Safety of Non-Operating Room Anesthesia With Propofol Sedation in Three Pediatric Patients With Central Sleep Apnea

Children with central sleep apnea may require sedation for procedures, including brain imaging as part of the evaluation of apnea. However, the safety of deep sedation without a protected airway is not known in this patient population. In this case series, we present 3 children with central sleep apnea who were sedated with propofol for brain imaging in a non-operating room setting. All 3 did well with no complications; those with a home oxygen requirement were on oxygen during the procedure but none experienced apnea, desaturation, or respiratory distress. While obstructive sleep apnea is a known contraindication to deep sedation with propofol, it may be safe in pediatric patients with central sleep apnea. Deep sedation may be a good option for these patients, thereby avoiding the need for general anesthesia and placement of an advanced airway.

Development of a Definition of Postacute Sequelae of SARS-CoV-2 Infection

Importance

SARS-CoV-2 infection is associated with persistent, relapsing, or new symptoms or other health effects occurring after acute infection, termed postacute sequelae of SARS-CoV-2 infection (PASC), also known as long COVID. Characterizing PASC requires analysis of prospectively and uniformly collected data from diverse uninfected and infected individuals.

Objective

To develop a definition of PASC using self-reported symptoms and describe PASC frequencies across cohorts, vaccination status, and number of infections.

Design, Setting, and Participants

Prospective observational cohort study of adults with and without SARS-CoV-2 infection at 85 enrolling sites (hospitals, health centers, community organizations) located in 33 states plus Washington, DC, and Puerto Rico. Participants who were enrolled in the RECOVER adult cohort before April 10, 2023, completed a symptom survey 6 months or more after acute symptom onset or test date. Selection included population-based, volunteer, and convenience sampling.

Exposure

SARS-CoV-2 infection.

Main Outcomes and Measures

PASC and 44 participant-reported symptoms (with severity thresholds).

Results

A total of 9764 participants (89% SARS-CoV-2 infected; 71% female; 16% Hispanic/Latino; 15% non-Hispanic Black; median age, 47 years [IQR, 35-60]) met selection criteria. Adjusted odds ratios were 1.5 or greater (infected vs uninfected participants) for 37 symptoms. Symptoms contributing to PASC score included postexertional malaise, fatigue, brain fog, dizziness, gastrointestinal symptoms, palpitations, changes in sexual desire or capacity, loss of or change in smell or taste, thirst, chronic cough, chest pain, and abnormal movements. Among 2231 participants first infected on or after December 1, 2021, and enrolled within 30 days of infection, 224 (10% [95% CI, 8.8%-11%]) were PASC positive at 6 months.

Conclusions and Relevance

A definition of PASC was developed based on symptoms in a prospective cohort study. As a first step to providing a framework for other investigations, iterative refinement that further incorporates other clinical features is needed to support actionable definitions of PASC.

Characteristics and Outcomes of Patients Receiving Sedation for Voiding Cystourethrography

Background

Voiding cystourethrography (VCUG) is used to diagnose vesicoureteral reflux (VUR); however, it is an invasive procedure and can be psychologically distressing. Procedural sedation is occasionally utilized to alleviate anxiety during VCUG, and some patient populations may get referred more readily for sedation than others. Sedative medications may also impact the results of the test due to their effects on smooth muscle. The goals of this study were to compare patient characteristics between those that were referred for procedural sedation and those that were not and to compare VCUG results between sedated and non-sedated patients.

Methodology

We performed a retrospective cohort study of patients aged 2-18 years undergoing VCUG during a five-year period. Sedated patients were matched with non-sedated patients controlling for referring provider and procedure year. Exclusion criteria included chronic catheterization, same-day surgery, current intensive care admission, and sedation restrictions. A total of 284 patients were included. Demographic information, medical comorbidities, and VCUG results were analyzed.

Results

There were no significant differences between sedated and non-sedated patients in any demographic variables. Neurologic, developmental, and gastrointestinal comorbidities were more common in sedated patients. On multivariate analysis, having more than one comorbid condition was the only significant predictor of referral for procedural sedation. There were no significant differences in VCUG results between sedated and non-sedated patients.

Conclusions

Patients with comorbidities were more likely to receive procedural sedation for VCUG. Procedural sedation did not have a significant impact on test results, suggesting its potential utility in relieving pain and anxiety associated with VCUG.

Profile of Data Sharing in the Clinical Neurosciences

Importance: In today’s climate of high healthcare costs and limited research resources, much attention has been given to inefficiency in research. Open access to research data has been proposed as a way to pool resources and make the most of research funding while also promoting transparency and scientific rigor. 

Objective: The clinical neurosciences stand to benefit greatly from the potential opportunities afforded by open data, and we sought to evaluate the current state of publicly available research findings and data sharing policies within the clinical neurosciences. 

Design: The Clarivate Analytics Web of Science journal citation reports for 2017 were used to sort journals in the category ‘Clinical Neurosciences’ by impact factor. The top 50 journals were selected and reviewed, but data was only collected from journals focused on original research (42/50). For each journal we reviewed the 10 most recent original research articles for 2016, 2017, and 2018 as designated by Scopus. 

Results: A data sharing policy existed for 60% (25/42) of the journals reviewed. Of the articles studied 41% (517/1255) contained source data, and the amount of articles with available source data increased from 2016 to 2018. Of all the articles reviewed, 49.4% (620/1255) were open access. Overall, 6.9% (87/1255) of articles had their source data accessible outside of the manuscript (e.g. registries, databases, etc.) and 8.9% (112/1255) addressed the availability of their source data within the publication itself. The availability of source data outside the manuscript and in-article discussion of source data availability both increased from 2016 to 2018. Only 3.9% (49/1255) of articles reviewed reported negative results for their primary outcome, and 7.6% (95/1255) of the articles could not be defined as primarily reporting positive or negative findings (characterization studies, census reporting, etc.). The distribution of negative versus positive results reported showed no significant trend over the years studied. 

