Doses of medial rectus muscle recessions for divergence insufficiency-type esotropia

We evaluated whether doses of bilateral medial rectus recessions greater than Parks's tables yielded superior outcomes for adult-onset divergence insufficiency. Forty-two patients underwent bilateral medial rectus recessions. Dose was analyzed as the average total per muscle (surgery + suture adjustment if performed) and compared with the standard dose tables (based on preoperative distance esodeviation), as difference between dose performed and dose indicated by Parks's tables. Each participant was classified as having received either Parks's dose (within 0.5 mm) or a dose greater than Parks's dose. Success was defined as "rarely" or "never" diplopia in distance straight-ahead gaze and reading. For patients classified as success, the mean difference between actual surgical dose performed and Parks's dose was calculated. Success was 91% (29/32) in those receiving greater than Parks's dose versus 67% (6/9) with Parks's dose (difference = 24%; 95% CI, -5% to 60%). The mean surgical dose was 1.0 mm greater than Parks's tables for the 35 successes (at 10 weeks) versus 0.7 mm greater for the 6 failures (difference = 0.4 mm; 95% CI, -0.2 to 0.9). For medial rectus recessions in adult-onset divergence insufficiency-type esotropia, a surgical dose 1 mm greater than Parks's tables, for each muscle, is a reasonable strategy.

Low-Dose 0.01% Atropine Eye Drops vs Placebo for Myopia Control: A Randomized Clinical Trial

Importance

Controlling myopia progression is of interest worldwide. Low-dose atropine eye drops have slowed progression in children in East Asia.

Objective

To compare atropine, 0.01%, eye drops with placebo for slowing myopia progression in US children.

Design, Setting, and Participants

This was a randomized placebo-controlled, double-masked, clinical trial conducted from June 2018 to September 2022. Children aged 5 to 12 years were recruited from 12 community- and institution-based practices in the US. Participating children had low to moderate bilateral myopia (-1.00 diopters [D] to -6.00 D spherical equivalent refractive error [SER]).

Intervention

Eligible children were randomly assigned 2:1 to 1 eye drop of atropine, 0.01%, nightly or 1 drop of placebo. Treatment was for 24 months followed by 6 months of observation.

Main Outcome and Measures

Automated cycloplegic refraction was performed by masked examiners. The primary outcome was change in SER (mean of both eyes) from baseline to 24 months (receiving treatment); other outcomes included change in SER from baseline to 30 months (not receiving treatment) and change in axial length at both time points. Differences were calculated as atropine minus placebo.

Results

A total of 187 children (mean [SD] age, 10.1 [1.8] years; age range, 5.1-12.9 years; 101 female [54%]; 34 Black [18%], 20 East Asian [11%], 30 Hispanic or Latino [16%], 11 multiracial [6%], 6 West/South Asian [3%], 86 White [46%]) were included in the study. A total of 125 children (67%) received atropine, 0.01%, and 62 children (33%) received placebo. Follow-up was completed at 24 months by 119 of 125 children (95%) in the atropine group and 58 of 62 children (94%) in the placebo group. At 30 months, follow-up was completed by 118 of 125 children (94%) in the atropine group and 57 of 62 children (92%) in the placebo group. At the 24-month primary outcome visit, the adjusted mean (95% CI) change in SER from baseline was -0.82 (-0.96 to -0.68) D and -0.80 (-0.98 to -0.62) D in the atropine and placebo groups, respectively (adjusted difference = -0.02 D; 95% CI, -0.19 to +0.15 D; P = .83). At 30 months (6 months not receiving treatment), the adjusted difference in mean SER change from baseline was -0.04 D (95% CI, -0.25 to +0.17 D). Adjusted mean (95% CI) changes in axial length from baseline to 24 months were 0.44 (0.39-0.50) mm and 0.45 (0.37-0.52) mm in the atropine and placebo groups, respectively (adjusted difference = -0.002 mm; 95% CI, -0.106 to 0.102 mm). Adjusted difference in mean axial elongation from baseline to 30 months was +0.009 mm (95% CI, -0.115 to 0.134 mm).

Conclusions and Relevance

In this randomized clinical trial of school-aged children in the US with low to moderate myopia, atropine, 0.01%, eye drops administered nightly when compared with placebo did not slow myopia progression or axial elongation. These results do not support use of atropine, 0.01%, eye drops to slow myopia progression or axial elongation in US children.

Trial Registration

ClinicalTrials.gov Identifier: NCT03334253.

Plasma Levels of Bevacizumab and Vascular Endothelial Growth Factor After Low-Dose Bevacizumab Treatment for Retinopathy of Prematurity in Infants

Importance

Intravitreal bevacizumab effectively treats severe retinopathy of prematurity (ROP), but it enters the bloodstream and may reduce serum vascular endothelial growth factor (VEGF), potentially causing detrimental effects on developing organs in the premature infant.

Objective

To evaluate the association of intravitreal bevacizumab with plasma bevacizumab and VEGF concentrations at 2 and 4 weeks after predefined, de-escalating doses of intravitreal bevacizumab were administered to infants with severe ROP.

Design, Setting, and Participants

This phase 1 dose de-escalation case series study was conducted at 10 US hospitals of ophthalmology institutions from May 21, 2015, to May 7, 2019. Blood samples were collected 2 and 4 weeks after intravitreal bevacizumab injection. Participants included 83 premature infants with type 1 ROP in 1 or both eyes and no previous ROP treatment. Data were analyzed from April 2017 to August 2021.

Interventions

Study eyes received a single bevacizumab injection of 0.250 mg, 0.125 mg, 0.063 mg, 0.031 mg, 0.016 mg, 0.008 mg, 0.004 mg, or 0.002 mg. When the fellow eye required treatment, one dose higher was administered. Total dose administered at baseline was defined as the sum of doses given to each eye within 3 days of initial study-eye injection.

Main Outcomes and Measures

Plasma bevacizumab concentration at 2 and 4 weeks after injection and the percentage change in plasma VEGF concentrations from pretreatment levels.

Results

A total of 83 infants (mean [SD] age, 25 [2] weeks; 48 boys [58%]) were included in this study. Higher doses of bevacizumab administered at baseline were associated with higher plasma bevacizumab concentrations at 2 weeks (ρ, 0.53; 95% CI, 0.31-0.70) and 4 weeks (ρ, 0.44; 95% CI, 0.18-0.64). Plasma VEGF concentrations decreased by 50% or more from pretreatment levels in 40 of 66 infants (61%) at 2 weeks and 31 of 61 infants (51%) at 4 weeks, but no association was observed between the total dose of bevacizumab administered at baseline and percentage change in plasma VEGF concentrations 2 weeks (ρ, -0.04; 95% CI, -0.28 to 0.20) or 4 weeks (ρ, -0.17; 95% CI, -0.41 to 0.08) after injection.

Conclusions and Relevance

Results of this phase 1 dose de-escalation case series study revealed that bevacizumab doses as low as 0.002 mg were associated with reduced plasma VEGF levels for most infants at 2 and 4 weeks after intravitreal administration; however, no association was observed between total bevacizumab dose administered and reductions in plasma VEGF levels from preinjection to 2 weeks or 4 weeks. Additional studies are needed to evaluate the long-term effects of low-dose bevacizumab on neurodevelopment and retinal structure.

Antibiotic-exposed patients with non-small-cell lung cancer preserve efficacy outcomes following first-line chemo-immunotherapy

BACKGROUND

Prior antibiotic therapy (pATB) is known to impair efficacy of single-agent immune checkpoint inhibitors (ICIs), potentially through the induction of gut dysbiosis. Whether ATB also affects outcomes to chemo-immunotherapy combinations is still unknown.

PATIENTS AND METHODS

In this international multicentre study, we evaluated the association between pATB, concurrent ATB (cATB) and overall survival (OS), progression-free survival (PFS) and objective response rate (ORR) in patients with non-small-cell lung cancer (NSCLC) treated with first-line chemo-immunotherapy at eight referral institutions.

