Delayed Presentation of Berardinelli-Siep Lipodystrophy in an Adolescent Female

Berardinelli-Siep syndrome (BSS) is a form of congenital generalized lipodystrophy that disrupts the pathways of lipid metabolism. It presents with physical exam findings, including muscular hypertrophy and lipoatrophy as well as serious metabolic consequences such as diabetes mellitus, hypertriglyceridemia, acute pancreatitis, hepatomegaly, and hepatic steatosis. Diagnosis generally occurs soon after birth or in childhood. The case presented is significant for a delayed diagnosis of suspected BSS Type 1 which is rather uncommon in a developed country. Due to the detrimental complications of BSS, such as hypertrophic cardiomyopathy, pancreatitis, and liver disease, early diagnosis and intervention are crucial. Pediatric providers must be knowledgeable about physical features of BSS and common presentations such as new onset diabetes, hypertriglyceridemia, or pancreatitis throughout early childhood and adolescence in order to avoid delayed diagnoses.

Nitrogen and fatty acid rumen metabolism in cattle offered high or low polyphenol oxidase red clover silage

Polyphenol oxidase (PPO) in red clover (RC) has been shown to reduce both lipolysis and proteolysis in silo and implicated (in vitro) in the rumen. However, all in vivo comparisons have compared RC with other forages, typically with lower levels of PPO, which brings in other confounding factors as to the cause for the greater protection of dietary nitrogen (N) and C18 polyunsaturated fatty acids (PUFA) on RC silage. This study compared two RC silages which when ensiled had contrasting PPO activities (RC+ and RC-) against a control of perennial ryegrass silage (PRG) to ascertain the effect of PPO activity on dietary N digestibility and PUFA biohydrogenation. Two studies were performed the first to investigate rumen and duodenal flow with six Hereford×Friesian steers, prepared with rumen and duodenal cannulae, and the second investigating whole tract N balance using six Holstein-Friesian non-lactating dairy cows. All diets were offered at a restricted level based on animal live weight with each experiment consisting of two 3×3 Latin squares using big bale silages ensiled in 2010 and 2011, respectively. For the first experiment digesta flow at the duodenum was estimated using a dual-phase marker system with ytterbium acetate and chromium ethylenediaminetetraacetic acid as particulate and liquid phase markers, respectively. Total N intake was higher on the RC silages in both experiments and higher on RC- than RC+. Rumen ammonia-N reflected intake with ammonia-N per unit of N intake lower on RC+ than RC-. Microbial N duodenal flow was comparable across all silage diets with non-microbial N higher on RC than the PRG with no difference between RC+ and RC-, even when reported on a N intake basis. C18 PUFA biohydrogenation was lower on RC silage diets than PRG but with no difference between RC+ and RC-. The N balance trial showed a greater retention of N on RC+ over RC-; however, this response is likely related to the difference in N intake over any PPO driven protection. The lack of difference between RC silages, despite contrasting levels of PPO, may reflect a similar level of protein-bound-phenol complexing determined in each RC silage. Previously this complexing has been associated with PPOs protection mechanism; however, this study has shown that protection is not related to total PPO activity.

Hemostatic effects of two desogestrel-containing combined oral contraceptive regimens: a multinational, multicenter, randomized, open-label study

PURPOSE OF INVESTIGATION

To compare the effects of desogestrel (DSG) 150 mcg/ethinyl estradiol (EE) 20 mcg for 21 days followed by either seven days of EE ten mcg (21/7-active) or no treatment (DSG/EE+no Tx) on hemostatic markers.

MATERIALS AND METHODS

This was a randomized, multicenter, open-label study that enrolled healthy premenopausal women. Non-inferiority of 21/7-active to DSG/EE+no Tx was determined if the upper limit of the two-sided 95% CI of the mean treatment difference in prothrombin fragment 1+2 (F1+2) over 24 weeks between groups was < 130 pmol/L.