Conclusion and Relevance: Our results demonstrate an opportunity for increased data sharing in neuroscience original research. These findings also suggest a trend towards increased adoption of open data sharing policies among journals and increased availability of unprocessed data in publications. This can increase the quality and speed at which new research is developed in the clinical neurosciences.

Association between Foramen Size and Febrile Seizure Status in the Pediatric Population: A Two-Center Retrospective Analysis

Objective Febrile seizures have been shown to occur in 2 to 5% of children between the ages of 6 months and 5 years, making them the most common seizures of childhood. Multiple risk factors for febrile seizures have been identified; however, no investigation has been conducted to explore foramen size and associated venous drainage as a potential risk factor for experiencing febrile seizures. Of particular interest are the parietal foramen and the condylar canal, which conduct the parietal emissary vein and the occipital emissary vein, respectively. Emissary veins lack valves, allowing them to play a crucial role in selective brain cooling via a bidirectional flow of blood from the head’s evaporating surface. Narrowed cranial apertures conducting these veins may lead to reduced cerebral venous outflow and delayed brain cooling, creating favorable conditions for a febrile event. This study seeks to explore the association between cranial aperture area and febrile seizure status.

Methods A retrospective cross-sectional medical record review study from January 2011 to December 2017 was conducted at a 500-bed academic hospital and a 977-bed private hospital in Lubbock, Texas, United States. A total of 101 complex febrile seizure patients were compared with a similarly aged group of 75 trauma patients representing the normal population. Parietal foramen area and condylar canal area were electronically measured and defined as having “normal” or “below normal” area.

Statistical Analysis Independent t-tests were used to compare foramen and canal areas by febrile seizure status. Logistic regression analyses were conducted to determine the association of small cranial aperture area with febrile seizure status.

Results Below normal parietal foramen area had a strong association with febrile seizures in our patient population. Male sex, white race, and complete vaccination status were also found to have significant associations with febrile seizure status.

Conclusion Our findings indicated that narrowed parietal foramen may be considered as a risk factor for febrile seizure development.

Child Abuse and Deformational Plagiocephaly in a West Texas Hospital System

Background  The aim of this study was to assess deformational plagiocephaly’s (DP) predictive value in neglect and physical abuse (nonaccidental trauma [NAT]) within the pediatric population. In addition, we sought to characterize the prevalence of DP and NAT for our hospital’s mostly rural catchment area.

Methods  Data on hospitalized patients diagnosed with NAT and/or neglect between 2012 and 2018 were collected via retrospective chart review. All enrolled children were younger than the age of 4 years at the time of diagnosis, and those without legible head computed tomographies or magnetic resonance images during their initial hospitalization were excluded. Utilizing neuroimaging, we calculated the cranial vault asymmetry index (CVAI) and cranial index for each patient to assess for DP. Differences between the two groups were assessed using Wilcoxon’s rank-sum test for continuous variables and Fisher’s exact test for categorical variables. A p -value of 0.05 or less was considered statistically significant. All analyses were conducted using SAS 9.4 (Cary, North Carolina, United States).

Results  The prevalence of DP within the combined cohort of NAT and neglect patients is 21%, similar to that reported in the literature for the general population (20–50%). There was no significance between the prevalence of DP and a history of NAT ( p > 0.1) or neglect ( p > 0.1). Furthermore, there was no correlation between CVAI and characteristics of initial presentation or history of trauma for either NAT ( p -values: 0.359 and 0.250, respectively) or neglect groups ( p -values: 0.116 and 0.770, respectively).

Conclusion  While there are many limitations to this study, our results suggest that abused children are no more likely to have history of DP than the general population, and the degree of DP is not associated with severity of trauma history or initial presentation. We hope the results of this study promote future investigations for unique and subtle predictive factors of child abuse/neglect.

Contrast-Induced Vomiting in Pediatric Patients Under Propofol Sedation: A Case Series

Gadolinium-based compounds are frequently used in contrast-enhanced magnetic resonance imaging studies. Rarely, adverse events have been reported with administration of these compounds, of which the most common are nausea and vomiting. Although well established in the adult literature, these adverse effects are less well described in the pediatric population, who often need sedation to complete imaging studies. In this case series, we present 3 children who experienced vomiting shortly after contrast administration while under sedation with propofol, which is known to have antiemetic properties. Although all 3 children recovered without complication, this case series illustrates the serious potential consequences of vomiting while sedated, and providers should be aware of these possible adverse events as pediatric sedation becomes more common outside the operating room.

Data Sharing in Neurosurgery and Neurology Journals

In this era of high health care cost and limited research resources, open access to de-identified clinical research study data may promote increased scientific transparency and rigor, allow for the combination and re-analysis of similar data sets, and decrease un-necessary replication of unpublished negative studies. Driven by expanded computing capabilities, advocacy for data sharing to maximize research value is growing in both translational and clinical research communities. The focus of this study is to report on the current status of publicly available research data from studies published in the top 40 neurology and neurosurgery clinical research journals by impact factor. The top journals were carefully reviewed for data sharing policies. Of the journals with data sharing policies, the 10 most current original research papers from December 2015 - February 2016 were reviewed for data sharing statements and data availability. A data sharing policy existed for 48% (19/40) of the 40 journals investigated. Of the 19 journals with an existing data sharing policy, 58% (11/19) of the policies stated that data should be made available to interested parties upon request and 21% (4/19) of these journals encouraged authors to provide a data sharing statement in the article of what data would be available upon request. Of the 190 articles reviewed for data availability, 21% (40/190) of these articles included some source data in the results, figures, or supplementary sections. This evaluation highlights opportunities for neurology and neurosurgery investigators and journals to improve access to study data and even publish the data prospectively for the betterment of clinical outcome analysis and patient care.

