's (FLIP) diagnostic utility by comparing FLIP measurements with results from other esophageal evaluation standards.

BACKGROUND

The FLIP is an esophageal evaluation technique performed at the time of endoscopy. Few studies have evaluated FLIP diagnostic capabilities compared with the established testing techniques, including high-resolution manometry (HRIM), time barium esophagram (TBE), and 24-hour impedance-pH monitoring.

PATIENTS AND METHODS

A retrospective review was performed for 413 preintervention patients who underwent FLIP testing during endoscopy. Data from HRIM, 24-hour pH monitoring, and TBE were compared.

RESULTS

Abnormal Distensibility Index (DI) was associated with abnormal integrated relaxation pressure (IRP; P = 0.003). Average DI was higher in patients with abnormal IRP (>15 mm Hg) when a hiatal hernia was present (P = 0.025). The total agreement between correlated diagnoses from FLIP and HRIM was 33.5%. DI was not associated with acid exposure time on pH monitoring. Agreement between FLIP and TBE was 49% with a sensitivity of 98.1% and a specificity of 36.5%. A 60 mL distension had a significantly lower detection rate than 40 mL and 50 mL for active peristalsis and was unaffected by pressure (P < 0.05).

CONCLUSIONS

FLIP as an adjunct to HRIM is supported by strong metric correlation. FLIP was not correlated to pH monitoring findings, suggesting FLIP is not useful in reflux assessment. The agreement between FLIP and TBE was lower than in previous studies. Hiatal hernia impacted the normality between DI and IRP, not between FLIP and TBE. We suggest analyzing peristaltic patterns on panometry at all fill volumes to optimize detection.

Comfort Levels of Outpatient Health Care Professionals When Asking About Substance Use-Related Sexual Activity: A Pilot Survey

BACKGROUND

Screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based intervention for substance use. Health care professionals may not receive SBIRT training or know of substance use's intersection with sexual activity. This pilot survey inquired about SBIRT training history, attitudes, and comfort among outpatient health care professionals, including assessing sexual activity-related use.

METHODS

We conducted a snowball cross-sectional survey of outpatient health care professionals at a large southeastern academic medical center in June 2021 with 4-point Likert questions covering demographics, substance use attitudes, SBIRT training history, and comfort implementing SBIRT. Analysis used descriptive statistics and stratification by demographic and practice characteristics.

RESULTS

Seventy-three professionals responded, of whom 82% were White and 66% were female. Forty-seven percent were 30 to 39 years old, 33% were internal medicine professionals, and 59% reported previous SBIRT training. All participants reported believing substance use is a significant health issue. Most reported that they were comfortable or somewhat comfortable assessing patients for substance use (85%), dropping to 60% discussing sexual activity. Advanced practice providers and physicians identified more comfort with rapport building around substance use than other health care respondents. Professionals in infectious diseases and psychiatry reported the greatest comfort assessing substance use with concurrent sexual activity.

CONCLUSIONS

There are gaps in SBIRT training and beliefs among health care professionals. Although health care workers report that assessing substance use is important, some professionals endorsed more comfort discussing substance use with patients than others, especially when inquiring about sexual activity. Future work could replicate the pilot to inform increasing comfort through training in the intersection of substance use and sexuality.

Long-term Impact of a 10-Year Intensive Lifestyle Intervention on a Deficit Accumulation Frailty Index: Action for Health in Diabetes Trial

BACKGROUND

Multidomain lifestyle interventions may slow aging as captured by deficit accumulation frailty indices; however, it is unknown whether benefits extend beyond intervention delivery.

METHODS

We developed a deficit accumulation frailty index (FI-E) to span the 10 years that the Action for Health in Diabetes (Look AHEAD) randomized controlled clinical trial delivered interventions (a multidomain lifestyle intervention focused on caloric restriction, increased physical activity, and diet compared to a control condition) and to extend across an additional 8 years post-delivery. The study cohort included 5 145 individuals, aged 45-76 years at enrollment, who had type 2 diabetes and either obesity or overweight.

RESULTS

Overall, FI-E scores were relatively lower among lifestyle participants throughout follow-up, averaging 0.0130 [95% confidence interval: 0.0104, 0.0156] (p < .001) less across the 18 years. During Years 1-8, the mean relative difference between control and lifestyle participants' FI-E scores was 0.0139 [0.0115, 0.0163], approximately 10% of the baseline level. During Years 9-18, this average difference was 0.0107 [0.0066, 0.0148]. Benefits were comparable for individuals grouped by baseline age and body mass index and sex but were not evident for those entering the trial with a history of cardiovascular disease.

CONCLUSIONS

Multidomain lifestyle intervention may slow biological aging long term, as captured by an FI-E. Clinical Trials Registration Number: NCT00017953.

Association Between Alcohol Consumption and Ectopic Fat in the Multi-Ethnic Study of Atherosclerosis

Background The relationship between alcohol consumption and ectopic fat distribution, both known factors for cardiovascular disease, remains understudied. Therefore, we aimed to examine the association between alcohol consumption and ectopic adiposity in adults at risk for cardiovascular disease. Methods and Results In this cross-sectional analysis, we categorized alcohol intake among participants in MESA (Multi-Ethnic Study of Atherosclerosis) as follows (drinks/day): <1 (light drinking), 1 to 2 (moderate drinking), >2 (heavy drinking), former drinking, and lifetime abstention. Binge drinking was defined as consuming ≥5 drinks on 1 occasion in the past month. Visceral, subcutaneous, and intermuscular fat area, pericardial fat volume, and hepatic fat attenuation were measured using noncontrast computed tomography. Using multivariable linear regression, we examined the associations between categories of alcohol consumption and natural log-transformed fat in ectopic depots. We included 6756 MESA participants (62.1±10.2 years; 47.2% women), of whom 6734 and 1934 had chest computed tomography (pericardial and hepatic fat) and abdominal computed tomography (subcutaneous, intermuscular, and visceral fat), respectively. In adjusted analysis, heavy drinking, relative to lifetime abstention, was associated with a higher (relative percent difference) pericardial 15.1 [95% CI, 7.1-27.7], hepatic 3.4 [95% CI, 0.1-6.8], visceral 2.5 [95% CI, -10.4 to 17.2], and intermuscular 5.2 [95% CI, -6.6 to 18.4] fat but lower subcutaneous fat -3.5 [95% CI, -15.5 to 10.2]). The associations between alcohol consumption and ectopic adiposity exhibited a J-shaped pattern. Binge drinking, relative to light-to-moderate drinking, was also associated with higher ectopic fat. Conclusions Alcohol consumption had a J-shaped association with ectopic adiposity. Both heavy alcohol intake and binge alcohol drinking were associated with higher ectopic fat.

The Opioid Overdose Resuscitation Education for Addiction Counselors and Trainees (Opioid Overdose REACT) naloxone response education pilot project improved confidence and knowledge among addiction counselors and trainees

INTRODUCTION

Community programs to teach nonmedical laypeople how to recognize an opioid overdose and effectively resuscitate the victim using naloxone have proliferated recently as a significant component of harm-reduction efforts. Although many such programs target laypeople like first responders or friends and family members of people who use drugs, there are currently no programs that specifically target addiction counselors, despite their work with a client population at high risk of an opioid overdose.

METHODS

The four-hour curriculum designed by the authors covered opioid agonist and antagonist pharmacology; opioid toxidrome signs; legal implications and indications for using the naloxone kits; and hands-on training. Participants were two cohorts of addiction counselors and addiction counseling trainees at our institution and an affiliated Opioid Treatment Program methadone clinic. Surveys testing participant knowledge and confidence were conducted at baseline, immediately post-training, six months post-training, and 12 months post-training.

RESULTS

Overall, opioid and naloxone pharmacology knowledge, as well as the confidence to intervene in an overdose emergency, improved among participants in both cohorts. Knowledge scores at baseline (n = 36, median 5/10) improved significantly immediately post-training (n = 31, median 7/10, P < 0.0001, Wilcoxon signed-rank test) and were sustained six (n = 19) and 12 months (n = 11) later. Two participants reported using their naloxone kits to successfully reverse a client overdose in the 12 months after taking the course.

DISCUSSION

These results from our knowledge translation pilot project suggest that our educational program to train addiction counselors in opioid pharmacology and toxicology, allowing them to recognize and respond to an opioid overdose, is feasible and could be effective. Specific barriers to implementing such educational programs include cost, stigma, and unclear best practice for designing and conducting these programs.