RESULTS

Among 302 patients with stage IV NSCLC, 216 (71.5%) and 61 (20.2%) patients were former and current smokers, respectively. Programmed death-ligand 1 tumour expression in assessable patients (274, 90.7%) was ≥50% in 76 (25.2%), 1%-49% in 84 (27.9%) and <1% in 113 (37.5%). Multivariable analysis showed pATB-exposed patients to have similar OS {hazard ratio (HR) = 1.42 [95% confidence interval (CI): 0.91-2.22]; P = 0.1207} and PFS [HR = 1.12 (95% CI: 0.76-1.63); P = 0.5552], compared to unexposed patients, regardless of performance status. Similarly, no difference with respect to ORR was found across pATB exposure groups (42.6% versus 57.4%, P = 0.1794). No differential effect was found depending on pATB exposure duration (≥7 versus <7 days) and route of administration (intravenous versus oral). Similarly, cATB was not associated with OS [HR = 1.29 (95% CI: 0.91-1.84); P = 0.149] and PFS [HR = 1.20 (95% CI: 0.89-1.63); P = 0.222] when evaluated as time-varying covariate in multivariable analysis.

CONCLUSIONS

In contrast to what has been reported in patients receiving single-agent ICIs, pATB does not impair clinical outcomes to first-line chemo-immunotherapy of patients with NSCLC. pATB status should integrate currently available clinico-pathologic factors for guiding first-line treatment decisions, whilst there should be no concern in offering cATB during chemo-immunotherapy when needed.

P–153 Comparison outcome of vitrified human embryos stored in vapor phase liquid nitrogen (LN2) and direct LN2

Study question

Is vapor cryopreserved LN2 storage beneficial for clinical outcomes of vitrified human embryos that are frozen compared to vitrified human embryos having direct contact with LN2.

Summary answer

There are no significant differences compared to clinical outcomes of human embryos stored in LN2 vapor and direct store in LN2.

What is known already

There has been concerned about potential cross-contamination and biohazard issues of embryos for long term storage using direct LN2. This study aimed to compare clinical outcomes of human embryos transfer between vapor phase and liquid LN2.

Study design, size, duration

The embryo has undergone vitrification for long term storage with vapor or direct contact in LN2. After the thawing of the embryo, we checked on the survival rates. We transferred only one or two embryos per patient and kept analyzing the implantation and pregnancy rates

Participants/materials, setting, methods

This retrospective study was carried out from January 2018 to December 2019 with 3272cycles 4713embryos; vitrified for long term storage in vapor phase or direct contact with LN2. We compared the clinical outcomes of frozen embryo transfer cycles using vitrified for long term storage in vapor phase and direct contact with LN2. Clinical outcomes monitored were embryo survival, subsequent implantation and pregnancy after single or double embryo transfer

Main results and the role of chance

A total of 4713 fertilized human embryos are vitrified and then stored in LN2 vapor (n = 2520 cycles) or direct contact LN2 (n = 752 cycles). The study showed that the blastocyst stored in vapor able to retain full development. Survival was 97.8% (vapor) and 97.6% (direct contact LN2), and the vapor storage of human embryos had no significant difference in survival rates after a long term storage. For single blastocyst transfer, pregnancy and implantation rates were 51.5%, 52.4% in vapor, 54.6%, 54.9% in direct LN2; respectively (p=NS). In double blastocyst transfer, the pregnancy and implantation rates were 61.8%, 42.0% in vapor and 64.7%, 44.5% in direct LN2; respectively (p=NS). There were also no significant differences between two groups.

Limitations, reasons for caution

The study showed that the blastocyst stored in vapor can retain full development. A vapor storage system thus is safe and effective for long term vapor storage of vitrified human embryos.Within the limits of this study, there was no detection of an adverse effect of vapor storage.

Wider implications of the findings: Vapor storage systems thus represent a useful alternative for safe and effective long-term storage of vitrified human embryos that can avoid cross contamination chances from having direct contact with LN2.

Trial registration number

Not applicable

A prospective study of treatments for adult-onset divergence insufficiency-type esotropia

PURPOSE

To describe 10-week and 12-month outcomes following treatment for divergence insufficiency-type esotropia in adults.

METHODS

In this prospective observational study, 110 adults with divergence insufficiency-type esotropia, with a distance esodeviation measuring 2^Δ to 30^Δ and at least 25% larger at distance than near, and binocular diplopia present at least "sometimes" at distance, were enrolled at 28 sites when initiating new treatment. Surgery, prism, or divergence exercises/therapy were chosen at the investigator's discretion. Diplopia was assessed at enrollment and at 10-week and 12-month outcome examinations using a standardized diplopia questionnaire (DQ). Success was defined as DQ responses of "rarely" or "never" when looking straight ahead in the distance, with no alternative treatment initiated.

RESULTS

Of the 110 participants, 32 (29%) were prescribed base-out prism; none had received prior treatment for esotropia. Success criteria were met by 22 of 30 at 10 weeks (73%; 95% CI, 54%-88%) and by 16 of 26 at 12 months (62%; 95% CI, 41%-80%). For the 76 (68%) who underwent strabismus surgery (82% of whom had been previously treated with prism), success criteria were met by 69 of 74 at 10 weeks (93%; 95% CI, 85%-98%) and by 57 of 72 at 12 months (79%; 95% CI, 68%-88%).

CONCLUSIONS

In this study cohort, both base-out prism as initial therapy and strabismus surgery (usually following prism) were successful in treating diplopia for most adults with divergence insufficiency-type esotropia when assessed during the first year of follow-up.

The gut microbiome: what the oncologist ought to know

The gut microbiome (GM) has been implicated in a vast number of human pathologies and has become a focus of oncology research over the past 5 years. The normal gut microbiota imparts specific function in host nutrient metabolism, xenobiotic and drug metabolism, maintenance of structural integrity of the gut mucosal barrier, immunomodulation and protection against pathogens. Strong evidence is emerging to support the effects of the GM on the development of some malignancies but also on responses to cancer therapies, most notably, immune checkpoint inhibition. Tools for manipulating the GM including dietary modification, probiotics and faecal microbiota transfer (FMT) are in development. Current understandings of the many complex interrelationships between the GM, cancer, the immune system, nutrition and medication are ultimately based on a combination of short‐term clinical trials and observational studies, paired with an ever-evolving understanding of cancer biology. The next generation of personalised cancer therapies focusses on molecular and phenotypic heterogeneity, tumour evolution and immune status; it is distinctly possible that the GM will become an increasingly central focus amongst them. The aim of this review is to provide clinicians with an overview of microbiome science and our current understanding of the role the GM plays in cancer.

144 Probable Delirium is A Presenting Symptom of COVID-19 in Frail, Older Adults: A Study of Hospitalised and Community-Based Cohorts

Introduction

COVID-19 exhibits a more severe disease course in older adults with frailty. Awareness of atypical presentations is critical to facilitate early disease identification. This study aimed to assess how frailty affects presenting symptoms of COVID-19 in older adults.

Methods

Observational study of two distinct cohorts: (i) Hospitalised patients aged 65 and over; unscheduled admission to a large London teaching hospital between March 1st, 2020-May 5th, 2020; COVID-19 confirmed by RT-PCR of nasopharyngeal swab (n = 322); (ii) Community-based adults aged 65 and over enrolled in the COVID Symptom Study mobile application between March 24th (application launch)-May 8th, 2020; self-report or report-by-proxy data; reported test-positive for COVID-19 (n = 535). Multivariable logistic regression analysis performed on age-matched samples of both cohorts to determine associations between frailty and symptoms of COVID-19 including delirium, fever and cough.

Results

Hospital cohort: there was a significantly higher prevalence of delirium amongst the frail sample, with no difference in fever or cough. Of those presenting with delirium, 10/53 (18.9%) presented with delirium as the only documented symptom. Community-based cohort: there was a significantly higher prevalence of probable delirium in the frail sample, and also of fatigue and shortness of breath. Of those reporting probable delirium, 28/84 (33%) did not report fever or cough.

Conclusions

This study demonstrates a higher prevalence of delirium as a presenting symptom of COVID-19 infection in older adults with frailty compared to their age-matched non-frail counterparts. Clinicians should suspect COVID-19 in frail older adults presenting with delirium. Early detection facilitates infection control measures to mitigate against catastrophic spread and preventable hospitalisations and deaths amongst this population. Our findings emphasise the need for systematic frailty assessment for all acutely ill older patients in both hospital and community settings, as well as systematic evaluation of any change in mental status.