Efficacy and safety of certolizumab pegol for Crohn's disease in clinical practice

BACKGROUND

Certolizumab pegol (CZP) is Food and Drug Administration (FDA)-approved to treat Crohn's disease (CD). However, the efficacy and safety of CZP outside clinical trials are not well established.

AIM

To report the efficacy, safety and predictors of response to CZP in CD patients treated during a 6-year period since FDA-approval at a tertiary care centre.

METHODS

All CD patients who received CZP at our institution between 2008 and 2013 were evaluated through retrospective medical record-based review of steroid-free complete response (SCR), loss of response and safety.

RESULTS

A total of 358 patients were included. One hundred twelve patients (31.3%) and 189 (52.8%) received CZP as their second and third biological agent, respectively. The probability of SCR at 26 week was 19.9% (95% CI, 15.9-24.5). The probability of survival free of loss of response at 2 year was 45.7% (95% CI, 32.5-59.5). A predictor of SCR was age at CD diagnosis of >40 years old (hazard ratio, HR relative to those <17, 4.69; 95% CI, 1.75-12.61). Negative predictors included present perianal fistula (HR, 0.39; 95% CI, 0.16-0.98) and prior primary nonresponse to adalimumab (ADA; HR relative to secondary loss of response, 0.18; 95% CI, 0.04-0.76). Twenty-three patients (6.4%) experienced serious adverse events and 19 patients (5.3%) discontinued CZP due to adverse events.

CONCLUSIONS

Certolizumab pegol was both effective and well tolerated for the treatment of Crohn's disease in this large tertiary care centre enriched with biologics-exposed patients. It may be more effective in patients without early-aged Crohn's disease diagnosis, prior primary nonresponse to adalimumab and present perianal fistula.

The Drosophila BTB domain protein Jim Lovell has roles in multiple larval and adult behaviors

Innate behaviors have their origins in the specification of neural fates during development. Within Drosophila, BTB (Bric-a-brac,Tramtrack, Broad) domain proteins such as Fruitless are known to play key roles in the neural differentiation underlying such responses. We previously identified a gene, which we have termed jim lovell (lov), encoding a BTB protein with a role in gravity responses. To understand more fully the behavioral roles of this gene we have investigated its function through several approaches. Transcript and protein expression patterns have been examined and behavioral phenotypes of new lov mutations have been characterized. Lov is a nuclear protein, suggesting a role as a transcriptional regulator, as for other BTB proteins. In late embryogenesis, Lov is expressed in many CNS and PNS neurons. An examination of the PNS expression indicates that lov functions in the late specification of several classes of sensory neurons. In particular, only two of the five abdominal lateral chordotonal neurons express Lov, predicting functional variation within this highly similar group. Surprisingly, Lov is also expressed very early in embryogenesis in ways that suggests roles in morphogenetic movements, amnioserosa function and head neurogenesis. The phenotypes of two new lov mutations that delete adjacent non-coding DNA regions are strikingly different suggesting removal of different regulatory elements. In lov⁴⁷, Lov expression is lost in many embryonic neurons including the two lateral chordotonal neurons. lov⁴⁷ mutant larvae show feeding and locomotor defects including spontaneous backward movement. Adult lov⁴⁷ males perform aberrant courtship behavior distinguished by courtship displays that are not directed at the female. lov⁴⁷ adults also show more defective negative gravitaxis than the previously isolated lov^91Y mutant. In contrast, lov⁶⁶ produces largely normal behavior but severe female sterility associated with ectopic lov expression in the ovary. We propose a negative regulatory role for the DNA deleted in lov⁶⁶.

Identification of genetic modifiers of TDP-43 neurotoxicity in Drosophila

Cytosolic aggregation of the nuclear RNA-binding protein TDP-43 is a histopathologic signature of degenerating neurons in amyotrophic lateral sclerosis (ALS), and mutations in the TARDBP gene encoding TDP-43 cause dominantly inherited forms of this condition. To understand the relationship between TDP-43 misregulation and neurotoxicity, we and others have used Drosophila as a model system, in which overexpression of either wild-type TDP-43 or its ALS-associated mutants in neurons is sufficient to induce neurotoxicity, paralysis, and early death. Using microarrays, we have examined gene expression patterns that accompany TDP-43-induced neurotoxicity in the fly system. Constitutive expression of TDP-43 in the Drosophila compound eye elicited widespread gene expression changes, with strong upregulation of cell cycle regulatory genes and genes functioning in the Notch intercellular communication pathway. Inducible expression of TDP-43 specifically in neurons elicited significant expression differences in a more restricted set of genes. Genes that were upregulated in both paradigms included SpindleB and the Notch target Hey, which appeared to be a direct TDP-43 target. Mutations that diminished activity of Notch or disrupted the function of downstream Notch target genes extended the lifespan of TDP-43 transgenic flies, suggesting that Notch activation was deleterious in this model. Finally, we showed that mutation of the nucleoporin Nup50 increased the lifespan of TDP-43 transgenic flies, suggesting that nuclear events contribute to TDP-43-dependent neurotoxicity. The combined findings identified pathways whose deregulation might contribute to TDP-43-induced neurotoxicity in Drosophila.

Natalizumab for moderate to severe Crohn's disease in clinical practice: the Mayo Clinic Rochester experience

BACKGROUND

Not all patients with Crohn's disease (CD) respond or maintain response to anti-tumor necrosis factor (TNF) agents and alternative treatment is necessary. Natalizumab, a monoclonal antibody to alpha-4 integrin approved for CD, has demonstrated efficacy in randomized clinical trials. We describe our experience with natalizumab in clinical practice at Mayo Clinic Rochester.