CONCLUSIONS

Further study of providing opioid pharmacology education and overdose and naloxone training to addiction counselors and counseling trainees appears to be warranted.

Incidence of Nonunion Following First Metatarsophalangeal Joint Arthrodesis for Hallux Valgus Deformity: A Retrospective Analysis of Four Different Constructs

Arthrodesis of the great toe joint is a valuable procedure for hallux valgus deformities. The primary aim of this study was to determine nonunion rates of a first metatarsophalangeal joint (MTPJ) arthrodesis for bunion deformity. This was a retrospective review of 166 consecutive limbs that underwent a first metatarsal phalangeal joint arthrodesis at Wake Forest Baptist Medical Center (WFBMC). Procedures were performed using 4 different constructs for the arthrodesis. Incidence of nonunion, intermetatarsal correction, infection, and recurrence were measured. Overall, 20 patients (12%) experienced nonunion following a first metatarsophalangeal joint arthrodesis. Eighty-seven patients (86%) of plate and screw patients achieved union while 14 (78%) of crossing screw patients achieved union. The minimum time of follow-up was 3 months and the maximum time was 15.4 months. The mean change in intermetatarsal and hallux valgus angle correction was 3.4° and 20.3°, with no statistical difference based on hardware construct or being diabetic. First metatarsophalangeal joint arthrodesis is a viable option for hallux valgus. However, the results of the present study suggest that there is a lower fusion rate of the first MTPJ using crossing screws for bunion deformities.

Reulceration and Reoperation Rates After Central Ray Amputations: A Retrospective Study

Reulceration is a common complication following ray amputations of the foot. The primary aim of this study was to evaluate the incidence of re-ulceration following isolated and combined central ray amputations. This was a retrospective review of 55 consecutive limbs that underwent central ray amputations at Wake Forest Baptist Medical Centers. Procedures were performed at the 3 central rays or a combination of central rays. Incidence of postoperative ulceration was evaluated on the ipsilateral foot. We hypothesized there would not be an association between which ray was resected and development of reulceration. 24 patients (43%) experienced repeat ulceration following a central ray amputation. Median follow up time was 17.4 months (range 4 days to 99 months). The estimated ulcer recurrence rate at 1 year was 41.8%. There was no statistical difference based on location of amputation (second, third, 4 rays) with regards to reulceration, further amputation, transmetatarsal amputation, or below knee amputations. However, reulceration seemed to be much quicker in those patients undergoing a third ray amputation. Like the medial and lateral rays, central ray amputations can be a good initial salvage procedure to clear devitalized tissue and prevent the spreading of infection. The results of the present study suggest that there is no detectable difference between location of central ray amputations and development of re-ulceration, more proximal amputations, or death among this cohort.

Change in Height Following Tibiotalocalcaneal Arthrodesis: Retrospective Radiographic Analysis

Tibiotalocalcaneal arthrodesis (TTCA) with an intramedullary rod is a viable treatment option for a myriad of pathologies involving the foot and ankle. While the current literature has focused on fixation techniques, deformity correction, and clinical outcomes, we are unaware of any studies specifically examining change in height following a TTCA. In the present study, we retrospectively analyzed radiographs with novel radiographic techniques to determine the change in height from preoperative to postoperative radiographs following TTCA. Patients were divided into 3 categories: Charcot, arthritis, and pes planus as the indication for surgical intervention. We found that Charcot and arthritis had an average decrease in height on anterior and posterior measurements of the height from the distal tibia to the calcaneus, while pes planus had an increase in height. The average Charcot change in height was -12.0 ± 24.4 mm anteriorly and -7.6 ± 15.5 mm posteriorly. The average change in height for the arthritis group was -6.9 ± 6.7 mm anteriorly and -3.8 ± 5.8 mm posteriorly. The pes planus group was found to have an average increase in height 0.5 ± 8.0 mm anteriorly and 2.9 ± 5.8 mm posteriorly. Overall, we found a statistically significant difference in height change between the 3 groups in anterior measurements (p = .012) and posterior measurement (p = .006). We recommend surgeons who perform this procedure to be aware of the potential change in height to better tailor surgical and postoperative care.

Nonadherence to appropriate tidal volume and PEEP in children with pARDS at a single center

BACKGROUND

Low tidal volume and adequate positive end-expiratory pressure (PEEP) are evidence-based approaches for pediatric acute respiratory distress syndrome (pARDS), however, data are limited regarding their use since pARDS guidelines were revised in 2015.

OBJECTIVE

To identify prevalence of, and factors associated with, nonadherence to appropriate tidal volume and PEEP in children with pARDS.

METHODS

Retrospective cohort study of children 1 month to <18 years with pARDS who received invasive mechanical ventilation from 2016 to 2018 in a single pediatric intensive care unit (PICU).

RESULTS

At 24 h after meeting pARDS criteria, 48/86 (56%) patients received tidal volume ≤8 ml/kg of ideal body weight and 45/86 (52%) received appropriate PEEP, with 22/86 (26%) receiving both. Among patients ≥2 years of age, a lower proportion of patients with overweight/obesity (9/25, 36%) had appropriate tidal volume versus those in the normal or underweight category (16/22, 73%, p = 0.02). When FIO2 was ≥50%, PEEP was appropriate in 19/60 (32%) cases versus 26/26 (100%) with FIO2  < 50% (p < 0.0001). pARDS was documented in the progress note in 7/86 (8%) patients at 24 h. Severity of pARDS, documentation in the progress note, and other clinical factors were not significantly associated with use of appropriate tidal volume and PEEP, however pARDS was documented more commonly in patients with severe pARDS.

CONCLUSIONS

In a single PICU in the United States, children with pARDS did not receive appropriate tidal volume for ideal body weight nor PEEP. Targets for improving tidal volume and PEEP adherence may include overweight patients and those receiving FIO2  ≥ 50%, respectively.

Discordance Between Oncology Clinician-Perceived and Radiologist-Intended Meaning of the Postradiotherapy Positron Emission Tomography/Computed Tomography Freeform Report for Head and Neck Cancer

Importance

Assessment of response after radiotherapy (RT) using 18F-fluorodeoxyglucose positron emission tomography (PET) with computed tomography (CT) is routine in managing head and neck squamous cell carcinoma (HNSCC). Freeform reporting may contribute to a clinician's misunderstanding of the nuclear medicine (NM) physician's image interpretation, with important clinical implications.

Objective

To assess clinician-perceived freeform report meaning and discordance with NM interpretation using the modified Deauville score (MDS).

Design, Setting, and Participants

In this retrospective cohort study that was conducted at an academic referral center and National Cancer Institute-designated Comprehensive Cancer Center and included patients with HNSCC treated with RT between January 2014 and December 2019 with a posttreatment PET/CT and 1 year or longer of follow-up, 4 masked clinicians independently reviewed freeform PET/CT reports and assigned perceived MDS responses. Interrater reliability was determined. Clinician consensus-perceived MDS was then compared with the criterion standard NM MDS response derived from image review. Data analysis was conducted between December 2021 and February 2022.

Exposures

Patients were treated with RT in either the definitive or adjuvant setting, with or without concurrent chemotherapy. They then underwent posttreatment PET/CT response assessment.

Main Outcomes and Measures

Clinician-perceived (based on the freeform PET/CT report) and NM-defined response categories were assigned according to MDS. Clinical outcomes included locoregional control, progression-free survival, and overall survival.

Results

A total of 171 patients were included (45 women [26.3%]; median [IQR] age, 61 [54-65] years), with 149 (87%) with stage III to IV disease. Of these patients, 52 (30%) received postoperative RT and 153 (89%) received concurrent chemotherapy. Interrater reliability was moderate (κ = 0.68) among oncology clinicians and minimal (κ = 0.36) between clinician consensus and NM. Exact agreement between clinician consensus and the NM was 64%. The NM-rated MDS was significantly associated with locoregional control, progression-free survival, and overall survival.

Conclusions and Relevance

The results of this cohort study suggest that considerable variation in perceived meaning exists among oncology clinicians reading freeform HNSCC post-RT PET/CT reports, with only minimal agreement between MDS derived from clinician perception and NM image interpretation. The NM use of a standardized reporting system, such as MDS, may improve clinician-NM communication and increase the value of HNSCC post-RT PET/CT reports.

Association of cognition with leptin and vascular endothelial growth factor in individuals with type 2 diabetes mellitus

OBJECTIVE

The 10-year intensive lifestyle intervention (ILI) of the Look AHEAD study left a legacy of relative deficits in cognitive function among participants who entered the clinical trial with obesity or a history of cardiovascular disease. We hypothesized that altered levels of two weight-sensitive proangiogenic cytokines, leptin and vascular endothelial growth factor (VEGF), accounted for this concerning finding.