Myocardial extracellular space expansion is related to burden of premature ventricular contractions in patients with hypertrophic cardiomyopathy without non-sustained ventricular tachycardia

Funding Acknowledgements

Type of funding sources: None.

Background

Current guidelines suggest the presence of non-sustained ventricular tachycardia (NSVT) as a risk factor of sudden cardiac death in patients with hypertrophic cardiomyopathy (HCM). However, high burden of premature ventricular contraction (PVC) may reflect myocardial fibrosis although the absence of NSVT.

Purpose

We investigated the association between PVC burden and myocardial extracellular space expansion in HCM patients without NSVT.

Methods

Of the 212 patients prospectively enrolled to the HCM registry of genetics, 84 patients were evaluated with both cardiac magnetic resonance and 24hr holter. Among them, 71 patients (58 males, mean age: 71 ± 13 years) have not been diagnosed with NSVT.

Results

Patients with NSVT (n = 13) showed more impaired LA functional indices and higher myocardial fibrosis burden compared with patients without NSVT (n = 71). Among patients who have not been diagnosed with NSVT, patients with late gadolinium enhancement (LGE, n = 46) had a higher total beats (109 ± 332 vs. 7 ± 13 beats per a day, p = 0.003) and burden (0.114 ± 0.225 vs. 0.008 ± 0.014 %, p = 0.003) of PVC during 24-hour compared with patients without LGE (n = 25). %LGE was correlated with total beats of PVC (r = 0.358, p = 0.002) and PVC burden (r = 0.377, p = 0.001). ECV also correlated with total beats of PVC (r = 0.387, p = 0.001) and PVC burden (r = 0.401, p = 0.001). The optimal cutoff value for PVC number was 45 (37.0% of sensitivity and 100% of specificity) with 0.733 of the area under the ROC curve (p &lt; 0.001). Pathogenic or likely pathogenic sarcomere mutation was higher in NSVT group than no NSVT group (p &lt; 0.05), and had a higher tendency in higher PVC burden group (0.05 &lt; p &lt; 0.1) than lower PVC burden group.

Conclusions

Total beats and burden of PVC are significantly related to increase in myocardial fibrosis in HCM patients without NSVT.

Abstract Figure. Mechanism of ventricular arrhythmia

Vaginal compared with intramuscular progestogen for preventing preterm birth in high-risk pregnant women (VICTORIA study): a multicentre, open-label randomised trial and meta-analysis

OBJECTIVE

To compare the efficacy of two types of progestogen therapy for preventing preterm birth (PTB) and to review the relevant literature.

DESIGN

A multicentre, randomised, open-label, equivalence trial and a meta-analysis.

SETTING

Tertiary referral hospitals in South Korea.

POPULATION

Pregnant women with a history of spontaneous PTB or short cervical length (<25 mm).

METHODS

Eligible women were screened and randomised at 16-22 weeks of gestation to receive either 200 mg of vaginal micronised progesterone daily (vaginal group) or an intramuscular injection of 250 mg 17α-hydroxyprogesterone caproate weekly (IM group). Stratified randomisation was carried out according to participating centres and indications for progestogen therapy. This trial was registered at ClinicalTrials.gov (NCT02304237).

MAIN OUTCOME MEASURE

Preterm birth (PTB) before 37 weeks of gestation.

RESULTS

A total of 266 women were randomly assigned and a total of 247 women (119 and 128 women in the vaginal and IM groups, respectively) were available for the intention-to-treat analysis. Risks of PTB before 37 weeks of gestation did not significantly differ between the two groups (22.7 versus 25.8%, P = 0.571). The difference in PTB risk between the two groups was 3.1% (95% CI -7.6 to 13.8%), which was within the equivalence margin of 15%. The meta-analysis results showed no significant differences in the risk of PTB between the vaginal and IM progestogen treatments.

CONCLUSION

Compared with vaginal progesterone, treatment with intramuscular progestin might increase the risk of PTB before 37 weeks of gestation by as much as 13.8%, or reduce the risk by as much as 7.6%, in women with a history of spontaneous PTB or with short cervical length.

TWEETABLE ABSTRACT

Vaginal and intramuscular progestogen showed equivalent efficacy for preventing preterm birth before 37 weeks of gestation.

Proton therapy in paediatric oncology: an Irish perspective

BACKGROUND

Proton therapy (PT) is a radiotherapy treatment modality that uses protons, rather than conventional photons. PT is often used in paediatric oncology due to its reported capability to reduce acute and late adverse treatment effects. As PT is unavailable in Ireland, patients are referred abroad for treatment.

AIMS

To: (1) produce a descriptive study of Irish children referred abroad for PT, and (2) discuss the case for PT in general.

METHODS

A retrospective review of all children referred for PT before October 2015 was performed. Information was gathered regarding demographics, diagnosis, referral timeline, adverse effects attributable to PT, current status and cost. A review of the relevant literature was performed.

RESULTS

Seventeen children treated in Ireland have been referred abroad for PT. The largest number was in the 0-4 year old group. At initial diagnosis the median age was 4.8 years. The average cost per child was €37,312. Two patients suffered disease relapse. Four have encountered PT-related adverse effects.

CONCLUSION

Despite the fact that >100,000 patients worldwide have been treated with PT, the level of published evidence to support superiority over conventional treatment remains low. It is debated that randomised control trials in this area would be inconsistent with the principle of clinical equipoise. In contrast, there is a call for level 1 evidence to justify drastic changes in patient care, particularly in light of recent reports of unexpected toxicities. In time, careful evaluation, follow-up and clinical trials will likely support the preferential use of PT in children.

THE INFLUENCE OF TOTAL OR SUB-TOTAL GASTRECTOMY ON GLUCOSE CONTROL IN DIABETIC AND NON-DIABETIC PATIENTS

Objective

Although bariatric surgery including gastrectomy has recently emerged as a useful treatment for type 2 DM with obesity, it is not clear whether gastrectomy itself can have beneficial effects on glucose metabolism. Therefore, in this study, we investigated changes in blood glucose in patients with and without diabetes who underwent gastrectomy.

Methods

From Jan 2010 to May 2014, 77 patients with diabetes and 77 patients without diabetes who underwent gastrectomy at Chonbuk National University Hospital, South Korea, were included. We compared fasting plasma glucose levels and HbA1c value before and after gastric surgery.

Results

After gastrectomy, 59 patients (38.3%) showed reduced fasting plasma glucose levels at the 1 year point, and 80 patients (51.9%) exhibited reduced fasting plasma glucose at 3 years, irrespective of their diabetes status. Among 77 patients with diabetes, decreased fasting plasma glucose was observed in 22 (28.6%) and 46 patients (59.7%) 1 and 3 years after gastrectomy, respectively. In patients who exhibited reduced fasting plasma glucose after gastrectomy, the degree of reduced glucose was as follows: 56.4±48.5 vs 23.2±16.1 mg/dL after 1 year, 58.3±52.3 vs 18.4±13.7 mg/dL after 3 years, in DM and non-DM patient respectively.

Conclusions

Although there was a significant drop in mean fasting glucose after gastrectomy, not all patients experienced a drop in fasting glucose. Gastrectomy did not show a consistent association with glucose reduction in patients with and without diabetes, and in about half of the patients, fasting plasma glucose levels increased after gastrectomy. Therefore, bariatric surgery including gastrectomy needs to be performed with care in diabetes, and glucose monitoring including oral glucose tolerance tests should be done for assessing or prediction of the glucose state after gastric surgery in non-DM patients.

Tonic pupil after botulinum toxin-A injection for treatment of esotropia in children

A total of 27 children with esotropia (mean age, 3.9 years; range, 9 months to 13.8 years) were enrolled in a 9-month observational study following botulinum toxin A (BTX-A) injection of one (n = 7) or both (n = 20) medial rectus muscles. BTX-A dosage ranged from 3.0 to 6.0 units per muscle. Three participants developed tonic pupil, noted at the first follow-up visit, occurring 12-19 days after injection. All 3 cases occurred in the left eye of participants who underwent bilateral BTX-A injection by the same surgeon. Anisocoria diminished from a maximum of 4 mm at the 2-week visit to 1-2 mm in all patients over the 9-month postinjection data collection period. No adverse visual outcomes were noted. Tonic pupil is an infrequently reported complication of BTX-A injection for strabismus. The experience of our investigator group suggests the need for careful injection technique and thorough preinjection counseling.