METHODS

Consecutive patients prescribed natalizumab for active CD were invited to participate and were followed prospectively. Incidence of infection, hospitalization, neoplasm, or other adverse events were recorded. Clinical activity was assessed using the Harvey-Bradshaw Index at each 30-day infusion visit.

RESULTS

Between April 2008 and September 2010, 36 patients were prescribed natalizumab and 30 (83.3%) agreed to participate. Median disease duration was 9 years (range, 3-43). Twenty-three patients had prior exposure to two anti-TNF agents, seven to one agent. All patients experienced at least one adverse event; none of the 13 patients in whom natalizumab was stopped (43%) discontinued due to adverse events. Five patients had infusions held for infection. No patient developed progressive multifocal leukoencephalopathy (PML). Fourteen patients (46%) had clinical response. The cumulative probability of achieving complete response within 1 year was 56% (28%-73%). Four of seven patients were weaned off corticosteroids.

CONCLUSIONS

In our experience with natalizumab in clinical practice, adverse events were manageable and did not result in treatment cessation. No PML cases were seen and clinical response was similar to that in clinical trials. Natalizumab results in clinical benefit in patients who have active disease and have failed anti-TNF therapy.

High-content RNAi screening identifies the Type 1 inositol triphosphate receptor as a modifier of TDP-43 localization and neurotoxicity

Cytosolic aggregation of the nuclear RNA-binding protein (RBP) TDP-43 (43 kDa TAR DNA-binding domain protein) is a suspected direct or indirect cause of motor neuron deterioration in amyotrophic lateral sclerosis (ALS). In this study, we implemented a high-content, genome-wide RNAi screen to identify pathways controlling TDP-43 nucleocytoplasmic shuttling. We identified ∼60 genes whose silencing increased the cytosolic localization of TDP-43, including nuclear pore complex components and regulators of G2/M cell cycle transition. In addition, we identified the type 1 inositol-1,4,5-trisphosphate (IP3) receptor (ITPR1), an IP3-gated, endoplasmic reticulum (ER)-resident Ca(2+) channel, as a strong modulator of TDP-43 nucleocytoplasmic shuttling. Knockdown or chemical inhibition of ITPR1 induced TDP-43 nuclear export in immortalized cells and primary neurons and strongly potentiated the recruitment of TDP-43 to Ubiquilin-positive autophagosomes, suggesting that diminished ITPR1 function leads to autophagosomal clearance of TDP-43. The functional significance of the TDP-43-ITPR1 genetic interaction was tested in Drosophila, where mutant alleles of ITPR1 were found to significantly extended lifespan and mobility of flies expressing TDP-43 under a motor neuron driver. These combined findings implicate IP3-gated Ca(2+) as a key regulator of TDP-43 nucleoplasmic shuttling and proteostasis and suggest pharmacologic inhibition of ITPR1 as a strategy to combat TDP-43-induced neurodegeneration in vivo.

RNA-binding proteins in neurodegenerative disease: TDP-43 and beyond

Neurodegenerative diseases are a diverse group of disorders that affect different neuron populations, differ in onset and severity, and can be either inherited or sporadic. One common pathological feature of most of these diseases is the presence of insoluble inclusions in and around neurons, which largely consist of misfolded and aggregated protein. For this reason, neurodegenerative diseases are typically thought to be disorders of aberrant protein processing, in which the cumulative effects of misfolded protein aggregates overwhelm the neuron's proteostatic capacity. However, a growing body of evidence suggests a role for abnormal RNA processing in neurodegenerative disease. The importance of RNA metabolism in disease was highlighted by the discovery of TDP-43 (TAR DNA-binding protein of 43 kDa), an RNA-binding protein (RBP), as a primary component of insoluble aggregates in patients with sporadic amyotrophic lateral sclerosis (ALS). Subsequently, inherited mutations in TDP-43 and the structurally related RBP, FUS/TLS (fused in sarcoma/translated in liposarcoma), were found to cause ALS. These exciting findings have ushered in a new era of ALS research in which the deregulation of RNA metabolism is viewed as a central cause of motor neuron deterioration. In addition, the fact that neuropathologically and anatomically distinct neurodegenerative diseases display altered RNA metabolism suggests that common pathologic mechanisms may underlie many of these disorders.

Ubiquilin modifies TDP-43 toxicity in a Drosophila model of amyotrophic lateral sclerosis (ALS)

TDP-43 (43-kDa TAR DNA-binding protein) is a major constituent of ubiquitin-positive cytosolic aggregates present in neurons of patients with amyotrophic lateral sclerosis (ALS) and ubiquitin-positive fronto-temporal lobar degeneration (FTLD-U). Inherited mutations in TDP-43 have been linked to familial forms of ALS, indicating a key role for TDP-43 in disease pathogenesis. Here, we describe a Drosophila melanogaster model of TDP-43 proteinopathy. Expression of wild-type human TDP-43 protein in Drosophila motor neurons led to motor dysfunction and dramatic reduction of life span. Interestingly, coexpression of ubiquilin 1, a previously identified TDP-43-interacting protein with suspected functions in autophagy and proteasome targeting, reduced steady-state TDP-43 expression but enhanced the severity of TDP-43 phenotypes. Finally, ectopically expressed TDP-43 was largely localized to motor neuron nuclei, suggesting that expression of wild-type TDP-43 alone is detrimental even in the absence of cytosolic aggregation. Our findings demonstrate that TDP-43 exerts cell-autonomous neurotoxicity in Drosophila and further imply that dose-dependent alterations of TDP-43 nuclear function may underlie motor neuron death in ALS.