METHODS

Serum leptin and VEGF concentrations were determined in 1,279 Look AHEAD participants at baseline, proximal to cessation of the interventions (Epoch 1), and an average of 4 years later (Epoch 2). Up to four standardized assessments of attention, executive function, and memory were collected during follow-up. Mixed effects models were used to assess relative differences in leptin and VEGF concentrations between intervention groups and whether these accounted for changes in cognitive composite scores.

RESULTS

ILI and diabetes support and education differences in VEGF, but not leptin, concentrations varied depending on baseline history of cardiovascular disease and obesity, but neither leptin nor VEGF concentrations accounted for the relative decrements in cognitive function in participants assigned to ILI.

CONCLUSIONS

Alterations in two weight-sensitive proangiogenic cytokines did not account for the long-term adverse effects of ILI on cognitive function among adults with diabetes and either obesity or cardiovascular disease.

Eight-Year Changes in Multimorbidity and Frailty in Adults With Type 2 Diabetes Mellitus: Associations With Cognitive and Physical Function and Mortality

BACKGROUND

Indices of multimorbidity and deficit accumulation (ie, frailty indices) have been proposed as markers of biological aging. If true, changes in these indices over time should predict downstream changes in cognition and physical function, and mortality.

METHODS

We examined associations that 8-year changes in (i) a multimorbidity index comprised of 9 chronic diseases and (ii) a frailty index (FI) based on deficit accumulation in functional, behavioral, and clinical characteristics had with subsequent measures of cognitive and physical function over 10 years. We drew data from 3 842 participants in the Action for Health in Diabetes clinical trial. They were aged 45-76 years at baseline and at risk for accelerated biological aging due to overweight/obesity and type 2 diabetes mellitus.

RESULTS

A total of 1 501 (39%) of the cohort had 8-year increases of 1 among the 9 diseases tracked in the multimorbidity index and 868 (23%) had increases of ≥2. Those with greatest increases in multimorbidity tended to be older individuals, males, and non-Hispanic Whites. Greater FI increases tended to occur among individuals who were older, non-Hispanic White, heavier, and who had more baseline morbidities. Changes in multimorbidity and FI were moderately correlated (r = 0.26; p < .001). Increases in both multimorbidity and FI were associated with subsequently poorer composite cognitive function and 400-m walk speed and increased risk for death (all p < .001).

CONCLUSIONS

Accelerated biological aging, as captured by multimorbidity and frailty indices, predicts subsequent reduced function and mortality. Whether intensive lifestyle interventions generally targeting multimorbidity and FI reduce risks for downstream outcomes remains to be seen. Clinical Trials Registration Number: NCT00017953.

Metatarsal Protrusion Distance and Its Influence on Recurrent Ulceration Rates After Partial First-Ray Amputations: A Retrospective Study

BACKGROUND

Recurrent ulceration is a common problem after partial first-ray amputations. Loss of the first metatarsophalangeal joint contributes to altered biomechanics and increased pressure on the foot. This may increase risk of adjacent ulcerations and additional amputations. Preserving first-ray length maintains the metatarsal parabola and limits transfer lesions, but few data support this. We aimed to evaluate the incidence of ulceration after partial first-ray amputations and to assess the association between metatarsal protrusion distance and recurrent ulceration.

METHODS

Thirty-two consecutive patients underwent unilateral partial first-ray amputation at various levels along the first metatarsal, and the metatarsal protrusion distance was measured after surgery. Incidence of ulceration was evaluated on the ipsilateral foot. We hypothesized that patients with a longer first metatarsal were less likely to ulcerate again on the ipsilateral foot.

RESULTS

Fourteen patients (43.8%) ulcerated again after partial first-ray amputation. Mean time to ulceration was 104 days. Active smoking status was associated with increased risk of another ulceration (P = .02), and chronic kidney disease was associated with a decreased risk of recurrent ulceration (P = .03). The average metatarsal protrusion distance for patients who ulcerated again after surgery was 36.1 mm versus 25.9 mm for patients who did not (P = .04). Logistic regression analysis of the receiver operating characteristic curve demonstrated an ideal cutoff length for recurrent ulceration of 37 mm (area under the curve = 0.7381). Patients with a protrusion distance greater than 37 mm were nine times as likely to ulcerate again (95% CI, 1.7-47.0).

CONCLUSIONS

Partial first-ray amputations can be a good initial salvage procedure to clear infection and prolong bipedal ambulatory status. Unfortunately, these patients are prone to recurrent ulceration. Significant loss of first metatarsal length is a poor prognostic indicator for recurrent ulceration.

Reulceration and Reoperation Incidence After Isolated Partial Fifth Ray Amputations: A Multicenter Study

Ulceration or reulceration is a common complication following partial or total fifth ray amputations. The primary aim of this study was to evaluate the incidence of reulceration following partial fifth ray amputations. This was a multicenter review of 117 consecutive limbs that underwent partial fifth ray amputations at the University of Pittsburgh Medical Center and Wake Forest Baptist Medical Centers. Procedures were performed at various levels along the fifth metatarsal. Incidence of postoperative ulceration was evaluated on the ipsilateral foot. We hypothesized there would be an association between location of resection and development of reulceration. Seventy-one of 117 patients (60.7%) experienced repeat ulceration following a partial fifth ray amputation. Median follow-up time was 19 months. There was no statistical difference based on location of amputation (proximal, middle, distal, isolated base) with regards to reulceration (p = .166), further amputation (p = .271), transmetatarsal amputation (p = .160), or below knee amputation (p = .769). There was statistical significance in the follow up time between study sites (p = .013), fifth ray amputation reoperation rate between study sites (p = .001), and reulceration rates between study sites (p = .017). Partial fifth ray amputations can be a good initial salvage procedure to clear infection and prolong bipedal ambulatory status. The results of the present study put forward that there is not an association between location of amputations of the fifth ray and development of reulceration, transfer lesions or more proximal amputations.

Elevated average maximum intrabolus pressure on high-resolution manometry is associated with esophageal dysmotility and delayed esophageal emptying on timed barium esophagram

BACKGROUND

Intrabolus pressure (IBP) recorded by high-resolution manometry (HRM) portrays the compartmentalized force on a bolus during esophageal peristalsis. HRM may be a reliable screening tool for esophageal dysmotility in patients with elevated average maximum IBP (AM-IBP). Timed barium esophagram (TBE) is a validated measure of esophageal emptying disorders, such as esophagogastric junction outflow obstruction and achalasia. This study aimed to determine if an elevated AM-IBP correlates with esophageal dysmotility on HRM and/or delayed esophageal emptying on TBE.

METHODS

A retrospective analysis of all HRM (unweighted sample n = 155) performed at a tertiary referral center from 09/2015-03/2017 yielded a case group (n = 114) with abnormal AM-IBP and a control group (n = 41) with a normal AM-IBP (pressure < 17 mmHg) as consistent with Chicago Classification 3. All patients received a standardized TBE, with abnormalities classified as greater than 1 cm of retained residual liquid barium in the esophagus at 1 and 5 min or as tablet retention after 5 min.

RESULTS

AM-IBP was significantly related to liquid barium retention (p = 0.003) and tablet arrest on timed barium esophagram (p = 0.011). A logistic regression model correctly predicted tablet arrest in 63% of cases. Tablet arrest on AM-IBP correlated with an optimal prediction point at 20.1 mmHg on HRM. Patients with elevated AM-IBP were more likely to have underlying esophageal dysmotility (95.6% vs. 70.7% respectively; p < 0.001), particularly esophagogastric junction outflow obstruction disorders. Elevated AM-IBP was associated with incomplete liquid bolus transit on impedance analysis (p = 0.002).

CONCLUSIONS

Our findings demonstrate that an elevated AM-IBP is associated with abnormal TBE findings of esophageal tablet retention and/or bolus stasis. An abnormal AM-IBP (greater than 20.1 mm Hg) was associated with a higher probability of retaining liquid bolus or barium tablet arrest on TBE and esophageal dysmotility on HRM. This finding supports the recent incorporation of IBP in Chicago Classification v4.0.