Systemic LPS and inflammatory response during consecutive days of exercise in heat

This investigation studied circulating LPS activity, potential intestinal damage, and the systemic inflammatory response (SIR) during the exercise heat acclimation process. 8 healthy males (Age=24±3 years) ran in a hot environment on 5 consecutive days until core temperature (Tc) was elevated 2°C above rest. Plasma was obtained pre-, post-, 1 h post-, and 3 h post-exercise on the 1(st), 3(rd), and 5(th) day of exercise and analyzed for TNF-α, IL-6, IL-10, IL-1ra, LPS, and intestinal fatty acid-binding protein (I-FABP). Plasma LPS (1.1 EU·ml(-1)±0.1 vs. 0.7 EU·ml(-1)±0.03; P<0.01) and I-FABP (930.7 pg·ml(-1)±149.0 vs. 640.2 pg·ml(-1)±125.0; P<0.001) were significantly increased post-exercise each. The SIR remained largely unchanged during the study except for TNF-α. Plasma TNF-α was significantly lower on Day 5 at 1 h (3.2 pg·ml(-1)±0.6 vs. 4.5 pg·ml(-1)±0.8; P=0.01) and 3 h (3.6 pg·ml(-1)±0.8 vs. 4.8 pg·ml(-1)±0.9; P=0.05) post-exercise as compared to Day 1. Findings indicate that adaptations to exercise in the heat resulting in reductions of intestinal damage and plasma LPS activity require longer time periods in moderately trained males.

Short communication: antiviral activity of subcritical water extract of Brassica juncea against influenza virus A/H1N1 in nonfat milk

Subcritical water extract (SWE) of Brassica juncea was studied for antiviral effects against influenza virus A/H1N1 and for the possibility of application as a nonfat milk supplement for use as an "antiviral food." At maximum nontoxic concentrations, SWE had higher antiviral activity against influenza virus A/H1N1 than n-hexane, ethanol, or hot water (80°C) extracts. Addition of 0.5mg/mL of B. juncea SWE to culture medium led to 50.35% cell viability (% antiviral activity) for Madin-Darby canine kidney cells infected with influenza virus A/H1N1. Nonfat milk supplemented with 0.28mg/mL of B. juncea SWE showed 39.62% antiviral activity against influenza virus A/H1N1. Thus, the use of B. juncea SWE as a food supplement might aid in protection from influenza viral infection.

Office probing for treatment of nasolacrimal duct obstruction in infants

PURPOSE

To determine whether demographic or clinical factors are associated with the outcome of office-based nasolacrimal duct probing for the treatment of congenital nasolacrimal duct obstruction (NLDO).

METHODS

In two multicenter prospective studies, 384 eyes of 304 children aged 6 to <15 months with NLDO underwent a nasolacrimal duct probing performed in the office using topical anesthesia. Treatment success, defined as no clinical signs of NLDO (epiphora, increased tear lake, or mucous discharge) and no reoperation, was assessed 1 month after probing in one study and 6 months after probing in the other study. Data from both studies were pooled to evaluate associations between baseline characteristics and treatment success.

RESULTS

Office probing was successful in 75% of eyes overall (95% CI, 70%-80%). The procedure was less successful in eyes of children with bilateral NLDO compared with unilateral NLDO (63% vs 80%; relative risk = 0.78 [95% CI, 0.66-0.92]) and in eyes that had 2 or 3 clinical signs of NLDO compared with one (71% vs 83%; relative risk = 0.88 [95% CI, 0.81-0.96]). Treatment success did not appear to be related to age, specific clinical signs of NLDO, prior treatment, or research study.

CONCLUSIONS

Performing nasolacrimal duct probing in the office successfully treats NLDO in the majority of cases in children aged 6 to <15 months. The success rate is lower with bilateral disease or when more than one clinical sign of NLDO is present.

Post breast conservation therapy imaging and local recurrence

Breast conservation therapy, which includes lumpectomy usually followed by breast irradiation, is an effective and commonly used therapy for women with resectable breast cancers. Although the rate of local recurrence has decreased over the years, these women continue to be at risk with an overall incidence of local recurrence of 1-2% per year for 10 years. The incidence of local recurrence varies according to age and receptor status. Studies have shown that early detection of in breast recurrence or second primaries reduces mortality. Mammography and clinical breast examination can be effective in the detection of recurrence. The efficacy of mammography, recommended intervals for screening and the various mammographic appearances of recurrence are addressed in this paper. Other breast imaging modalities including breast ultrasound and breast magnetic resonance imaging have less of a defined role. There is little data on ultrasound in this setting and the available data on magnetic resonance imaging after breast conservation therapy is evolving and will be presented. Finally, benign disease mimicking tumor recurrence and commonly missed appearance of tumor recurrence are discussed.

A comparison of treatment approaches for bilateral congenital nasolacrimal duct obstruction

PURPOSE

To compare the clinical outcomes of two treatment approaches for bilateral nasolacrimal duct obstruction (NLDO) in infancy.

DESIGN

Multicenter, randomized clinical trial.

METHODS

We studied 57 infants between the ages of 6 and <10 months who had bilateral NLDO. Participants were randomized to receive either (1) immediate office-based probing within two weeks (n = 31) or (2) 6 months of observation and nonsurgical management followed by surgical facility-based probing for unresolved cases (n = 26). Treatment success was defined as the absence of clinical signs of NLDO (epiphora, increased tear lake, mucous discharge) in both eyes on masked examination at 18 months of age.

RESULTS

In the observation and deferred facility probing group, resolution without surgery occurred by 6 months after randomization in both eyes for 14 participants (56%), in one eye for 5 (20%), and in neither eye for 6 (24%). Eight participants in the observation and deferred facility probing group underwent facility probing (one of whom later had a second facility probing). Four participants in the immediate office probing group later underwent an additional procedure in a surgical facility. In the immediate office probing group, treatment success at 18 months of age occurred in both eyes for 19 of 29 (66%) participants and in one eye for 3 (10%); in the observation and deferred facility probing group, treatment success occurred in both eyes for 19 of 25 (76%) participants and in one eye for 3 (12%) (difference in success = -10%; 95% CI = -35% to 14%).

CONCLUSIONS

Both the immediate office probing approach and the observation and deferred facility probing approach are successful and reasonable treatment options for infants with bilateral NLDO.

Distinct patterns of C4d immunoreactivity in placentas with villitis of unknown etiology, cytomegaloviral placentitis, and infarct

C4d deposition is considered to be evidence of antibody-mediated rejection. This study was conducted to compare C4d immunoreactivity between villitis of unknown etiology (VUE) and cytomegaloviral placentitis. C4d immunohistochemistry was performed in cases with VUE (n = 16) and cytomegaloviral placentitis (n = 5). Distinct, linear C4d immunoreactivity along the syncytiotrophoblast was found in all VUE cases. In cytomegaloviral placentitis, the intensity of C4d immunoreactivity along the syncytiotrophoblast was not prominent, but cytoplasmic C4d immunoreactivity of villous cytotrophoblasts was frequently observed. Further screening of the cases with placental infarcts (n = 5) demonstrated prominent C4d immunoreactivity in the chorionic villi adjacent to the infarct. We report the characteristic co-localization of VUE and C4d immunoreactivity. The overall findings in this study strongly suggest that the complement activation is a common mechanism of diverse placental injuries associated with rejection, infection, and ischemia.

Molecular genetic, cardiac and neurodevelopmental findings in cases of prenatally diagnosed rhabdomyoma associated with tuberous sclerosis complex

OBJECTIVE

Rhabdomyoma is the most common type of cardiac tumor in fetuses and is often associated with tuberous sclerosis complex (TSC) with neurologic sequelae. The purpose of this study was to investigate the cardiac and neurodevelopmental outcomes of fetal rhabdomyoma.

METHODS

We reviewed the clinical characteristics of 23 cases of cardiac rhabdomyoma diagnosed prenatally by fetal echocardiography at the Asan Medical Center between January 1998 and December 2009. We also reviewed postnatal results of brain magnetic resonance imaging, echocardiography, renal ultrasound examination and molecular genetic analysis to confirm the presence of cardiac rhabdomyoma with or without TSC.