Potentiation of amyotrophic lateral sclerosis (ALS)-associated TDP-43 aggregation by the proteasome-targeting factor, ubiquilin 1

TDP-43 (43-kDa TAR DNA-binding domain protein) is a major constituent of ubiquitin-positive cytoplasmic aggregates present in neurons of patients with fronto-temporal lobular dementia and amyotrophic lateral sclerosis (ALS). The pathologic significance of TDP-43 aggregation is not known; however, dominant mutations in TDP-43 cause a subset of ALS cases, suggesting that misfolding and/or altered trafficking of TDP-43 is relevant to the disease process. Here, we show that the presenilin-binding protein ubiquilin 1 (UBQLN) plays a role in TDP-43 aggregation. TDP-43 interacted with UBQLN both in yeast and in vitro, and the carboxyl-terminal ubiquitin-associated domain of UBQLN was both necessary and sufficient for binding to polyubiquitylated forms of TDP-43. Overexpression of UBQLN recruited TDP-43 to detergent-resistant cytoplasmic aggregates that colocalized with the autophagosomal marker, LC3. UBQLN-dependent aggregation required the UBQLN UBA domain, was mediated by non-overlapping regions of TDP-43, and was abrogated by a mutation in UBQLN previously linked to Alzheimer disease. Four ALS-associated alleles of TDP-43 also coaggregated with UBQLN, and the extent of aggregation correlated with in vitro UBQLN binding affinity. Our findings suggest that UBQLN is a polyubiquitin-TDP-43 cochaperone that mediates the autophagosomal delivery and/or proteasome targeting of TDP-43 aggregates.

Upper airway occlusion by soil--an unusual cause of death in vehicle accidents

Upper airway obstruction by soil is a rare cause of death in motor vehicle accidents. Four cases were found in a search of the records of the Forensic Science Centre in Adelaide, South Australia over a twenty-year period from January 1982 to December 2001. Case 1: A 68-year-old male driver died from sand inhalation after he was trapped in his vehicle following an accident. His mouth and upper airway were packed with sand. Case 2: A 33-year-old male pedestrian died from smothering after he had been knocked over and had his head pressed face down into sandy soil by a vehicle wheel. Case 3: A 12-year-old male passenger died from soil inhalation after the vehicle in which he was travelling rolled over and filled with soil. His mouth and upper airway were packed with soil. In these cases the victims had been trapped with the face covered in fine, or loose, soil or sand. In Case 4 a 41-year-old male passenger was ejected from a vehicle. He died from blunt chest trauma exacerbated by occlusion of the mouth and nose by soil. Careful scene descriptions are required in the assessment of such cases, in addition to evaluation of the relative contribution of injuries and asphyxia to the fatal episode.

Suicide methods in the elderly in South Australia 1981-2000

The files of the Forensic Science Centre in Adelaide, Australia were examined over a 20-year period from 1981 to 2000 for cases of suicide in individuals aged 65 years and over. A total of 445 cases were found (13.8% of all suicides) with an age range of 65-94 years (average= 73.5 years). All cases had undergone full autopsies and police investigation. There were significantly more male than female victims; M:F = 330:115 (p < 0.001). Hangings accounted for the highest proportion of cases (107/445; 24%) followed by gunshot wounds (96/445; 21.6%), drug toxicity (82/435; 18.9%), drowning (66/445; 14.8%), and carbon monoxide toxicity (52/445; 11.7%). A miscellaneous group accounted for 42 of 445 cases (9.2%). No significant changes occurred in either the total suicide rate or in the rates in males and females, except for drowning deaths in males, which showed a significant decrease over time (p < 0.01). Female victims tended to avoid violent methods such as gunshot wounds in favour of drug overdose. Gunshot wound deaths were far less common than published data from other countries would indicate, with relative increases in deaths due to hanging, drug toxicity, drowning and carbon monoxide toxicity. An awareness of the considerable variability that occurs among populations in suicide methods and rates is important in determining local requirements for suicide prevention campaigns.

Fatal unintentional traumatic asphyxia in childhood

OBJECTIVE

The present study was undertaken to examine specific features of unintentional traumatic asphyxial deaths in childhood.

METHODS

Coronial files and records at the Forensic Science Centre in Adelaide, South Australia, were examined over a 35-year period from 1966 to 2000 for all cases of traumatic asphyxial death occurring in children under the age of 17 years.

RESULTS

Six cases of unintentional fatal traumatic asphyxia were identified. All of the victims were boys with an age range of 2-15 years (mean 6.8 years) and all were found dead at the scene. Fatal traumatic asphyxia resulted from entrapment beneath a chest of drawers, beneath a table tennis table, between a pile of wooden pallets and a metal fence, between a conveyor belt and its frame, and under a motor vehicle (in two cases).

CONCLUSIONS

Fatal traumatic asphyxia in childhood is a rare event, with younger children commonly being trapped by furniture or by industrial equipment while playing, and older children being trapped under motor vehicles in similar circumstances to adult traumatic asphyxial deaths. Unsupervised play of young children around heavy and potentially unstable pieces of furniture may be dangerous, particularly if more than one child is present. Unsupervised play of young children in industrial yards should be avoided.

Death due to electrocution in childhood and early adolescence

OBJECTIVES

To delineate the clinicopathological features of fatal childhood electrocutions and to identify specific risk factors.

METHODS

Coronial files in Adelaide (Australia) were searched from 1967 to 2001 and Medical Examiners' files in San Diego (USA) were searched from 1988 to 2001, for cases of deaths of children and adolescents younger than 16 years attributed to electrocution.