National trends in the surgical management of metastatic lung cancer to the spine using the national inpatient sample database from 2005 to 2014

Optimal management of metastatic lung cancer to the spine (MLCS) incorporates a multidisciplinary approach. With improvements in lung cancer screening andnonsurgical treatment, the role for surgerymay be affected. The objective of this study is to assess trends in the surgical management of MLCS using the National Inpatient Sample (NIS) database. The NIS was queried for patients with MLCS who underwent surgery from 2005 to 2014. The frequencies of spinal decompression alone, spinal stabilization with or without (+/-) decompression, and vertebral augmentation were calculated. Statistical analysis was performed to analyze the effect of patient characteristics on outcomes. The most common procedure performed was vertebral augmentation (10719, 44.3%), followed by spinal stabilization +/- decompression (8634, 35.7%) and then decompression alone (4824, 20.0%). The total number of surgeries remained stable, while the rate of spinal stabilizations increased throughout the study period (p < 0.001). Invasive procedures such as stabilization and decompression were associated with greater costs, length of stay,complications and mortality. Increasingcomorbidity was associated with increased odds of complication, especially in patients undergoing more invasive procedures. In patients with lowpre-operative comorbidity, the type of procedure did not influence the odds of complication. Graded increases in length of stay, cost and mortality were seen with increasing complication rate.The rate of spinal stabilizations increased, which may be due to either increased early detection of disease facilitating use of outpatient vertebral augmentation procedures and/or the recognition that surgical decompression and stabilization are necessary for optimal outcome in the setting of MLCS with neurological deficit.

Legacy of a 10-Year Multidomain Lifestyle Intervention on the Cognitive Trajectories of Individuals with Overweight/Obesity and Type 2 Diabetes Mellitus

INTRODUCTION

Weight loss and increased physical activity interventions are commonly recommended for individuals with type 2 diabetes (T2D) and overweight or obesity. We examined the impact of randomization to an intensive lifestyle intervention (ILI) on trajectories of cognitive function over 10 years in a cohort of participants in a randomized clinical trial who had T2D and overweight/obesity at baseline.

METHODS

Participants aged 45-76 years were enrolled in 2001-2004 and were randomized to the ILI or a diabetes support and education (DSE) condition. Cognitive function was assessed in 3,938 participants at up to 4 time points 8-18 years after randomization. General linear mixed effects models examined cognitive trajectories over time. Subgroup analyses focused on sex, individuals with baseline body mass index >30, those carrying the APOE ε4 allele, and those with a baseline history of cardiovascular disease (CVD).

RESULTS

Overall, there were no differences in the rate of cognitive decline by intervention arm. Subgroup analyses showed that participants who had a baseline history of CVD and were randomized to the ILI arm of the study performed significantly worse on the Stroop Color Word Test than those in the DSE arm.

DISCUSSION/CONCLUSIONS

The ILI did not result in preserved cognitive function or slower rates of cognitive decline in this cohort of individuals who had T2D and were overweight or obese at baseline.

Current trends in incidence, characteristics, and surgical management of metastatic breast cancer to the spine: A National Inpatient Sample analysis from 2005 to 2014

Management of metastatic breast cancer to the spine (MBCS) incorporates a multimodal approach. Improvement in screening and nonsurgical therapies may alter the trends in surgical management of MBCS. The objective of this study is to assess trends in surgical management of MBCS and short-term outcomes based on the National Inpatient Sample (NIS) database. The NIS database was queried for patients with MBCS who underwent surgery from 2005 to 2014. The weighted frequencies of spinal decompression alone, spinal stabilization +/- decompression, and vertebral augmentation were calculated. Multivariate analysis was performed to analyze the effect of patient characteristics on outcomes stratified by procedure. The most common procedure performed was vertebral augmentation (11,114, 53.4%), followed by stabilization +/- decompression (6,906, 33.2%) and then decompression alone (3,312, 13.4%). The total population-adjusted rate of surgical management for MBCS remained stable, while the rate of spinal stabilization increased (P < 0.001) and vertebral augmentation decreased (p < 0.003). The risk of complication increased with spinal stabilization and decompression compared to vertebral augmentation procedures in those with fewer comorbidities. This relative increase in risk abated in patients with higher numbers of pre-operative comorbidities. Any single complication was associated with increases in length of stay, cost, and mortality. The rate of in-hospital interventions remained stable over the study period. Stratified by procedure, the rate of stabilizations increased with a concomitant decrease in vertebral augmentations, which suggests that patients who require hospitalization for MBCS are becoming more likely to represent advanced cases that are not amenable to palliative vertebral augmentation procedures.

Influence of early-life nutritional stress on songbird memory formation

In birds, vocal learning enables the production of sexually selected complex songs, dialects and song copy matching. But stressful conditions during development have been shown to affect song production and complexity, mediated by changes in neural development. However, to date, no studies have tested whether early-life stress affects the neural processes underlying vocal learning, in contrast to song production. Here, we hypothesized that developmental stress alters auditory memory formation and neural processing of song stimuli. We experimentally stressed male nestling zebra finches and, in two separate experiments, tested their neural responses to song playbacks as adults, using either immediate early gene (IEG) expression or electrophysiological response. Once adult, nutritionally stressed males exhibited a reduced response to tutor song playback, as demonstrated by reduced expressions of two IEGs (Arc and ZENK) and reduced neuronal response, in both the caudomedial nidopallium (NCM) and mesopallium (CMM). Furthermore, nutritionally stressed males also showed impaired neuronal memory for novel songs heard in adulthood. These findings demonstrate, for the first time, that developmental conditions affect auditory memories that subserve vocal learning. Although the fitness consequences of such memory impairments remain to be determined, this study highlights the lasting impact early-life experiences can have on cognitive abilities.

Risk of percutaneous renal biopsy of native kidneys in the evaluation of acute kidney injury

Background

Percutaneous renal biopsy (PRB) of native kidneys (NKs) to better understand and treat acute kidney injury (AKI) is being advocated, but little is known about the risk of complications.

Methods

We performed a retrospective study of PRB of NKs in 955 adults from 1991 to 2015 at an academic medical center with real-time ultrasound and automated biopsy needles. Patients undergoing PRB for evaluation of AKI (n = 160) were compared with 795 patients biopsied for other reasons (not-AKI) for postbiopsy complications [need for transfusion of packed red blood cells (PRBCs), an interventional radiologic or surgical procedure, readmission or death].

Results

Patients biopsied for AKI were older (58 ± 16 versus 44 ± 16 years; P < 0.0001), with a higher serum creatinine (SCr) (4.5 ± 2.7 versus 1.8 ± 1.6 mg/dL; P < 0.0001) and lower hemoglobin (Hgb) (10.4 ± 1.7 versus 12.1 ± 2.1; P < 0.0001) and a greater proportion had an abnormal bleeding time (12.5% versus 7.4%, P 0.04), partial thromboplastin time (15.2% versus 5.3%, P < 0.0001) and/or prothrombin time (27.0% versus 12.8%; P < 0.0001) compared with not-AKI patients. Complications post-PRB were significantly greater in patients biopsied for AKI {11.3% versus 6.7%; P=0.04; odds ratio [OR] 1.78 [95% confidence interval (CI) 1.01–3.12]} with patients biopsied for AKI requiring more blood transfusions (10.0% versus 5.3%; P 0.02; OR 2.04 (95% CI 1.12–3.74)]. By multivariate analysis, baseline features predictive of a complication were increased SCr and decreased Hgb level, as well as female gender and increased systolic blood pressure.

Conclusion

Patients biopsied for evaluation of AKI are at greater risk of complications due to increased risk factors.

Single-dose aprepitant vs ondansetron for the prevention of postoperative nausea and vomiting: a randomized, double-blind phase III trial in patients undergoing open abdominal surgery

BACKGROUND

The neurokinin(1) antagonist aprepitant is effective for prevention of chemotherapy-induced nausea and vomiting. We compared aprepitant with ondansetron for prevention of postoperative nausea and vomiting.

METHODS

Nine hundred and twenty-two patients receiving general anaesthesia for major abdominal surgery were assigned to receive a single preoperative dose of oral aprepitant 40 mg, oral aprepitant 125 mg, or i.v. ondansetron 4 mg in a randomized, double-blind trial. Vomiting episodes, use of rescue therapy, and nausea severity (verbal rating scale) were documented for 48 h after surgery. Primary efficacy endpoints were complete response (no vomiting and no use of rescue therapy) 0-24 h after surgery and no vomiting 0-24 h after surgery. The secondary endpoint was no vomiting 0-48 h after surgery.