RESULTS

Among 23 cases, outcome data were available for 17 (73.9%) and six cases (26.1%) were lost to follow-up. The survival rate was 100.0% (17/17). Among the 17 cases with outcome data, spontaneous tumor regression occurred in eight (47.1%), and no change in tumor size and number was observed in the remaining nine cases (52.9%). There was no evidence of long-term cardiac dysfunction caused by persisting rhabdomyomas, regardless of tumor size. TSC was found in nine patients (52.9%), of whom five (55.6%) showed neurodevelopmental morbidity. We identified mutations in one of the TSC1 or TSC2 genes in four of nine TSC infants whose parents allowed us to perform molecular genetic analysis. Three of these (75.0%) were found to have neurologic impairment. Seven (77.8%) of nine TSC cases were non-familial.

CONCLUSIONS

The overall outcome of isolated cardiac rhabdomyoma appears to be favorable. We suggest that systematic postnatal evaluation of TSC be performed even in cases of cardiac rhabdomyoma without a family history of TSC. Molecular characterization of TSC1 and TSC2 might be helpful in predicting short- and long-term neurodevelopmental outcomes.

Tobacco use, exposure to second-hand smoke, and cessation training among the third-year medical and dental students in selected Member States of South-East Asia region: a trend analysis on data from the Global Health Professions Student Survey, 2005-2011

BACKGROUND

The Medical and Dental Global Health Professions Student Surveys (GHPSS) are surveys based in schools that collect self-administered data from students on the prevalence of tobacco use, exposure to second-hand smoke, and tobacco cessation training, among the third-year medical and dental students.

MATERIALS AND METHODS

Two rounds of medical and dental GHPSS have been conducted in Bangladesh, India, Myanmar, Nepal, Sri Lanka, and Thailand, among the third-year medical and dental students, between 2005 and 2006 and 2009 and 2011.

RESULTS

The prevalence of any tobacco use among third-year male and female medical students did not change in Bangladesh, India, and Nepal between 2005 and 2006 and 2009 and 2011; however, it reduced significantly among females in Myanmar (3.3% in 2006 to 1.8% in 2009) and in Sri Lanka (2.5% in 2006 to 0.6% in 2011). The prevalence of any tobacco use among third-year male dental students did not change in Bangladesh, India, Nepal, and Thailand between 2005 and 2006 and 2009 and 2011; however, in Myanmar, the prevalence increased significantly (35.6% in 2006 to 49.5% in 2009). Among the third-year female students, a significant increase in prevalence was noticed in Bangladesh (4.0% in 2005 to 22.2% in 2009) and Thailand (0.7% in 2006 to 2.1% in 2011). It remained unchanged in the other three countries. Prevalence of exposure to second-hand smoke (SHS) both at home and in public places, among medical students, decreased significantly in Myanmar and Sri Lanka between 2006 and 2009 and in 2011. Among dental students, the prevalence of SHS exposure at home reduced significantly in Bangladesh, India, and Myanmar, and in public places in India. However, there was an increase of SHS exposure among dental students in Nepal, both at home and in public places, between 2005 and 2011. Medical students in Myanmar, Nepal, and Sri Lanka reported a declining trend in schools, with a smoking ban policy in place, between 2005 and 2006 and 2009 and 2011, while proportions of dental students reported that schools with a smoking ban policy have increased significantly in Bangladesh and Myanmar. Ever receiving cessation training increased significantly among medical students in Sri Lanka only, whereas, among dental students, it increased in India, Nepal, and Thailand.

CONCLUSION

Trends of tobacco use and exposure to SHS among medical and dental students in most countries of the South-East Asia Region had changed only relatively between the two rounds of GHPSS (2005-2006 and 2009-2011). No significant improvement was observed in the trend in schools with a policy banning smoking in school buildings and clinics. Almost all countries in the SEA Region that participated in GHPSS showed no significant change in ever having received formal training on tobacco cessation among medical and dental students.

Comparison of peripheral nerve damages according to glucose control timing in experimental diabetes

OBJECTIVE

In addition to tight glucose control, early intensive therapy has been reported to be more important for the prevention of diabetic micro- and macro-vascular complications. What is not known exactly is the quantitative difference according to timing delay in glucose control and whether early period control is really better than late control in terms of diabetic peripheral neuropathy. In this study, we investigated the effect of timing differences in glucose control on the peripheral nerves in an experimental diabetic model.

METHODS

5 groups (6-8 rats in each group) were comprised of normal glucose rats (designated control), rats with hyperglycemia (designated DM), rats with glucose control for the entire 28-week study period (designated DM + INS [W0-28]), rats with glucose control for the early 14-week period followed by hyperglycemia for the late 14-week period (designated DM + INS [W0-14]), and rats with hyperglycemia for the early 14-week period followed by glucose control in the late 14-week period (designated DM + INS [W15-28]).

RESULTS

We found that the current perception threshold (CPT) was lower in the DM + INS (W0-28) and DM + INS (W15-28) groups than in the DM + INS (W0-14) or DM groups (P<0.05). The mean myelinated fiber area of the sciatic nerve was significantly greater in the DM + INS (W0-28) and DM + INS (W15-28) groups (63.5±2.32 and 60.1±2.14 um, respectively) than in the DM + INS (W0-14) or DM groups (55.5±2.81 or 51.5±2.64 um, respectively) (P<0.05), and the intraepidermal nerve fiber (IENF) density was significantly higher in the DM + INS (W0-28) and DM + INS (W15-28) groups (6.9±0.46 and 6.8±0.11, respectively) than in the DM + INS (W0-14) or DM groups (59.5±0.32 and 5.3±0.39/mm, respectively) (P<0.05).

CONCLUSION

Our results indicate that continuous glucose control is necessary to alleviate peripheral nerve damage and that glycemic control during the later period may be more important than early period management. The importance of continuous glucose control, including the later period of diabetes, should therefore be emphasized in diabetic peripheral neuropathy.

Pharmacokinetics of veterinary drugs in laying hens and residues in eggs: a review of the literature

Poultry treated with pharmaceutical products can produce eggs contaminated with drug residues. Such residues could pose a risk to consumer health. The following is a review of the information available in the literature regarding drug pharmacokinetics in laying hens, and the deposition of drugs into eggs of poultry species, primarily chickens. The available data suggest that, when administered to laying hens, a wide variety of drugs leave detectable residues in eggs laid days to weeks after the cessation of treatment.

Symptom experience and functional status among HIV-infected women

Irrespective of powerful drug therapies, there has been a slight increase in newly diagnosed cases of AIDS in women. HIV/AIDS-related symptoms develop from the illness itself, treatments or medications. Symptoms and their reoccurrence remain problematic. This study is a secondary analysis of data exploring symptoms, symptom distress and functional status in 104 ethnically diverse HIV-positive women. Measures included the Brief Symptom Inventory, a General Symptom Questionnaire, the Center for Epidemiological Studies Depression Scale, and the Inventory of Functional Status. Findings indicate that this sample of women was distressed, at risk for depression and had a moderate level of physical functioning. These findings support the need for symptom management interventions that enhance emotional wellbeing and self-care activities for HIV-infected women.

PTPN11 analysis for the prenatal diagnosis of Noonan syndrome in fetuses with abnormal ultrasound findings

Noonan syndrome (NS) is an autosomal dominant disorder characterized by short stature, congenital heart defects and distinctive facies. The disorder is genetically heterogeneous with approximately 50% of patients having PTPN11 mutations. Prenatally, the diagnosis of NS has been suspected following certain ultrasound findings, such as cystic hygroma, increased nuchal translucency (NT) and hydrops fetalis. Studies of fetuses with cystic hygroma have suggested an NS prevalence of 1-3%. A retrospective review was performed to assess the utility of PTPN11 testing based on prenatal sonographic findings (n = 134). The most commonly reported indications for testing were increased NT and cystic hygroma. Analysis showed heterozygous missense mutations in 12 fetuses, corresponding to a positive test rate of 9%. PTPN11 mutations were identified in 16% and 2% of fetuses with cystic hygroma and increased NT, respectively. Among fetuses with isolated cystic hygroma, PTPN11 mutation prevalence was 11%. The mutations observed in the three fetuses with hydrops fetalis had previously been reported as somatic cancer mutations. Prenatal PTPN11 testing has diagnostic and possible prognostic properties that can aid in risk assessment and genetic counseling. As NS is genetically heterogeneous, negative PTPN11 testing cannot exclude the diagnosis and further study is warranted regarding the other NS genes.