RESULTS

Sixteen cases were identified aged between 10 months and 15 years (mean 8.0 years) with a male : female ratio of 5 : 3. Deaths were due to accidents occurring while playing with or near faulty electrical equipment at home or at school (n = 8), electrical equipment while in the bath (n = 2), damaged outdoor electrical equipment (n = 1), overhead wires (n = 1), and a high voltage electricity substation (n = 1). In addition, one death was due to suicide involving an electrical appliance placed in a bath, and two other deaths occurred in older children who were moving equipment under overhead wires. No homicides were identified.

CONCLUSIONS

Childhood deaths due to electrocution are rare and are more likely to occur when children are playing around electrical wires or equipment, and often result from either faulty apparatus, or a lack of understanding of the potential dangers involved. The majority of deaths (11/16; 69%) occur in the home environment. In contrast to adult electrical deaths, high-voltage electrocutions, suicides and workplace deaths are uncommon. Strategies for eliminating childhood electrocution should concentrate on ensuring safe domestic environments with properly maintained electrical devices.

Management of calcium oxalate stones

This article discusses the incidence and prevalence of calcium oxalate renal stones. Etiology and risk factors for all renal stone formation are reviewed. The evaluation, diagnostic procedures, and management for new and recurrent stone formation are detailed. Management includes long-term pharmacologic and nonpharmacologic measures for successful prevention or reduction in the frequency of recurrent stones. Specific patient education factors, patient and family psychological aspects, and referral resources are discussed.

The hemodynamic effects of propofol in children with congenital heart disease

We studied the hemodynamic effects of propofol during elective cardiac catheterization in 30 children with congenital heart disease. Sixteen patients were without cardiac shunt (Group I), six had left-to-right cardiac shunt (Group II), and eight had right-to-left cardiac shunt (Group III). The mean (+/-SD) ages were 3.8+/-3.1 yr (Group I), 3.2+/-3.7 yr (Group II), and 1.0+/-0.6 yr (Group III). After sedation and cardiac catheter insertion, hemodynamic data and oxygen consumption were measured before and after the administration of propofol (2-mg/kg bolus, 50- to 200-microg x kg(-1) x min(-1) infusion), and values were compared by using a paired t-test (significance: P < 0.05). After the propofol administration, systemic mean arterial pressure and systemic vascular resistance decreased significantly and systemic blood flow increased significantly in all patient groups; heart rate, pulmonary mean arterial pressure, and pulmonary vascular resistance were unchanged. Pulmonary to systemic resistance ratio increased (Group I, P = 0.005; Group II, P = 0.03; Group III, P = 0.10). In patients with cardiac shunt, propofol resulted in decreased left-to-right flow and increased right-to-left flow; the pulmonary to systemic flow ratio decreased significantly (Group II, P = 0.005; Group III, P = 0.01). Clinically relevant decreases in Pao2 (P = 0.008) and Sao2 (P = 0.01) occurred in Group III patients. We conclude that propofol can result in clinically important changes in cardiac shunt direction and flow.

IMPLICATIONS

The principal hemodynamic effect of propofol in children with congenital heart defects is a decrease in systemic vascular resistance. In children with cardiac shunt, this results in a decrease in the ratio of pulmonary to systemic blood flow, and it can lead to arterial desaturation in patients with cyanotic heart disease.

Chronic pulmonary hypertension increases fetal lung cGMP phosphodiesterase activity

An experimental ovine fetal model for perinatal pulmonary hypertension of the neonate (PPHN) was characterized by altered pulmonary vasoreactivity and structure. Because past studies had suggested impaired nitric oxide-cGMP cascade in this experimental model, we hypothesized that elevated phosphodiesterase (PDE) activity may contribute to altered vascular reactivity and structure in experimental PPHN. Therefore, we studied the effects of the PDE inhibitors zaprinast and dipyridamole on fetal pulmonary vascular resistance and PDE5 activity, protein, mRNA, and localization in normal and pulmonary hypertensive fetal lambs. Infusion of dipyridamole and zaprinast lowered pulmonary vascular resistance by 55 and 35%, respectively, in hypertensive animals. In comparison with control animals, lung cGMP PDE activity was elevated in hypertensive fetal lambs (150%). Increased PDE5 activity was not associated with either an increased PDE5 protein or mRNA level. Immunocytochemistry demonstrated that PDE5 was localized to vascular smooth muscle. We concluded that PDE5 activity was increased in experimental PPHN, possibly by posttranslational phosphorylation. We speculated that these increases in cGMP PDE activity contributed to altered pulmonary vasoreactivity in experimental perinatal pulmonary hypertension.

Developmental changes in lung cGMP phosphodiesterase-5 activity, protein, and message

During transitional circulation, the pulmonary vascular bed undergoes a rapid and profound reduction in both tone and vascular smooth-muscle (VSM) content. 3',5'-Guanylate cyclic monophosphate (cGMP) is a crucial mediator in the regulation of pulmonary vascular resistance (PVR) and VSM proliferation. Hydrolysis of cGMP is achieved predominately by cGMP-specific phosphodiesterases (PDEs). Among the cGMP-specific PDEs, PDE5 is quantitatively prevalent in lung tissue. We have investigated the levels of pulmonary PDE5 enzymatic activity, protein, and messenger RNA (mRNA) in ovine and mouse lung during perinatal development. We report that within 1 h following birth, PDE5 activity, protein, and mRNA levels decrease in both species, in a manner that correlates with known decreases in PVR in early transition. However, from 4 to 7 d following birth, a secondary increase in PDE5 activity, protein, and mRNA occurs in both ovine and mouse lung, suggesting a complex regulation of PVR and VSM proliferation in late perinatal development. Our data imply that PDE5 may be an important mediator in the regulation of PVR in normal and possibly in pathologic states, and may ultimately provide a basis for PDE5 inhibitors as a treatment for pulmonary hypertension.