RESULTS

Aprepitant at both doses was non-inferior to ondansetron for complete response 0-24 h after surgery (64% for aprepitant 40 mg, 63% for aprepitant 125 mg, and 55% for ondansetron, lower bound of 1-sided 95% CI > 0.65), superior to ondansetron for no vomiting 0-24 h after surgery (84% for aprepitant 40 mg, 86% for aprepitant 125 mg, and 71% for ondansetron; P < 0.001), and superior for no vomiting 0-48 h after surgery (82% for aprepitant, 40 mg, 85% for aprepitant, 125 mg, and 66% for ondansetron; P < 0.001). The distribution of peak nausea scores was lower in both aprepitant groups vs ondansetron (P < 0.05).

CONCLUSIONS

Aprepitant was non-inferior to ondansetron in achieving complete response for 24 h after surgery. Aprepitant was significantly more effective than ondansetron for preventing vomiting at 24 and 48 h after surgery, and in reducing nausea severity in the first 48 h after surgery. Aprepitant was generally well tolerated.

Combined data from two phase III trials of the NK1 antagonist aprepitant plus a 5HT 3 antagonist and a corticosteroid for prevention of chemotherapy-induced nausea and vomiting: effect of gender on treatment response

GOALS OF WORK

Prevention of chemotherapy-induced nausea and vomiting (CINV) with standard antiemetics has been more difficult to achieve in female patients. Data from two phase III trials of the NK1 antagonist aprepitant were assessed for potential effect of gender on treatment response.

PATIENTS AND METHODS

1,044 patients receiving cisplatin (> or = 70 mg/m2) were randomly assigned to control regimen [ondansetron (O) 32 mg i.v. and dexamethasone (D) 20 mg p.o. on day 1; D 8 mg twice daily on days 2-4] or aprepitant (A) regimen (A 125 mg p.o. plus O 32 mg and D 12 mg on day 1; A 80 mg and D 8 mg once daily on days 2-3; and D 8 mg on day 4). The primary endpoint was overall complete response (no emesis and no rescue therapy over days 1-5). Data were analyzed by a modified intent-to-treat approach. Between-treatment comparisons for each gender were made using logistic regression.

MAIN RESULTS

Women comprised 42 and 43% of the aprepitant and control groups, respectively. In the control group, 41% of women had overall complete response compared with 53% of men. In the aprepitant group, 66% of women had overall complete response compared with 69% of men.

CONCLUSION

The addition of aprepitant may negate the adverse prognostic effect of female gender on the prevention of CINV in patients receiving highly emetogenic chemotherapy.

The oral NK(1) antagonist, aprepitant, given with standard antiemetics provides protection against nausea and vomiting over multiple cycles of cisplatin-based chemotherapy: a combined analysis of two randomised, placebo-controlled phase III clinical trials

In early clinical trials, the NK(1) receptor antagonist, aprepitant (EMEND(R)) was shown to improve the protection provided by the best available therapy (hereafter referred to as 'standard therapy': a 5-HT(3) receptor antagonist and dexamethasone) against chemotherapy-induced nausea and vomiting over multiple cycles of cisplatin-based chemotherapy. To further study the sustainment of antiemetic efficacy of aprepitant plus standard therapy over more than one cycle of chemotherapy, we examined combined data from the multiple cycles extensions of two phase III clinical trials of oral aprepitant plus standard therapy for the prevention of chemotherapy-induced nausea and vomiting. Data were pooled from two multicentre, randomised, double-blind, placebo-controlled studies with identical design and treatment regimens. Cancer patients receiving a first cycle of cisplatin-based (>or=70 mg/m(2)) chemotherapy were randomised to one of two treatment groups as follows: the standard therapy group received ondansetron 32 mg intravenously (i.v.) and dexamethasone 20 mg on day 1 and dexamethasone 8 mg twice daily (b.i.d.) on days 2-4. The aprepitant group received aprepitant 125 mg, ondansetron 32 mg i.v., and dexamethasone 12 mg on day 1, aprepitant 80 mg and dexamethasone 8 mg on days 2-3, and dexamethasone 8 mg on day 4. Patients had the option to receive the same blinded treatment for up to five additional cycles. The analysis used a combined exploratory endpoint of no emesis and no significant nausea (i.e. nausea which interfered with a patient's normal activities) over the 5 days following cisplatin, for up to six cycles of chemotherapy. A cumulative probabilities approach incorporating a model for transitional probabilities was used to analyse the data. Tolerability was assessed by reported adverse events and physical and laboratory assessments. Baseline characteristics, reasons for discontinuation, and drop-out rates were similar between groups. In every cycle, the estimated probabilities (rates) of no emesis and no significant nausea were significantly higher (P<0.006) in the aprepitant group: in the first cycle, rates were 61% in the aprepitant group (N=516) and 46% in the standard therapy group (N=522), and thereafter, rates for the aprepitant regimen remained higher throughout (59% (N=89) versus 40% (N=78) for the standard therapy, by cycle 6). Repeated dosing with aprepitant over multiple cycles was generally well tolerated. Compared with patients who received standard therapy alone (a 5-HT(3) antagonist plus dexamethasone), those who received aprepitant in addition to standard therapy had consistently better antiemetic protection that was well maintained over multiple cycles of highly emetogenic chemotherapy

Addition of the Oral NK1 Antagonist Aprepitant to Standard Antiemetics Provides Protection Against Nausea and Vomiting During Multiple Cycles of Cisplatin-Based Chemotherapy

Purpose: This analysis evaluated whether the antiemetic efficacy of the NK1 receptor antagonist aprepitant (EMEND™, Merck, Whitehouse Station, NJ) plus standard antiemetics could be sustained for up to six cycles of cisplatin-based chemotherapy.

Patients and Methods: Patients receiving cisplatin ≥ 70 mg/m2 were blindly assigned to receive one of the following three regimens: (1) aprepitant 375 mg 1 hour before cisplatin on day 1 and aprepitant 250 mg on days 2 to 5 (n = 35); (2) aprepitant 125 mg before cisplatin and aprepitant 80 mg on days 2 to 5 (n = 81); or (3) placebo before cisplatin on days 2 to 5 (n = 86). All groups received ondansetron 32 mg and dexamethasone 20 mg before cisplatin, and dexamethasone 8 mg on days 2 to 5. The primary end point was complete response (no emesis and no rescue therapy) over 5 days following cisplatin in up to six cycles. A cumulative probability analysis using a model for transitional probabilities was used to analyze the data. The aprepitant 375/250-mg regimen was discontinued early in light of new pharmacokinetic data.

Results: In the first cycle, 64% of patients in the aprepitant group and 49% in the standard therapy group had a complete response. Thereafter, complete response rates for the aprepitant group were still 59% by cycle 6, but decreased to 34% by cycle 6 for the standard therapy group. Reasons for discontinuation were similar across treatment groups.

Conclusion: Compared with patients who received standard therapy, those who received only the aprepitant regimen had better and more sustained protection against chemotherapy-induced nausea and vomiting over multiple cycles.

Differential involvement of neurotransmitters through the time course of cisplatin-induced emesis as revealed by therapy with specific receptor antagonists

Advances in antiemetic therapy for chemotherapy-induced emesis have resulted in improved protection against symptoms occurring within 24 h of chemotherapy. However, the vomiting which tends to occur beyond 24 h after chemotherapy (delayed-phase vomiting) is still relatively poorly controlled by the currently available drugs, suggesting that more than one mechanism may mediate these symptoms. The standard antiemetic regimen currently recommended for prevention of chemotherapy-induced emesis includes a serotonin (5-HT(3)) antagonist and a corticosteroid. The neurokinin-1 (NK(1)) antagonist aprepitant represents a new class of antiemetic currently in clinical development. Using data obtained in 2 Phase II clinical trials of aprepitant in patients receiving chemotherapy based on the highly emetogenic chemotherapeutic agent cisplatin, we compared the time course of antiemetic effect of aprepitant, a 5-HT(3) antagonist, or a combination of both. Over the entire observation period (up to 7 days post-cisplatin), patients who received the NK(1) antagonist had a superior prevention of emesis. However, in the first 24 h after cisplatin, emesis occurred in fewer patients who received the 5-HT(3) antagonist than in patients who did not receive this class of drug. Furthermore, the majority of treatment failures in patients who received the NK(1) antagonist occurred within the first 8-12 h of chemotherapy, whereas the treatment failures in patients who received a 5-HT(3) antagonist were more evenly distributed over time. Patients who received both drugs had superior control of symptoms compared with patients who received one or the other. The difference in the time course of emesis blockade observed with two different classes of receptor antagonists provides substantial evidence for involvement of separate pathophysiological mechanisms in chemotherapy-induced vomiting. Serotonin mediates the early vomiting process that occurs within 8-12 h following cisplatin-based chemotherapy, after which time substance P acting at NK(1) receptors becomes the dominant mediator of vomiting

Differential leukocytosis and lymphocyte mitogenic response to acute maximal exercise in the young and old

Despite the increasing use of exercise in the elderly as a means of improving muscle function, little is known regarding the effects of exercise on the senescent immune system.