RESULTS

246 subjects (n = 125, 21/7-active; n = 121, DSG/EE+no Tx) comprised the primary analysis. Mean F1+2 levels increased in both 21/7-active and DSG/EE+no Tx regimens (least square [LS] mean changes +45 pmol/L and +56.8 pmol/L, respectively). LS mean treatment difference was -11.8 pmol/L (95% CI: -54.8, 31.2).

CONCLUSION

The effect of adding EE ten mcg to the seven-day hormone-free interval of DSG/EE on F1+2 levels was non-inferior to traditional DSG/EE.

The effect of high polyphenol oxidase grass silage on metabolism of polyunsaturated fatty acids and nitrogen across the rumen of beef steers

Polyphenol oxidase (PPO) activity in red clover (Trifolium pratense) has been reported to reduce both proteolysis and lipolysis, resulting in greater N use efficiency and protection of PUFA across the rumen. Although high levels of PPO have been reported in grasses such as cocksfoot (orchard grass; Dactylis glomerata), no in vivo research has determined whether grass PPO elicits the same response as red clover PPO. To test the hypothesis that silage ensiled from grass with high levels of PPO protects N and PUFA across the rumen, 6 steers with ruminal and duodenal cannulas were offered cocksfoot silage (CO; high-PPO grass), perennial ryegrass silage (PR; Lolium perenne; low-PPO grass), or red clover silage (RC; high-PPO control) at 16 g DM/kg BW daily with the experiment consisting of two 3 × 3 Latin squares with 21-d periods, consisting of 12 d of diet adaptation, 6 d of duodenal marker infusion, 2 d of duodenal sampling, and 1 d of ruminal sampling. All silages were well preserved, with DM of 34.4, 55.3, and 45.4% for CO, PR, and RC. Activity of PPO in silages was low due to deactivation but was greater in CO than either PR or RC (0.15 vs. 0.05 and 0.08 μkatal/g DM). Protein-bound phenol (mg/g DM) as a measure of the degree of oxidation and an indication of PPO protection was greatest for RC (15.9) but comparable for PR (10.1) and CO (12.2). Biohydrogenation of C18 PUFA was significantly lower on RC compared to the 2 grass silages with CO greater than PR. Despite lower levels of total fatty acid intake and subsequent duodenal flow, CO resulted in greater levels of phytanic acid and total branched and odd chain fatty acids in duodenal digesta than RC or PR. Ruminal ammonia concentration was greatest for RC, with no difference between the grasses. Duodenal flow of microbial N and efficiency of microbial protein synthesis were lowest for CO and comparable for RC and PR. The CO (high-grass PPO) did not result in elevated levels of C18 PUFA escaping the rumen or improve efficiency of total N transfer through the rumen compared to PR. The RC resulted in a greater flow of N and nonmicrobial N to the duodenum than the 2 grasses with PR greater than CO.

Improved upper limits on the stochastic gravitational-wave background from 2009-2010 LIGO and Virgo data

Gravitational waves from a variety of sources are predicted to superpose to create a stochastic background. This background is expected to contain unique information from throughout the history of the Universe that is unavailable through standard electromagnetic observations, making its study of fundamental importance to understanding the evolution of the Universe. We carry out a search for the stochastic background with the latest data from the LIGO and Virgo detectors. Consistent with predictions from most stochastic gravitational-wave background models, the data display no evidence of a stochastic gravitational-wave signal. Assuming a gravitational-wave spectrum of Ω_{GW}(f)=Ω_{α}(f/f_{ref})^{α}, we place 95% confidence level upper limits on the energy density of the background in each of four frequency bands spanning 41.5-1726 Hz. In the frequency band of 41.5-169.25 Hz for a spectral index of α=0, we constrain the energy density of the stochastic background to be Ω_{GW}(f)<5.6×10^{-6}. For the 600-1000 Hz band, Ω_{GW}(f)<0.14(f/900  Hz)^{3}, a factor of 2.5 lower than the best previously reported upper limits. We find Ω_{GW}(f)<1.8×10^{-4} using a spectral index of zero for 170-600 Hz and Ω_{GW}(f)<1.0(f/1300  Hz)^{3} for 1000-1726 Hz, bands in which no previous direct limits have been placed. The limits in these four bands are the lowest direct measurements to date on the stochastic background. We discuss the implications of these results in light of the recent claim by the BICEP2 experiment of the possible evidence for inflationary gravitational waves.