Current status of transurethral thermotherapy at the Mayo Clinic

With the ever-expanding elderly population in the United States, benign prostatic hyperplasia (BPH) has become a widespread condition. Although surgical intervention (open prostatectomy and transurethral resection of the prostate) was the typical management approach for BPH in the past, other options currently include drug therapy and transurethral thermotherapy, a minimally invasive procedure that involves the targeting of heat deep within the prostate transition zone while cooling the surrounding anatomic structures with circulating water. Two thermo-therapy-devices--the Prostatron and the T3 transurethral thermoablation therapy catheter--have been studied in randomized controlled clinical trials at the Mayo Clinic. Both devices were shown to be effective in a substantial subset of patients with BPH: symptom scores decreased, peak urinary flow rates increased, and total serum prostate-specific antigen levels increased, an indication of destruction of adenomatous tissue. All patients were able to complete the treatment without the need for general or regional anesthesia, and thermotherapy was associated with few postprocedural events. Although this therapeutic strategy is currently used selectively in patients with lateral lobe prostatic adenoma, improvements in technology and understanding of the thermoregulatory properties of the prostate should broaden the application of thermotherapy devices in the management of BPH.

Correlation between prostate size estimated by digital rectal examination and measured by transrectal ultrasound

OBJECTIVES

To correlate prostate size estimates performed by single or multiple examiners through digital rectal examination (DRE) with volume measured by transrectal ultrasound (TRUS) and to propose measures for predicting prostate volume using DRE estimates in clinical settings.

METHODS

Data from four sources were analyzed: (1) the Olmsted County community study of 397 patients examined by a single urology nurse, with TRUS measurements done by multiple examiners; (2) a community study in Stirling, Scotland, involving 480 patients with DRE and TRUS performed by one urologist; (3) baseline data from the Veterans Affairs Cooperative Study No. 359 in 1222 patients with DRE and TRUS measurements by multiple personnel at 31 centers; and (4) a clinical series of 100 men with DRE and TRUS by a single urologist.

RESULTS

DRE estimates and TRUS volumes were significantly correlated (r = 0.4 to 0.9), but prostate size was underestimated by 25% to 55% for men with a prostate volume over 40 mL, depending on the study, with greater variability for studies involving multiple examiners. In one study that assessed prostate dimensions by DRE, posterior surface area (SA) correlated with overall TRUS volume (r = 0.4). According to receiver operating characteristic curves, SA showed a 70% and 76% chance of correctly identifying men with prostate volume greater than 30 or 40 mL, respectively; those with larger prostates were best distinguished by SA greater than 7 cm2 (sensitivity greater than 0.74, specificity greater than 0.50).

CONCLUSIONS

DRE underestimates prostate size, particularly if TRUS volume is greater than 30 mL. However, DRE estimates may help identify prostates likely to be larger than certain cutpoints by TRUS. Posterior SA may be useful as a preliminary assessment when prostate size is an important predictor of therapeutic response.

Role of a urology nurse in evaluating patients with prostatism

Nurses play a prominent role in educating patients. This article presents experiences of one certified urology nurse collaborating with a urologist in the initial evaluation of 475 men randomly selected from the community for urinary symptoms or health status work-ups. Referrals to the urologist for further diagnosis and treatment were made for suspicion of prostate cancer, moderate to severe symptoms of prostatism, and microhematuria. The nurse also provided information about treatment options and watchful waiting. Participants showed a strong acceptance of the nurse in performing assessments.

Does the mode of questionnaire administration affect the reporting of urinary symptoms?

OBJECTIVES

To assess the effect of modes of administration (self-administered questionnaires, oral face-to-face interview, and telephone interview) on responses to the American Urological Association Symptom Index (AUASI) in randomly selected community men.

METHODS

An age-stratified random sample of 475 white male residents of Olmsted County, Minnesota, aged 40 to 79 years, without prior prostate surgery or prostate cancer were queried about urinary symptom frequency twice at baseline and twice approximately 2 years later using questions with wording similar to the AUASI: At baseline and first follow-up, questionnaires were self-administered initially, followed by a structured interview by a female urology nurse within 2 to 28 weeks. A subset of 200 randomly selected men received a telephone interview by a female research assistant following the self-administered questionnaire given at a second follow-up approximately 4 years after baseline.

RESULTS

Mean symptom scores obtained by oral interview were 1 to 2 points lower than those from self-administered questionnaires (P < 0.01). In a random subset (n = 200) interviewed by telephone, mean AUASI scores were as much as 4 points lower than those from self-completed questionnaires.

CONCLUSIONS

Values of the AUASI obtained by interviewer administration may be lower than those obtained by self-administered questionnaires. When assessment of change in urinary symptoms over time is of interest, the same standardized method of questionnaire administration should be used at baseline and follow-up evaluations to avoid introducing artifactual differences related to the mode of administration.

Evaluation of a sexual assault prevention program

The purpose of this investigation was to empirically evaluate a sexual assault prevention program. Of the 360 female college students who participated in the investigation, 181 students were in the treatment group and 165 students were in the control group. Although the program was not effective in decreasing the incidence of sexual assault for women with a sexual assault history, it was effective in decreasing the incidence of sexual assault for women without a sexual assault history. The program also led to a decrease in dating behaviors found to be associated with acquaintance rape and an increase in knowledge about sexual assault for the treatment group. The implications of these results for future preventive efforts are discussed.

Evaluation of a sexual assault prevention program

The purpose of this investigation was to empirically evaluate a sexual assault prevention program. Of the 360 female college students who participated in the investigation, 181 students were in the treatment group and 165 students were in the control group. Although the program was not effective in decreasing the incidence of sexual assault for women with a sexual assault history, it was effective in decreasing the incidence of sexual assault for women without a sexual assault history. The program also led to a decrease in dating behaviors found to be associated with acquaintance rape and an increase in knowledge about sexual assault for the treatment group. The implications of these results for future preventive efforts are discussed.