PURPOSE

The purpose of this study was to determine the effects of acute maximal exercise on blood leukocyte numbers, leukocyte subsets, and the T cell mitogenic response in the elderly.

METHODS

Previously sedentary elderly (N = 33, 65.3 +/- 0.8 yr) and young (N = 14, 22.4 +/- 0.7 yr) subjects participated in a modified Balke maximal exercise treadmill test. Venous blood samples were collected pre-, immediately post-, and 20 min postexercise. Blood was analyzed for leukocyte counts, leukocyte subsets via immunofluorescence, and whole blood mitogenesis in response to various doses of mitogens.

RESULTS

Whereas VO2max was lower in the elderly, maximal RQ, age-predicted heart rates, and times to fatigue were not different, indicating that both groups achieved relative maximal exercise intensity. There were significant exercise-induced leukocytoses in both the elderly and young made up largely of a lymphocytosis and neutrophilia. The magnitude of the leukocytosis was lower in the elderly and failed to return to pre-exercise levels by 20 min postexercise. Acute maximal exercise increased CD8+ (153% vs 112% in young and old, respectively) and CD4+ (57% vs 22% in young and old, respectively) T cells when measured immediately postexercise. By 20 min postexercise, concentrations in the young were not significantly different from baseline, whereas CD8 cell number was still elevated in the old. The elderly had significantly higher percentages of memory (i.e., CD45RO+) and significantly lower percentages of naive (i.e., CD45RA+) CD4 and CD8 T cells pre-exercise, and the young and old recruited approximately equal numbers of CD8+ naive and memory cells to the blood in response to exercise. In contrast, the aged recruited significantly fewer numbers of CD4+ naive and transitional (CD45RA+RO+) cells. At most doses of Con A and PHA, the lymphoproliferative response was lower in the elderly subjects even though they had significantly higher numbers and percentages of CD3+ cells. Interestingly, immediately postexercise, young (but not old) subjects demonstrated reduced proliferative ability on a per CD3+ cell basis.

CONCLUSIONS

These data indicate that several blood leukocyte responses to maximal exercise stress are similar in the young and the old. However, the elderly demonstrate a less resilient leukocytosis and a different lympho-proliferative response following acute maximal exercise.

Effects of 6 months of moderate aerobic exercise training on immune function in the elderly

The purpose of this study was to determine the effects of 6 months of moderate aerobic exercise on age-dysregulated measures of T lymphocyte and natural killer (NK) cell number and function. Previously sedentary elderly (age = 65 +/- 0.8 years) subjects were randomly assigned to supervised 3 time/week exercise intervention group (EXC, n = 14) or flexibility/toning control group (FT-CON, n = 15). Fasting resting blood samples were drawn prior to and after the 6 month intervention. The EXC group exhibited a significant (P < 0.05) 20% increase in VO2 max, whereas the FT-CON group had a smaller non-significant (P = 0.07) increase (9%). Immune results revealed that, in general, changes in immune function in response to 6 months of exercise training at an average intensity of 52% heart rate reserve (HRR) were similar when compared to FT-CON who exercised at approximately 21% HRR. There were no intervention-induced changes in total white blood cell, neutrophil, lymphocyte, monocyte, eosinophil, or basophil blood counts. Furthermore, the percentage and number of CD3+, CD4+ and CD8+ T cells in the blood remained unchanged. There was a tendency for the percentage and number of CD4+ and CD8+ näive cells (CD45RA+) to increase and for CD4+ memory cells (CD45RO+) to decrease post-intervention, especially in FT-CON. Both groups exhibited a small intervention-induced increase in the T-cell proliferative response to mitogenic stimulation: the percentage change of which was higher in the EXC group at several doses of Con A. Unstimulated NK cell cytolysis versus K562 cells tended to increase (P < 0.1) in the EXC group with little change in FT-CON. We conclude that 6 months of supervised exercise training can lead to nominal increases in some measures of immune function, while not affecting others, in previously sedentary elderly.

Effects of maximal exercise on natural killer (NK) cell cytotoxicity and responsiveness to interferon-alpha in the young and old

We investigated the effects of a graded maximal exercise treadmill test on natural killer (NK) cell number, activity, and responsiveness to interferon-alpha (IFN-alpha) in young (22+/-0.7 yrs) and elderly (65+/-0.8 yrs) sedentary subjects. NK cell cytotoxicity (NKCC) was determined using Ficoll purified peripheral blood mononuclear cells (PBMCs) by a 51Cr release assay against NK-sensitive (K562) and NK-insensitive (Daudi) target cells at various effector:target (E:T) ratios before and immediately after exercise. PBMCs were incubated with rhu IFN-alpha (125 and 250u/10(6) PBMCs) or without for 2 hrs before addition to the 51Cr release assay. There were no differences in unstimulated NKCC against K562 or Daudi targets between the old and the young despite significantly (p=.01) higher percentages of CD56+ NK cells (21.1+/-2.3% in old vs 12.5+/-2.5% in young, pre-exercise). IFN-alpha increased NKCC versus both targets, and NK cells from old subjects were hyporesponsive to IFN-alpha stimulation; this was especially evident at low E:T ratios versus Daudi cells. Maximal exercise significantly increased (50-200%) unstimulated NKCC versus K562 and Daudi targets similarly in both young and old and increased the percentage of CD56+ cells in the PBMC fraction to 33.3+/-3.7% and 23.3+/-3.6% in old and young, respectively. We found a significant correlation between %CD56+ and basal NKCC versus K562s and Daudi cells in the young (i.e., r=.55; p=.02 vs K562s), but not the old (i.e., r=.20; p=.29 vs K562s) subjects. This indicates that, in the young, part of the exercise-induced increase in NKCC is due to an increase in NK cell number. Maximal exercise did not affect unstimulated per cell killing of K562s, but tended to increase per cell killing of Daudis. These results indicate that CD56+ cells from old subjects have an intrinsic defect in their ability to perform cytolysis and respond to IFN-alpha. Furthermore, a single bout of maximal exercise increases NKCC and CD56+ cell number similarly in both young and old subjects regardless of the target cell used.

Predictors of the progression of renal insufficiency in patients with insulin-dependent diabetes and overt diabetic nephropathy. The Collaborative Study Group

We designed a prospective, double-blind controlled trial to determine predictors of loss of renal function in patients with insulin dependent diabetes and established nephropathy. A total of 409 insulin-dependent diabetic patients with established nephropathy enrolled in a trial on the effect of Captopril on the rate of progression of renal disease. Baseline demographic, clinical (history and physical) and laboratory parameters were analyzed as risk factors for time to progression. Dichotomous characteristics were compared by Fisher's exact test and continuous characteristics with the Wilcoxon rank-sum test. Univariate proportional hazards regression analysis was used to estimate relative risk of nephropathy progression, and bivariate proportional hazard regression to identify interactions with the treatment group assignment. Multivariate proportional hazard regression was employed to determine which characteristics were independent risk factors. We found that a number of demographic and clinical characteristics were significantly associated with nephropathy progression even after adjustment for treatment group. However, after multivariate analysis, the risk factors that independently predicted progression were onset of IDDM later in life, parental diagnosis of IDDM, the presence of edema, increased mean arterial pressure, and an abnormal electrocardiogram. Likewise, a number of laboratory characteristics were also predictive of nephropathy progression. A low hematocrit, high blood sugar, and higher protein excretion predicted nephropathy progression as did a higher serum creatinine, particularly in the face of a normal serum albumin. In conclusion, this study identifies a number of clinical and laboratory risk factors that can predict which patients with insulin-dependent diabetes with established nephropathy are more likely to sustain a clinically important decrease in renal function over a median follow-up of three years.

Emergency hormonal contraception usage in genitourinary medicine clinic attenders

OBJECTIVE

To assess the indications for usage of emergency hormonal contraception amongst a population of London genitourinary medicine clinic attenders.

METHODS

In a prospective study, 150 consecutive women receiving emergency hormonal contraception (EHC) were enrolled. The attending doctor completed a questionnaire of patient details and prescribed EHC with prophylactic prochlorperazine. Follow-up was arranged three weeks later, at which time outcomes and side-effects of therapy were recorded. For those women who did not reattended as planned case notes were reviewed at three months.