A high yield of fetal nucleated red blood cells isolated using optimal osmolality and a double-density gradient system

OBJECTIVES

To increase the yield of fetal nucleated red blood cells (NRBCs) from maternal blood using a discontinuous Percoll gradient and to determine the effects of osmolality on NRBC yield.

METHODS

Fetal NRBCs were isolated from combined umbilical cord blood and adult female blood, or from maternal blood using single or double Percoll gradients with different osmolalities. Magnetic activated cell sorting was used to enrich isolated NRBCs, and morphological differentiation was performed with Kleihauer-Betke stain. We also isolated fetal NRBCs from 25 10 mL samples of maternal blood and determined fetal sex by fluorescence in situ hybridization (FISH), using X-Y probes.

RESULTS

For single-density Percoll columns, the greatest number of NRBCs was isolated using 280 mOsm/kg H(2)O with 1.077 g/mL Percoll and 520 mOsm/kg H(2)O with 1.119 g/mL Percoll. Significantly more fetal NRBCs were isolated with double Percoll density gradients than with double-Histopaque gradients (p = 0.043). FISH analysis on NRBC in 25 cases correctly identified 15 male and 9 female euploid fetuses and one Trisomy 21 fetus.

CONCLUSION

The NRBC enrichment method we present requires less maternal blood and yields more NRBCs compared to previous methods.

Constitutive immune defences correlate with life-history variables in tropical birds

1. It has been suggested that immune defences are shaped by life history and ecology, but few general patterns have been described across species. We hypothesized that 'fast' life-history traits (e.g. short development times, large clutch sizes) would be associated with developmentally inexpensive immune defences, minimizing the resource demands of young animals' immune systems during periods of rapid growth. Conversely, 'slow' life histories should be associated with well developed antibody-mediated defences, which are developmentally costly. 2. We therefore predicted that 'fast-living' species would exhibit higher levels of complement proteins, a component of non-specific innate defence, but lower levels of constitutive ('natural') antibodies. Additionally, we predicted that constitutive immune defences in general would be higher in species with ecological characteristics that might increase exposure to pathogens, such as open nests, omnivorous diets, gregariousness, and closed forested habitat. 3. Across 70 Neotropical bird species, we found a strongly positive relationship between incubation period and natural antibody levels in adult birds, suggesting that longer developmental times might allow the production of a more diverse and/or more reactive adaptive immune system. Complement activity was positively, although weakly, correlated with clutch size, providing some support for the hypothesis that faster-living species rely more on innate defences, such as complement. Unexpectedly, solitary species had higher natural antibody titres than species that frequently join flocks. 4. Our results suggest that, despite probably widespread differences in the intensity and diversity of pathogen exposure, species-level variation in constitutive immune defences is understandable within the context of life-history theory.

Stability of visual acuity improvement following discontinuation of amblyopia treatment in children aged 7 to 12 years

OBJECTIVE

To assess the stability of visual acuity improvement during the first year after cessation of amblyopia treatment other than spectacle wear in children aged 7 to 12 years.

METHODS

At the completion of a multicenter randomized trial during which amblyopia treated with patching and atropine improved by at least 2 lines on the electronic Early Treatment of Diabetic Retinopathy Study testing protocol, 80 patients aged 7 to 12 years were followed up while not receiving treatment (other than spectacle wear) for 1 year.

MAIN OUTCOME MEASURE

Ten letters or more (> or =2 lines) worsening of visual acuity (measured using the electronic Early Treatment of Diabetic Retinopathy Study testing protocol) during the year following treatment discontinuation.

RESULTS

During the year following cessation of treatment, the cumulative probability of worsening visual acuity (> or =2 lines) was 7% (95% confidence interval, 3%-17%); 82% of patients maintained an increase in visual acuity of 10 letters or more compared with their visual acuity before starting treatment.

CONCLUSION

Visual acuity improvement occurring during amblyopia treatment is sustained in most children aged 7 to 12 years for at least 1 year after discontinuing treatment other than spectacle wear.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00094692.

A symptom survey and quality of life questionnaire for nasolacrimal duct obstruction in children

PURPOSE

To develop and validate a new parental questionnaire addressing symptoms and health-related quality of life (HRQL) in childhood nasolacrimal duct obstruction (NLDO).

DESIGN

Cross-sectional study.

PARTICIPANTS

Children ages 6 to younger than 48 months with and without clinical signs of NLDO.

METHODS

A new questionnaire was developed using semistructured interviews with parents of children with NLDO and through discussions with expert clinicians. Questionnaires were completed by parents of children with and without NLDO. Cronbach's alpha was calculated as a measure of internal-consistency reliability. Factor analysis was used to evaluate a priori subscales: symptoms and HRQL. Discriminant construct validity was assessed by comparing questionnaire scores between children with and without NLDO and between affected and unaffected eyes of children with unilateral NLDO. Instrument responsiveness was determined by comparing presurgical and postsurgical intervention scores in a subset of NLDO patients who underwent surgical treatment.

MAIN OUTCOME MEASURE

The NLDO questionnaire score.

RESULTS

Eighty-seven children were enrolled, 56 with and 31 without NLDO. All but 2 questions on the questionnaire showed a good distribution of responses, a high correlation with the rest of the questionnaire, and excellent discrimination between patients with and without NLDO. Cronbach's alpha values were good for the overall questionnaire (0.95), and for 2 predetermined subscales: symptoms (0.95) and HRQL (0.85). On a 0 to 4 scale, NLDO patients had worse scores compared with non-NLDO patients for both symptoms (mean difference, 2.1; 95% confidence interval [CI], 1.9-2.3) and HRQL (mean difference, 1.2; 95% CI, 0.9-1.5) subscales. The NLDO patients had worse scores before intervention compared with after intervention for both the symptoms (mean difference, 2.2; 95% CI, 1.6-2.9) and HRQL (mean difference, 1.4; 95% CI, 0.8-2.1) subscales. Finally, NLDO patients had worse symptom scores for affected eyes compared with unaffected eyes (mean difference, 2.3; 95% CI, 1.9-2.6).

CONCLUSIONS

This novel NLDO questionnaire is useful in quantifying parental perception of symptoms and HRQL in childhood NLDO. The questionnaire may have a role in future clinical studies of NLDO.

A randomized pilot study of near activities versus non-near activities during patching therapy for amblyopia

BACKGROUND

To plan a future randomized clinical trial, we conducted a pilot study to determine whether children randomized to near or non-near activities would perform prescribed activities. A secondary aim was to obtain a preliminary estimate of the effect of near versus non-near activities on amblyopic eye visual acuity, when combined with 2 hours of daily patching.

METHODS

Sixty-four children, 3 to less than 7 years of age, with anisometropic, strabismic, or combined amblyopia (20/40 to 20/400) were randomly assigned to receive either 2 hours of daily patching with near activities or 2 hours of daily patching without near activities. Parents completed daily calendars for 4 weeks recording the activities performed while patched and received a weekly telephone call in which they were asked to describe the activities performed during the previous 2 hours of patching. Visual acuity was assessed at 4 weeks.

RESULTS

The children assigned to near visual activities performed more near activities than those assigned to non-near activities (by calendars, mean 1.6 +/- 0.5 hours versus 0.2 +/- 0.2 hours daily, P < 0.001; by telephone interviews, 1.6 +/- 0.4 hours versus 0.4 +/- 0.5 hours daily, P < 0.001). After 4 weeks of treatment, there was a suggestion of greater improvement in amblyopic eye visual acuity in those assigned to near visual activities (mean 2.6 lines versus 1.6 lines, P = 0.07). The treatment group difference in visual acuity was present for patients with severe amblyopia but not moderate amblyopia.

CONCLUSIONS

Children patched and instructed to perform near activities for amblyopia spent more time performing those near activities than children who were instructed to perform non-near activities. Our results suggest that performing near activities while patched may be beneficial in treating amblyopia. Based on our data, a formal randomized amblyopia treatment trial of patching with and without near activities is both feasible and desirable.