Pacing, the missing piece of the puzzle to high-intensity interval training

This study examined physiological and perceptual responses to matched work high-intensity interval training using all-out and 2 even-paced methodologies. 15 trained male cyclists performed 3 interval sessions of three 3-min efforts with 3 min of active recovery between efforts. The initial interval session was completed using all-out pacing, with the following 2 sessions being completed with computer- and athlete-controlled pacing in a randomised and semi-counterbalanced manner. Computer- and athlete-controlled intervals were completed at the mean power from the corresponding interval during the all-out trial. Oxygen consumption and ratings of perceived exertion were recorded during each effort. 20 min following each session, participants completed a 4-km time trial and provided sessional rating of perceived exertion. Oxygen consumption was greater during all-out (54.1±6.6 ml.kg(-1).min(-1); p<0.01) and athlete-controlled (53.0±5.8 ml.kg(-1).min(-1); p<0.01) compared with computer-controlled (51.5±5.7 ml.kg(-1).min(-1)). Total time ≥85% maximal oxygen consumption was greater during all-out compared to both even-paced efforts. Sessional ratings of perceived exertion were greater after all-out compared to both even-paced sessions. Mean 4-km power output was lower after all-out compared with both even paced intervals. Distribution of pace throughout high-intensity interval training can influence perceptual and metabolic stress along with subsequent performance and should be considered during the prescription of such training.

The effect of high polyphenol oxidase grass silage on metabolism of polyunsaturated fatty acids and nitrogen across the rumen of beef steers

Polyphenol oxidase (PPO) activity in red clover (Trifolium pratense) has been reported to reduce both proteolysis and lipolysis, resulting in greater N use efficiency and protection of PUFA across the rumen. Although high levels of PPO have been reported in grasses such as cocksfoot (orchard grass; Dactylis glomerata), no in vivo research has determined whether grass PPO elicits the same response as red clover PPO. To test the hypothesis that silage ensiled from grass with high levels of PPO protects N and PUFA across the rumen, 6 steers with ruminal and duodenal cannulas were offered cocksfoot silage (CO; high-PPO grass), perennial ryegrass silage (PR; Lolium perenne; low-PPO grass), or red clover silage (RC; high-PPO control) at 16 g DM/kg BW daily with the experiment consisting of two 3 × 3 Latin squares with 21-d periods, consisting of 12 d of diet adaptation, 6 d of duodenal marker infusion, 2 d of duodenal sampling, and 1 d of ruminal sampling. All silages were well preserved, with DM of 34.4, 55.3, and 45.4% for CO, PR, and RC. Activity of PPO in silages was low due to deactivation but was greater in CO than either PR or RC (0.15 vs. 0.05 and 0.08 μkatal/g DM). Protein-bound phenol (mg/g DM) as a measure of the degree of oxidation and an indication of PPO protection was greatest for RC (15.9) but comparable for PR (10.1) and CO (12.2). Biohydrogenation of C18 PUFA was significantly lower on RC compared to the 2 grass silages with CO greater than PR. Despite lower levels of total fatty acid intake and subsequent duodenal flow, CO resulted in greater levels of phytanic acid and total branched and odd chain fatty acids in duodenal digesta than RC or PR. Ruminal ammonia concentration was greatest for RC, with no difference between the grasses. Duodenal flow of microbial N and efficiency of microbial protein synthesis were lowest for CO and comparable for RC and PR. The CO (high-grass PPO) did not result in elevated levels of C18 PUFA escaping the rumen or improve efficiency of total N transfer through the rumen compared to PR. The RC resulted in a greater flow of N and nonmicrobial N to the duodenum than the 2 grasses with PR greater than CO.