RESULTS

Of 150 women surveyed, 100 (66%) reported contraceptive method failure, 48 (32%) had used no contraception at the time of last sexual intercourse and two requested EHC after sexual assault. Ninety three (62%) reported condom failure, 7 (5%) oral contraceptive pill failure. Seventy five (50%) had used EHC before (range 1-10 times). Seventy one (47%) women reattended within three months. Five (3.3%) of the 150 women were pregnant; none of these cases had experienced nausea or vomiting whilst taking EHC. Side-effects were reported by 22 (31%) of the 71 patients who reattended. Nine (6%) women had been followed-up in the family planning advisory clinic. Of the 71 women who reattended, 39 (55%) reported that their preferred future method of contraception would be condoms. Of the 150 women 19 (13%) underwent tests for sexually transmissible infections within one month of presentation.

CONCLUSIONS

EHC usage in this population was associated with a failure rate of at least 3.3% and an overall side effect rate of 31%. Despite requests for emergency contraception because of condom failure many elected to continue using condoms as their preferred method of contraception. The majority of women (53%) did not return for follow-up or family planning advice, and so we believe that future contraceptive plans must be addressed at the time EHC is prescribed.

Determinants of preterm delivery in low-risk pregnancies. The RADIUS Study Group

From 14,948 low-risk singleton pregnancies, we calculated incidence, risk ratios, and attributable risks for characteristics associated with spontaneous and medically induced preterm delivery. There were 754 women who gave birth prior to 37 weeks of gestation (50.4/1000 deliveries). The greatest fraction of the incidence of prematurity among low-risk pregnancies was due to unknown factors associated with carrying a first live birth, regardless of preterm delivery mechanism (i.e., spontaneous labor, PROM, medical intervention), with population-attributable risk percents (PAR%) ranging from 16.0 to 30.5%. Other than nulliparity, male sex of the fetus accounted for the greatest fraction of spontaneous labor-induced prematurity incidence (PAR% = 13.6%), and maternal age greater than 30 years or a positive urine culture accounted for the greatest fraction of PROM-induced prematurity incidence (PAR% = 7.9 and 6.7, respectively). All other risk factors for either preterm labor or PROM accounted for less than 5% of the incidence. Three characteristics explained a large fraction of medically induced prematurity: women over 150 pounds at the onset of pregnancy (PAR% = 23.8), a > or = 2+ prenatal urine protein (PAR% = 18.7%), and cigarette smoking during the first trimester (PAR% = 8.6). Our results suggest known risk factors may explain only a small fraction of spontaneous preterm delivery incidence in low-risk pregnancies.

Incidence of symptomatic urinary tract infections in HIV seropositive patients and the use of cotrimoxazole as prophylaxis against Pneumocystis carinii pneumonia

OBJECTIVES

To determine the incidence of symptomatic urinary tract infections in HIV seropositive patients and to assess whether this varies with stage of disease, risk group or the use of co-trimoxazole as prophylaxis against Pneumocystis carinii pneumonia.

METHODS

A retrospective case note review of 175 HIV-infected patients attending The Royal London Hospital between July 1988 and December 1992 was performed. A urinary tract infection was defined as a pure culture of > or = 10(5) colony forming units in a mid-stream specimen of urine from a patient with symptoms consistent with a urinary tract infection.

RESULTS

Urinary tract infections occurred in 10 (5.7%) of 175 patients, with an incidence of 1.49 per hundred patient years. Urinary tract infections were significantly more common in patients with AIDS or a CD4 lymphocyte count below 0.2 x 10(9)/l (or both) when compared to those without AIDS and a CD4 lymphocyte count above 0.2 x 10(9)/l (5.4 vs. 0.5 urinary tract infections per hundred patient years, p = 0.00005). Women with AIDS or a CD4 count below 0.2 x 10(9)/l (or both) had an incidence of urinary tract infection of 18.5 per hundred patient years. No significant difference was found between the incidence of urinary tract infections in those taking co-trimoxazole as Pneumocystis carinii pneumonia prophylaxis and those taking alternative or no prophylaxis (2.6 vs 6.4 per hundred patient years, p = 0.39).

CONCLUSIONS

Urinary tract infection represents a considerable health problem amongst HIV infected patients. Our data show that urinary tract infections are more common in patients with advanced compared with early HIV infection. Cotrimoxazole, when taken by patients as prophylaxis against Pneumocystis carinii pneumonia did not appear to reduce the incidence of urinary tract infection.

Is smoking an indication for prenatal ultrasonography? RADIUS Study Group

OBJECTIVE

To evaluate whether ultrasound screening during pregnancy decreases the frequency of smoking in women who present with a history of smoking.

DESIGN

The Routine Antenatal Diagnostic Imaging with Ultrasound Study was a multicenter, randomized clinical trial of ultrasound screening during pregnancy. We obtained information on smoking habits during pregnancy from birth certificate records for the subset of women who were delivered of a neonate in Missouri hospitals, and determined the effect of ultrasound screening on smoking habits during pregnancy.

SETTING

The study was conducted in multiple practices in six states.

PARTICIPANTS

Women who registered for prenatal care at participating practices.

INTERVENTION

Women in the screened group were routinely scheduled for ultrasound screening at 16 to 22 weeks' gestation and at 31 to 35 weeks' gestation. Those in the control group received ultrasound screening only for medical indications, as determined by their physicians.

MAIN OUTCOME MEASURE

Smoking habits were measured by the number of cigarettes smoked per day.

RESULTS

There was no difference in the rates of smoking cessation between the screened group and the control group. For those who continued smoking, the mean number of cigarettes smoked per day, as reported at the time of delivery, was slightly higher in the screened group.

CONCLUSION

Ultrasound screening does not reduce the frequency of smoking during pregnancy.

Analgesia for the reduction of fractures in children: a comparison of nitrous oxide with intramuscular sedation

A prospective, randomized study was undertaken to compare the effectiveness of nitrous oxide with intramuscular sedation (meperidine and promethazine) in providing analgesia and amnesia during the reduction and treatment of children's fractures in an outpatient clinic setting. Fifteen patients received a 50:50 mixture of nitrous oxide and oxygen, and 15 received intramuscular injection. The two groups were similar in regard to gender distribution, age, and fracture types. Pain response was recorded using the Children's Hospital of Eastern Ontario (Canada) Pain Scale (CHEOPS) at the time of fracture reduction and 30 min postreduction. At the first follow-up visit a questionnaire regarding the patient's memory and subjective experience of the fracture reduction was answered. Data between the two groups were compared using the Mann-Whitney test. The CHEOPS scores, and the memory and subjective experience of the fracture reduction were similar between the two groups. Time in the outpatient department averaged 83 min for the intramuscular group and 30 min for the nitrous oxide group (p < 0.01). All of the nitrous oxide patients stated they would use nitrous oxide again, whereas only eight of 15 intramuscular patients stated they would try intramuscular sedation again. Nitrous oxide is as effective as intramuscular sedation in providing analgesia and amnesia in the treatment of children's fractures while having a more rapid onset and a shorter recovery period with greater patient acceptance.

Epidemiologic predictors of cesarean section in nulliparous patients at low risk. RADIUS Study Group. Routine Antenatal Diagnostic Imaging with Ultrasound Study

OBJECTIVES

We sought to determine whether certain maternal and fetal characteristics influenced the risk of maternal- and fetal-indicated cesarean sections in pregnant women at low risk for adverse perinatal outcomes.

STUDY DESIGN

From a cohort of 6393 low-risk nulliparous patients maternal and fetal indicated cesarean section rates with 95% confidence intervals were calculated and stratified by demographic, anthropometric, and clinical tests and measurements. The strongest risk factors were modeled by means of multiple logistic regression.

RESULTS

Few risk factors distinguished maternal from fetal characteristics preceding cesarean delivery. Maternal age was associated with increased cesarean section risk in the tallest group of women only, and cesarean section rates decreased with increasing height, increased with higher prepregnancy weights, and was highest in women carrying male fetuses. Higher first prenatal visit diastolic blood pressure, increasing numbers of nonstress tests, > or = 2+ prenatal urine protein, late sonograms, geographic region, and practice type were statistically significant risk factors as well. Interestingly, results of prenatal visit tests and measurements contributed less to the prevalence of cesarean section than did age, fetal sex, and anthropometric parameters. However, the generalizability of these results is limited to low-risk (predominantly white) populations.