Isoflurane partially preserves energy balance in isolated hepatocytes during in vitro anoxia

We investigated whether a volatile anesthetic (1.5% isoflurane or 1.0% halothane) or an added anaerobic energy source (10 mM glucose or fructose) could act directly on liver cells to protect energy status during 20-30 min of anoxia. We used hepatocytes freshly isolated from fed rats or rats that had fasted, suspended them in Krebs' buffer, and incubated them in sealed flasks under O2/CO2 or N2/CO2 (95%:5%). The adenosine triphosphate (ATP) to adenosine diphosphate (ADP) ratio (ATP/ADP) measured cellular energy balance--the balance between overall ATP supply and demand. Lactate levels measured the extent to which ATP was supplied by the nonmitochondrial pathway, (anaerobic) glycolysis. Maximum values of energy balance were seen in cells from fed rats incubated in the presence of glucose and O2. When glucose was replaced by fructose, ATP/ADP decreased and lactate increased. During anoxia (O2 replaced by N2), increases in lactate were also seen with glucose; and ATP/ADP decreased to similarly low values with both substrates. In cells from fasted rats, ATP/ADP decreased significantly below the value for cells from fed rats only in the presence of glucose and O2. Compared with cells from fed rats, cells from fasted rats showed decreased lactate in the face of decreased ATP/ADP, suggesting that glycolysis was impaired. Isoflurane partially prevented anoxia-induced decreases in ATP/ADP. This protective effect on energy balance occurred equally with glucose and fructose, but was not seen in cells from fasted rats or with halothane. Thus, 1 MAC isoflurane and some factor(s) related to the fed state combined to protect partially the energy balance in anoxic liver cells through action(s) at the cellular level.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunomodulatory action of levamisole--II. Enhancement of concanavalin A response by levamisole is associated with an oxidation degradation product of levamisole formed during lymphocyte culture

Previously we determined that levamisole (LMS), when stored for a period of time, breaks down to three degradation products at neutral and alkaline pH. At low concentrations (10(-6) M), Product 1 inhibits the lymphocyte response to concanavalin A (Con A). Product 2 enhances the response and Product 3 has no effect. At higher concentrations (10(-5) M) all three products inhibit the response. To determine if these products are formed in culture media under culture conditions (e.g. in RPMI-1640 bicarbonate buffered medium, 37 degrees C, pH 7.0-7.5, during a 72 h culture period), we added freshly prepared LMS solutions to culture media with and without lymphocytes present and maintained the pH at 7.0, 7.25 or 7.5 by varying the amount of CO2 present. Periodically over a 72 h period, aliquots of the media were removed and analyzed for the presence of LMS and the three degradation products. Within 4 h, two of the degradation product began to form in culture media with or without lymphocytes present. Product No. 1, 3-(2-mercaptoethyl)-5-phenylimidazolidine-2-one or dl-2-oxy-3-(2-mercaptoethyl)-5-phenylimidazolidine (OMPI), which inhibits the lymphocyte response to concanavalin A (Con A) at concentrations above 0.4 micrograms/ml, was formed at pH 7.0, 7.25 and 7.5, but the compound did not reach inhibitory concentrations in the lymphocyte cultures during the 72 h culture period. Product No. 2, 6-phenyl-2,3-dihydroimidazo (2,1-b) thiazole, which enhances the Con A response between concentrations of 0.5 and 10 micrograms/ml, was detected at concentrations between 2.5 and 3.5 micrograms/ml at pH 7.25 and 7.5. Product 2 was not detected in cultures at pH 7.0 and subsequently when we cultured lymphocytes with freshly prepared LMS and maintained the pH at 7.0, no significant enhancement of the Con A response was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunomodulatory action of levamisole--I. Structural analysis and immunomodulating activity of levamisole degradation products

In our laboratory we observed that solutions of levamisole (LMS) stored at 4 degrees C consistently enhanced the lymphocyte proliferation response to concanavalin A (Con A) more than freshly prepared solutions did. To determine if the increased immunopotentiation observed with the stored solutions of LMS was due to products formed from LMS, we assessed the stability of LMS when stored at 4 or 37 degrees C at pH 6, 7, 7.5 and 8. Analysis of the various solutions by high pressure liquid chromatography demonstrated that LMS decomposes during storage in neutral and alkaline conditions to form three products. The formation of the products was accelerated by increasing the temperature from 4 to 37 degrees C. The three degradation products were purified by preparative high pressure liquid chromatography and their structures determined by mass spectrometry, infrared spectrometry and homo- and heteronuclear two dimensional nuclear magnetic resonance spectroscopy. The degradation products, denoted as No. 1, No. 2 and No. 3, based on their high pressure liquid chromatography retention times, were identified as: No. 1, 3-(2-mercaptoethyl)-5-phenylimidazolidine-2-one; No. 2, 6-phenyl-2,3-dihydroimidazo (2,1-b) thiazole and No. 3, bis [3-(2-oxo-5-phenylimidazolidin-1-yl) ethyl] disulfide. Product 2 significantly enhanced murine lymphocyte proliferation responses to concanavalin A (Con A) at concentrations between 0.5 and 10.0 micrograms/ml (whereas the optimum concentration of LMS is 10-100 fold higher (50-100 micrograms/ml)). Products 1, 2 and 3 significantly inhibited the lymphocyte proliferative response at concentrations greater than 2.2, 10.0 and 10.0 micrograms/ml, respectively. These studies indicate that under relatively mild conditions, including physiological conditions, LMS may decompose to products which inhibit or enhance lymphocyte responses to Con A.