Search for gravitational waves associated with γ-ray bursts detected by the interplanetary network

We present the results of a search for gravitational waves associated with 223 γ-ray bursts (GRBs) detected by the InterPlanetary Network (IPN) in 2005-2010 during LIGO's fifth and sixth science runs and Virgo's first, second, and third science runs. The IPN satellites provide accurate times of the bursts and sky localizations that vary significantly from degree scale to hundreds of square degrees. We search for both a well-modeled binary coalescence signal, the favored progenitor model for short GRBs, and for generic, unmodeled gravitational wave bursts. Both searches use the event time and sky localization to improve the gravitational wave search sensitivity as compared to corresponding all-time, all-sky searches. We find no evidence of a gravitational wave signal associated with any of the IPN GRBs in the sample, nor do we find evidence for a population of weak gravitational wave signals associated with the GRBs. For all IPN-detected GRBs, for which a sufficient duration of quality gravitational wave data are available, we place lower bounds on the distance to the source in accordance with an optimistic assumption of gravitational wave emission energy of 10(-2)M⊙c(2) at 150 Hz, and find a median of 13 Mpc. For the 27 short-hard GRBs we place 90% confidence exclusion distances to two source models: a binary neutron star coalescence, with a median distance of 12 Mpc, or the coalescence of a neutron star and black hole, with a median distance of 22 Mpc. Finally, we combine this search with previously published results to provide a population statement for GRB searches in first-generation LIGO and Virgo gravitational wave detectors and a resulting examination of prospects for the advanced gravitational wave detectors.

Search for gravitational waves associated with γ-ray bursts detected by the interplanetary network

We present the results of a search for gravitational waves associated with 223 γ-ray bursts (GRBs) detected by the InterPlanetary Network (IPN) in 2005-2010 during LIGO's fifth and sixth science runs and Virgo's first, second, and third science runs. The IPN satellites provide accurate times of the bursts and sky localizations that vary significantly from degree scale to hundreds of square degrees. We search for both a well-modeled binary coalescence signal, the favored progenitor model for short GRBs, and for generic, unmodeled gravitational wave bursts. Both searches use the event time and sky localization to improve the gravitational wave search sensitivity as compared to corresponding all-time, all-sky searches. We find no evidence of a gravitational wave signal associated with any of the IPN GRBs in the sample, nor do we find evidence for a population of weak gravitational wave signals associated with the GRBs. For all IPN-detected GRBs, for which a sufficient duration of quality gravitational wave data are available, we place lower bounds on the distance to the source in accordance with an optimistic assumption of gravitational wave emission energy of 10(-2)M⊙c(2) at 150 Hz, and find a median of 13 Mpc. For the 27 short-hard GRBs we place 90% confidence exclusion distances to two source models: a binary neutron star coalescence, with a median distance of 12 Mpc, or the coalescence of a neutron star and black hole, with a median distance of 22 Mpc. Finally, we combine this search with previously published results to provide a population statement for GRB searches in first-generation LIGO and Virgo gravitational wave detectors and a resulting examination of prospects for the advanced gravitational wave detectors.

Constraints on cosmic strings from the LIGO-Virgo gravitational-wave detectors

Cosmic strings can give rise to a large variety of interesting astrophysical phenomena. Among them, powerful bursts of gravitational waves (GWs) produced by cusps are a promising observational signature. In this Letter we present a search for GWs from cosmic string cusps in data collected by the LIGO and Virgo gravitational wave detectors between 2005 and 2010, with over 625 days of live time. We find no evidence of GW signals from cosmic strings. From this result, we derive new constraints on cosmic string parameters, which complement and improve existing limits from previous searches for a stochastic background of GWs from cosmic microwave background measurements and pulsar timing data. In particular, if the size of loops is given by the gravitational backreaction scale, we place upper limits on the string tension Gμ below 10(-8) in some regions of the cosmic string parameter space.