CONCLUSIONS

Of the risk factors we were able to assess, a large proportion of the incidence of cesarean section in this population of nulliparous patients at low risk was attributable to age, sex of fetus, and anthropometric patient profiles.

A randomized trial of prenatal ultrasonographic screening: impact on the detection, management, and outcome of anomalous fetuses. The RADIUS Study Group

OBJECTIVE

The objective of this randomized clinical trial was to test the hypothesis that ultrasonographic screening would significantly alter perinatal outcome as a result of the antenatal detection of fetal congenital malformations.

STUDY DESIGN

Pregnant women without a specific indication for ultrasonography were randomly assigned to have either two screening sonograms (15 to 22 weeks and 31 to 35 weeks) or conventional obstetric care with ultrasonography used only as determined by the clinical judgment of the patient's physician. The frequency of birth defect detection in the screened and control populations was compared, as was the impact of discovery on pregnancy outcome.

RESULTS

Major congenital malformations occurred in 2.3% of the 15,281 fetuses and infants in this study. Antenatal ultrasonography detected 35% of the anomalous fetuses in the screened group versus only 11% in the control population (relative detection rate 3.1; 95% confidence interval 2.0 to 5.1). Ultrasonography screening did not, however, significantly influence the management or outcome of pregnancies complicated by congenital malformations. Specifically, only 9 abortions were performed for anomalies among 7685 fetuses in the screened group whereas 4 pregnancies were terminated for fetal anomalies detected among 7596 control subjects. Ultrasonography screening also had no significant impact on survival rates among infants with potentially treatable, life-threatening anomalies despite the opportunity to take precautionary measures such as delivery in a tertiary center.

CONCLUSIONS

Ultrasonography screening in a low-risk pregnant population had no significant impact on the frequency of abortion for fetal anomalies. Survival rates for anomalous fetuses were also unaffected by screening.

Biometric measurements in fetuses of different race and gender

Sonographic fetal biometric measurements on 6082 low-risk patients were compared in the second and third trimesters of pregnancy with respect to fetal race and gender. Ultrasonic measurements were obtained from fetuses of women participating in the Routine Antenatal Diagnostic Imaging with Ultrasound Study (RADIUS), who underwent both an early sonographic evaluation between 15 and 22 weeks' gestation and a later scan between 31 and 35 weeks' gestation. In the 16-21-week scans, male fetuses had significantly larger biparietal diameter measurements compared to female fetuses (estimated difference 0.852 mm, 95% CI 0.737-0.967). There was only minimal difference in biparietal diameter between Black and White fetuses. Femur length was similar in both female and male fetuses, but longer in Black compared to White fetuses (estimated difference 0.808 mm, 95% CI 0.539-1.078). During the 31-35-week scans, male fetuses continued to have larger biparietal diameter measurements compared to female fetuses (estimated difference 1.22 mm, 95% CI 1.04-1.40), and femur lengths were persistently longer in Black compared to White fetuses (estimated difference 0.563 mm, 95% CI 0.234-0.893). Further investigation is necessary to evaluate the effect of these slight differences in morphometric fetal measurements between races and genders, so that we can determine how best to use them for optimizing prenatal care.

Attitudes of medical students to HIV and AIDS

OBJECTIVE--To assess the knowledge and attitudes of medical students to HIV/AIDS and whether attitudes correlate with knowledge and clinical experience. To determine if students felt adequately prepared to deal with medical and psychological aspects of HIV/AIDS. SUBJECTS AND METHODS--The subjects consisted of 190 London and 99 Cambridge medical students at the end of their genitourinary medicine attachment, plus 230 Cambridge medical students at the end of their second pre-clinical year. Between March 1991 and February 1992 all were asked to complete an anonymous questionnaire, covering factual knowledge and attitudes towards HIV/AIDS. MAIN RESULTS--Cambridge genitourinary medicine students, despite spending less time studying HIV infection than their London counterparts gave more correct answers to the factual questions, although this difference did not reach significance (52.4% vs. 47.5%, p = 0.14). One third of students believed that many health care workers were at high risk of acquiring HIV at work and one fifth thought doctors should have the right to refuse to treat people with HIV. Fourteen percent of Cambridge genitourinary medicine students indicated that most British people with HIV have only themselves to blame, by comparison with 4% of London students (p = 0.003). Thirty-nine per cent of Cambridge genitourinary medicine students expressed reluctance to care for someone with AIDS by comparison with 10% of London students (p = 0.0001). CONCLUSIONS--It is important that medical educators convey accurate information about HIV, including the actual risks posed by occupational exposure and try to ensure that medical students spend sufficient time seeing patients with HIV/AIDS during their training.

Leukemic infiltration of the esophagus

BACKGROUND

Leukemic infiltrates of the esophagus have been described occasionally in autopsy series, but there are no reports of antemortem diagnosis.

METHODS

Case reports are presented for three patients with acute myeloid leukemia in whom leukemic infiltration of the esophageal mucosa was diagnosed histologically and cytologically by endoscopic examination. Autopsies of patients with leukemia from 1976-1988 were reviewed.

RESULTS

The autopsy review of 207 patients with leukemia showed evidence of leukemic infiltration in the esophagus in 7.2% of cases. The only clinical factor identified to be significantly associated with esophageal involvement by leukemic cells was a high initial leukocyte count. Esophageal involvement was associated with leukemic infiltration of other soft tissues and organs.

CONCLUSIONS

Although the etiology of dysphagia in patients with acute leukemia is usually related to infection, reflux, chemotherapy toxicity, or benign strictures, the frequency of esophageal leukemic infiltration in this autopsy series suggests that this diagnosis must be considered. Esophageal leukemia is usually associated with widely disseminated soft tissue and visceral infiltrates.

Leukapheresis induced changes in cell cycle distribution and nucleoside transporters in patients with untreated acute myeloid leukemia

Bone marrow leukemia cells from eight adults with untreated acute myeloid leukemia (AML) were evaluated before and after three daily leukaphereses to determine if mechanical cytoreduction can modulate the cell cycle distribution. The percentage of cells in S-phase and the proliferative fraction (PF = %S + %G2M) were determined by flow cytometry after dual labeling with bromodeoxyuridine and propidium iodide. Prior to pheresis the median %S and PF were 5.4 and 15.4%, respectively. The median change in %S was +2.5% (range -5.5 to +18.8) with increases greater than or equal to 3.7% in 4/8 patients. The median change in PF was +6.1% (range -13.8 to +25.3) with an increase of greater than or equal to 3.6% in 6/8 patients. The median absolute changes of 2.5 and 6.1% represent increases of 47% for %S and 40% for PF compared to the day 1 (pre-pheresis) median values. As the number of nucleoside transporters in the cell membrane [nitrobenzylmercaptopurine riboside (NBMPR) binding sites] has been related to the percentage of cells in S-phase and to cytosine arabinoside (ara-C) cellular pharmacology, these were also measured before and after leukapheresis. Changes in the number of NBMPR binding sites varied widely with a median increase of 365 sites per cell (range -26,061 to +10,396). The change in NBMPR sites was significantly and positively correlated with changes in %S (r = 0.829, p = 0.042). These data suggest that mechanical cytoreduction by leukapheresis can increase the fraction of leukemia cells in S-phase and the PF in some patients with AML. The increase in %S is accompanied by an increase in NBMPR binding sites per cell. These changes in leukemia cell characteristics would be expected to result in an increase in efficacy of ara-C or other S-phase specific agents.

Oestrogen-induced changes in renal haemodynamics in the rat: influence of plasma and intrarenal renin

The effect of oestrone acetate (in total doses of 5 and 10 mg) on systemic and renal haemodynamics and the renin-angiotensin system has been studied in adult female rats. The administration of 10 mg of oestrogen resulted in a significant fall in renal blood flow associated with significant rises in both renal vascular resistance and mean arterial pressure. No changes were noted in cardiac output or total peripheral resistance at either dose. Whilst the higher dose of oestrogen induced a significant increase in plasma renin activity, no change was noted in animals receiving 5 mg of oestrogen. Both regimens caused significant reductions in plasma and intrarenal renin concentrations. Although renal blood flow correlated with plasma renin activity in animals with a normal renal blood flow, no such correlation was noted in animals with oestrogen-induced reductions in renal blood flow. The present study demonstrates that oestrogen-induced reductions in renal blood flow result from a rise in intrarenal vascular resistance which cannot be accounted for by simultaneous changes in either plasma renin activity or renal renin concentration.