Alterations in sleep during pregnancy and postpartum: a review of 30 years of research

Pregnancy, childbirth, and early motherhood physiologically and psychologically affect a woman's sleep. Hormonal alterations during early pregnancy, enlargement of the fetus during late pregnancy, and a newborn with random sleep-wake patterns all contribute to disrupted sleep. Since the initial study of sleep and pregnancy in 1968, fewer than 20 articles have been published which address alterations in sleep architecture related specifically to childbearing women. Furthermore, many of these studies suffer from small sample sizes and lack statistical power for consistent interpretation and replication of findings. While almost all of these studies included both nulliparas and multiparas in their samples, rarely have effects of parity been reported. The majority of older studies were cross-sectional designs, with comparisons to age-matched healthy controls. More recent studies have been longitudinal designs to describe changes in sleep during the course of pregnancy. However, women's baseline, prepregnancy sleep patterns or sleep histories have not been considered. With very few published reports of sleep changes related to mental health outcomes, we are no closer to understanding the implications of altered sleep patterns on postpartum depression or other women's health outcomes than we were when it was originally questioned 30 years ago.

Capped mRNAs with reduced secondary structure can function in extracts from poliovirus-infected cells

Extracts from poliovirus-infected HeLa cells were used to study ribosome binding of native and denatured reovirus mRNAs and translation of capped mRNAs with different degrees of secondary structure. Here, we demonstrate that ribosomes in extracts from poliovirus-infected cells could form initiation complexes with denatured reovirus mRNA, in contrast to their inability to bind native reovirus mRNA. Furthermore, the capped alfalfa mosaic virus 4 RNA, which is most probably devoid of stable secondary structure at its 5' end, could be translated at much higher efficiency than could other capped mRNAs in extracts from poliovirus-infected cells.

The influence of sleep and activity patterns on fatigue in women with HIV/AIDS

The cause of HIV-related fatigue is most likely multifactorial. When presented as a chief complaint, clinicians often include an assessment of stress level, depression, anemia, infection, and amount of sleep and activity. The empirical bases for these evaluations vary in their validity and implementation in clinical practice, but the basis for evaluating adequate amounts of sleep and activity currently lacks empirical research. The purpose of this study was to describe HIV seropositive women's sleep and activity patterns related to their fatigue experience. Sleep and activity were assessed with wrist actigraphy to obtain objective measures of total sleep time, number of awakenings, and sleep efficiency, as well as level of daytime activity, 24-hour activity rhythm, and naps. This sample of 100 women with HIV/AIDS averaged only 6.5 hours of sleep at night, and 45% of the sample napped. CD4 cell counts were unrelated to sleep and fatigue measures. Compared to the low-fatigue group, the women with high fatigue had significantly more difficulty falling asleep, more awakenings from nighttime sleep, poorer daytime functioning, and a higher frequency of depressive symptoms. Findings from this study provide clinicians with empirically based support for detailed clinical evaluations of sleep and activity patterns, as well as anxiety and depression, in clients who complain of fatigue. Findings also provide data for potential interventions to improve sleep and activity in persons living with HIV/AIDS and to reduce fatigue and depressive symptoms.

Sleep and fatigue

This chapter provides a review and synthesis of research on women's sleep and fatigue from a nursing perspective. Most of the research involves four primary issues for women: menstrual cycles, childbearing, chronic mental or physical illness, and oncology. Research with healthy women focused on diurnal fluctuations in fatigue and relationships to sleep, without regard for exercise or level of daytime activity. Research on chronic illness and cancer fatigue focused on general fatigue and its impact on activity, without regard for sleep or therapeutic use of rest and naps. A comparison of these two areas highlights gaps in nursing knowledge about sleep and fatigue. Further research is needed to understand relationships between nonrestorative sleep, fatigue, and symptoms related to poor quality of life. From a synthesis of these studies, nonpharmacologic interventions that could be prove useful in promoting a higher quality of life for those with either acute or chronic fatigue are then proposed.

Tandem translocation of chromosomes 22 and 15 with two preserved satellite stalk regions and deletion 22q13.3-qter

We describe here a case of a tandem 22/15 translocation with deletion of the 22q13.3-qter region and retention of the NOR of chromosome 15. A 2(1/2)-year-old Korean girl was referred for chromosome analysis after a clinical evaluation for developmental delay. Physical examination revealed hypotonia, developmental delay, delay of gross motor milestones and speech delay. No dysmorphic features of face, hands or feet were evident in the patient. G-banded peripheral blood lymphocyte chromosomes showed a tandem translocation between chromosomes 22 and 15, with the satellite stalks of chromosome 15 apparently being retained. All-telomere FISH analysis using a TTAGGG repeat probe showed absent signals at the junction of the translocation. Sequential G-banding and FISH analysis using a beta satellite probe showed positive signals close to the junction of the translocation, an indication that the short arms of the chromosome 15 involved in the translocation are retained. FISH with a probe for arylsulfatase, mapped to 22q13.3 region, was negative on the translocation chromosome. Therefore, the 22q13.3 region is deleted.

Increased frequencies of glutathione S-transferase (GSTM1 and GSTT1) gene deletions in Korean patients with acquired aplastic anemia

Patients with reduced ability to metabolize environmental carcinogens or toxins may be at risk of developing aplastic anemia. Glutathione S-transferase (GST) has been implicated in detoxifying mutagenic electrophilic compounds. This study asked whether the homozygous gene deletions of GSTM1 and GSTT1 affect the likelihood of developing aplastic anemia. The incidence of GSTM1 and GSTT1 gene deletions was significantly higher for aplastic anemia patients (odds ratio [OR]: 3.1, P =.01 and OR: 3.1, P =.004, respectively) than for healthy controls. Among the aplastic anemia patients, 17.5% (10:57) had chromosomal abnormalities at the time of diagnosis, and all aplastic anemia patients with chromosomal abnormalities showed GSTT1 gene deletions (P =.048). Individuals with GSTM1 and GSTT1 gene deletions may have greater susceptibility to aplastic anemia. It is possible that genetic instability or chromosomal damage due to abnormal detoxification of environmental toxins might have worked as an important pathophysiologic mechanism of aplastic anemia for patients with GSTT1 gene deletions.

Symptom experience in women after hysterectomy

OBJECTIVE

To review the literature addressing the symptom experience of women after hysterectomy.

DATA SOURCES

Computerized searches in MEDLINE and CINAHL, as well as texts and references cited in articles. Key concepts in the searches included hysterectomy, sleep disturbance and pain, hysterectomy and fatigue, hysterectomy, depression, and depressed mood.

STUDY SELECTION

Articles and comprehensive works relevant to key concepts and published after 1970, with an emphasis on new findings from 1990 to 2000. Sixty-four citations were identified as useful to this review.

DATA EXTRACTION

Data were organized under the following headings: women and hysterectomy, biopsychosocial perspectives, common symptoms after hysterectomy (pain, disturbed sleep, fatigue, depressed mood, anxiety), and significance of review (implications).

DATA SYNTHESIS

Literature suggests that after a hysterectomy, women experience complications during the postoperative recovery period that may vary with the type of surgical procedure. During this period, the quantity and quality of sleep as well as other symptoms (pain, fatigue, anxiety, and depression) are influenced by various physiologic, psychologic, and social factors. Despite limited evidence that sleep problems may occur frequently during the recovery period, only a few researchers have systematically examined sleep patterns in women after hysterectomy. None of these studies, however, used objective sleep measures or examined multiple dimensions of these women's lives.

CONCLUSIONS

This review conceptualized the women's symptom experience as the experience of specific symptoms (pain, sleep disturbance, fatigue, depressed mood, and anxiety) that were influenced by biopsychosocial factors.