Early prediction of pathological complete response (pCR) of rectal cancer after 1 week of preoperative radiochemotherapy (RCT) using positron emission computererized tomography (PET-CT) imaging

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Background: Preoperative radiochemotherapy (RCT) is the standard treatment of locally advanced rectal cancer (LARC), obtaining pathological complete response (pCR) in 15%-30% of cases. Post-RCT reduction of 18F-fluorodeoxyglucose (FDG) uptake within the tumor compared with the baseline, i.e. the tumor's metabolic response, correlates with pCR. However, an earlier prediction of pCR could enable tailored modifications of the treatment. We hence evaluated the correlation between the metabolic response after only one week of RCT for LARC and the actual pCR at the post-RCT surgery.

Methods: Patients (pts) were eligible for this prospective study if they had LARC, defined as T3-4NX or TxN+ tumors by pre-treatment PET-CT and endoscopic ultrasound. Pts received standard RCT regimen, consisting of 50.4Gy radiotherapy concurrently with a fluoropyrimidine-based chemotherapy, followed by surgery. Pts underwent baseline FDG-PET-CT imaging within 2 weeks prior to the initiation of RCT and a second one on day 8 of RCT. Maximum standardized uptake value (SUV-max) was measured in both scans and changes in FDG- uptake were recorded. Man-Whitney test was used to evaluate differences in the SUV-max between baseline and day 8 in pts obtaining pCR and those who did not.

Results: Twenty pts participated in the study. Half were males and the median age was 64 years. Ten pts had T3N0 tumors and 10 had T3N+ disease. Radical surgery was done in 19 pts and local excision in one. Considering the entire group, there was a borderline-significant difference between the metabolic response of pts with pCR and those without pCR (Chi-square = 3.429, p = 0.064). Yet, the changes in FGD-uptake were able to identify pts who achieved pCR and those who did not: only pts with a decrease of more than 33% in SUV-max had pCR while none of the pts who had less than 8.9% decrease in SUV-max had pCR.

Conclusions: A decrease in SUV-max between baseline-PET-CT scans and scans done after only one week of RCT for LARC may be able to predict the achievement of pCR in the post-RCT surgical specimen. Validation in a larger independent cohort is planned.

No significant financial relationships to disclose.

The role of postoperative PET-CT in the evaluation of patients with high-risk stage III colorectal cancer (CRC)

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Background: Routine PET-CT evaluation is still not indicated for stage III CRC patients; however accumulating data suggest that it may modify these patients' staging and treatment. We hence evaluated the role of PET-CT in high risk stage III CRC patients and to characterize positive predictors.

Methods: Retrospective chart review of stage III CRC patients who underwent PET-CT for being at high risk for systemic disease attributable to: early T stage (T < 3), grade > 3, < 12 lymph-nodes examined, > 3 involved lymph-nodes, elevated postoperative CEA and/or CA-19.9. The demographic and clinicopathological characteristics of patients found to have metastatic disease were compared to those who were negative.

Results: Seventy-three patients (33 males [45%], median age 67 years [range: 29-88 years]) were included. Pathologic FDG-uptake was observed in 33 (45%) patients. Of them, 16 (22%) were upstaged with altered treatment protocol, 13 (18%) required further work-up and 4 (5%) were found to have post operative changes. Elevated post-operative CEA and CA-19.9 levels correlated with positive PET-CT (p = 0.002 and p = 0.015, respectively). None of the other examined parameters differed between the groups. With a median follow-up of 26 months (range:1-63 months), overall survival was 88% in patients with positive PET-CT and 92% in patients with negative PET-CT. Eight patients in the positive group were disease free following metastectomy, five were alive with disease, two patients died of disease and one patient died of other cause.

Conclusions: Selective postoperative PET-CT influenced staging/therapy in 22% of high risk stage III CRC patients. Postoperative CEA and CA-19.9 levels may play a role in selecting eligible patients. Failure to identify other parameters may be related to the preexisting selection bias and the small cohort.

No significant financial relationships to disclose.

The Jamaica Injury Surveillance System: a profile of the intentional and unintentional injuries in Jamaican hospitals

BACKGROUND

Injuries in Jamaica are a major public health problem as demonstrated by a hospital based computerized injury surveillance system established in 1999 that provides a risk profile for injuries.

SUBJECTS AND METHOD

Injury data from 2004 were selected to provide an annual profile, as comprehensive injury data were available from nine public hospitals. These nine public hospitals provide care for 70% of the Jamaicans admitted to hospitals annually.