Multiple phosphorylation of rhodopsin and the in vivo chemistry underlying rod photoreceptor dark adaptation

Dark adaptation requires timely deactivation of phototransduction and efficient regeneration of visual pigment. No previous study has directly compared the kinetics of dark adaptation with rates of the various chemical reactions that influence it. To accomplish this, we developed a novel rapid-quench/mass spectrometry-based method to establish the initial kinetics and site specificity of light-stimulated rhodopsin phosphorylation in mouse retinas. We also measured phosphorylation and dephosphorylation, regeneration of rhodopsin, and reduction of all-trans retinal all under identical in vivo conditions. Dark adaptation was monitored by electroretinography. We found that rhodopsin is multiply phosphorylated and then dephosphorylated in an ordered fashion following exposure to light. Initially during dark adaptation, transduction activity wanes as multiple phosphates accumulate. Thereafter, full recovery of photosensitivity coincides with regeneration and dephosphorylation of rhodopsin.

A repetitive element containing a critical tyrosine residue is required for transcriptional activation by the EWS/ATF1 oncogene

Chromosomal fusion of the N-terminal region of the Ewings Sarcoma Oncogene (EWS-activation-domain, EAD) to the DNA-binding domains of a variety of cellular transcription factors produce oncogenic proteins (EWS-fusion proteins (EFPs)) that cause distinct malignancies. In EFPs, the EAD acts as a potent transcriptional activation domain and this ability is repressed in the context of normal, non-tumorigenic, EWS. Trans-activation by the EAD is therefore a specific characteristic of EFPs and it is thought that EFPs induce tumorigenesis via improper transcriptional activation of cellular genes. Functional elements required for transcriptional activation are dispersed throughout the EAD, as are thirty-one copies of a Degenerate Hexapeptide Repeat (DHR, consensus SYGQQS). This suggests that the EAD contains a highly reiterated functional element related to DHRs. Here we show that in the context of EWS/ATF1, the EFP that causes malignant melanoma of soft parts, trans-cooperation by small regions of the EAD ( approximately 30 residues) results in potent transcriptional activation dependent on the conserved tyrosine residues present in DHRs. These findings provide the first evidence for a role of DHRs in EAD-mediated trans-activation and demonstrate that the EAD represents a novel tyrosine-dependent transcriptional activation domain.

Both E6 and E7 oncoproteins of human papillomavirus 16 inhibit IL-18-induced IFN-gamma production in human peripheral blood mononuclear and NK cells

Cervical carcinoma is the predominant cancer among malignancies in women throughout the world, and human papillomavirus (HPV) 16 is the most common agent linked to human cervical carcinoma. The present study was performed to investigate the mechanisms of immune escape in HPV-induced cervical cancer cells. The presence of HPV oncoproteins E6 and E7 in the extracellular fluids of HPV-containing cervical cancer cell lines SiHa and CaSki was demonstrated by ELISA. The effect of HPV 16 oncoproteins E6 and E7 on the production of IFN-gamma by IL-18 was assessed. E6 and E7 proteins reduced IL-18-induced IFN-gamma production in both primary PBMCs and the NK0 cell line. FACS analysis revealed that the viral oncoproteins reduced the binding of IL-18 to its cellular surface receptors on NK0 cells, whereas there was no effect of oncoproteins on IL-1 binding to its surface IL-1 receptors on D10S, a subclone of the murine Th cell D10.G4.1. In vitro pull-down assays also revealed that the viral oncoproteins and IL-18 bound to IL-18R alpha-chain competitively. These results suggest that the extracellular HPV 16 E6 and E7 proteins may inhibit IL-18-induced IFN-gamma production locally in HPV lesions through inhibition of IL-18 binding to its alpha-chain receptor. Down-modulation of IL-18-induced immune responses by HPV oncoproteins may contribute to viral pathogenesis or carcinogenesis.

Social interactions, perceived support, and level of distress in HIV-positive women

Although powerful pharmacological therapies are helping women with HIV infection live longer, women continue to experience the stressors of chronic illness. This study used a person-environment systems framework to describe social interactions, perceived social support, and psychological distress in HIV-positive women. A convenience sample of 104 HIV-positive women living in the San Francisco Bay Area completed a questionnaire on social interactions, perceived social support, and distress. Women reported limited social interactions with family and friends and a low level of perceived social support. Social support and level of distress did not differ by ethnicity. Limited perceived social support was a significant predictor of distress in this sample of women. Supportive interactions from health care providers can be useful in mediating the relationship between the stressor of HIV disease and distress in HIV-positive women. Community-based nurses can enhance HIV-positive women's support network by providing positive and supportive interactions as they intervene with women in symptom management, case management, and other health care services.

Restless legs syndrome and sleep disturbance during pregnancy: the role of folate and iron

Restless legs syndrome (RLS) is a neurosensory disorder that typically begins in the evening and often prevents a person from falling asleep. It has been associated with iron deficiency anemia and dopaminergic pathways and is often treated with iron infusion or dopamine agonists. The purpose of this secondary analysis of longitudinal data collected on women before, during, and after pregnancy is to document the prevalence of RLS during pregnancy, contrast its effect on sleep and mood state, and explore the role of folate and iron in the expression of RLS, specifically during the third trimester when the syndrome is most distressing. The prevalence increased from 0 during preconception to 23% (n = 7) during the third trimester of pregnancy. Only 1 subject continued to experience RLS after delivery. Compared with those without complaints of restless legs, those with restless legs had low serum ferritin at preconception and significantly lower folate levels during preconception and at each trimester. In addition, time to sleep onset was significantly delayed and depressed mood was significantly higher in the RLS group. Rather than indicators of iron deficiency anemia (serum ferritin, serum iron, and hemoglobin) or pernicious anemia (vitamin B(12)), it was reduced serum folate level that was associated with RLS in this sample of pregnant women. Findings indicate a need to reconsider recommendations about the normal ranges of serum ferritin and serum folate levels during pregnancy to minimize the complaints of restless legs and promote more consolidated sleep and better daytime mood state during pregnancy.

Stereopsis in patients with albinism: clinical correlates

PURPOSE

A hallmark of albinism is excessive decussation of retinostriate projections at the optic chiasm. This misprojection might lead to abnormalities in the retinal correspondence and may account for the usual absence of stereovision. We report on 2 groups of patients with albinism who have either fine or gross stereopsis and compare the clinical findings of these groups to other patients with albinism with similar visual acuities but no stereopsis.

METHODS

A retrospective chart review of patients with albinism was used to segregate those with a letter visual acuity of 20/100 or better in one eye, assessment of stereopsis, and strabismus < or = 10 PD. Forty-five patients were identified. Albinism type, best-corrected visual acuity, motility, Titmus vectograph stereoacuity, iris and macula transparency grades, and the presence or absence of both melanin and an annular reflex in the macula were tabulated. A comparison of the clinical characteristics of the groups with and without stereopsis was made.

RESULTS

Those albino subjects who demonstrated stereopsis had better visual acuity, less iris transillumination, more frequent presence of melanin in the macula, less nystagmus, and less marked foveal hypoplasia than the albino subjects without stereopsis. No nystagmus was clinically detected in 5 patients with fine stereopsis. All these differences were statistically significant. Macular transparency grade was not significantly different between the groups.

CONCLUSIONS

Patients with albinism who demonstrate stereopsis tend to have better visual acuity, more iris pigment, and more melanin pigment in the macula than their counterparts without stereopsis.

An hsRPB4/7-dependent yeast assay for trans-activation by the EWS oncogene

Chromosomal fusions of the N-terminal region of the Ewings Sarcoma Oncogene (EWS-Activation-Domain, EAD) to the DNA-binding domains of a variety of cellular transcription factors, produce oncogenic proteins (EWS-fusion proteins (EFPs)) that cause a variety of malignancies. The EAD can act as a potent transcriptional activation domain and is required for the oncogenic activity of EFPs. Previous studies demonstrating a physical interaction between the EAD and the human RNA Polymerase II subunit hsRPB7 suggest a crucial role for RPB7 and its partner, RPB4, in EAD function. Homologues of hsRPB4/7 exist in S. cerevisiae, and here we describe an RPB4/7-dependent yeast assay for EAD-mediated trans-activation. Conditional yeast strains lacking RPB4 are defective for trans-activation by a Gal4/EAD fusion protein at the permissive temperature. Introduction of hsRPB4 alone is unable to rescue trans-activation, while a combination of hsRPB4 and hsRPB7 significantly rescues activity. These findings provide the first functional evidence for a direct role of the RPB4/7 complex in EAD-mediated trans-activation. In addition, the yeast assay provides a tractable system for further molecular analysis of EAD and RPB4/7 action.