RESULTS

Data are presented on unintentional injuries where falls caused 44%, lacerations 27% and accidental blunt injuries were 17% of these. For motor vehicle related injuries, 55% were sustained while commuting by motorcars, 17% while riding motorbikes/bicycles and 16% of those injured were pedestrians. Most violence related injuries were due to fights (76%) with acquaintances (47%) who used sharp objects (40%) to inflict the injury.

CONCLUSION

The Jamaica Injury Surveillance System (JISS) data, augmented by data collected on injuries from the health centres and the sentinel surveillance system, give a measure of the magnitude of the impact of injuries on the health services. The JISS provides data on the profile of injuries seen and treated at health facilities in Jamaica. In collaboration with police data and community-based surveys, it can be used to complete the risk profiles for different types of injuries. The data generated at the parish, regional and national levels form the basis for the design and monitoring of prevention programmes, as well as serve to support and evaluate policy, legislative control measures and measures that impact on interventions.

Segawa's disease: dopa-responsive dystonia

The genetics and symptoms of Segawa's disease are described. The latter can show considerable variation, especially if the onset of the condition is delayed. It is usually of autosomal dominant inheritance, but a recessive form can occur. The dominant and recessive forms are caused by a gene mapped to chromosome 14. The fluctuating dystonia is typical, but is not essential for the diagnosis. Affected children can suffer from sleep disorders, such as excessive sleepiness and nightmares. In some children with this condition mutations in the GCH-1 gene coding for guanosine triphosphate cyclohydrolase 1 have been found. The enzyme catalyses the first step in the biosynthesis of tetrahydrobiopterin. A point mutation in the tyrosine hydrolase gene has been found in some of the recessive forms, and the gene mapped to chromosome 11, but this cannot be called Segawa's disease. The deficiency of guanosine triphosphate cyclohydrolase 1 causes a defect in serotonin metabolism and in the biosynthesis of tetrabiopterin and a disturbance of dopamine metabolism. This leads to a deficiency of dopamine in the striatum, and to the motor dysfunction of the syndrome. The diagnosis can be established by cerebrospinal fluid examination, and confirmed in some patients by genetic studies. Treatment is with levodopa, and the results are dramatic.

Oral health care for children attending a malnutrition clinic in South Africa

Most health problems dealt with at a primary care level have an oral health impact, making it vital for oral health services to find means to integrate with other facility-based programmes at primary health care (PHC) centres.

AIM

1) To determine the oral status of the children attending a facility-based nutrition programme and the oral health knowledge, attitude and practices of their parents/caregivers; and 2) To develop a framework for an oral health component to complement this programme.

METHOD

A descriptive study of children and their parents/caregivers attending a facility-based nutrition programme (n = 60 children). A structured, administered questionnaire for parents/caregivers and an oral examination for the children was used for data collection.

FINDINGS

The response rate was 82% (n = 49). Most parents start cleaning their children's mouths between 12 and 24 months (64%), add sugar to food and feeding bottles, and visit a dentist only when the child is symptomatic. These factors clearly place this group at risk for developing dental caries and gingivitis. Their malnutrition status/history increases their risk of oral diseases. The oral examination found plaque deposits, gingivitis, caries and 'white spots'.

CONCLUSION

This study clearly shows the need for an oral health component for children attending the facility-based nutrition programme. Promotion, prevention and therapeutical oral care can be maximized by the involvement of a wide range of stakeholders and an interdisciplinary approach. This shows an expanded role for the dental team with specific reference the oral hygienist in such an environment.

Unexpected development of artistic talents

The development of exceptional and unexpected artistic skills at any age must be a matter of curiosity. This can occur among young children with severe learning difficulties, especially if they are autistic. Some examples of these so called idiot-savants are given, and the way in which their brains may function. It is also true that elderly people who suffer from frontotemporal dementia can find that they are able to express themselves in remarkable art forms. This can occur in other types of dementia, but then more often it is the changes that result in the paintings of established artists, for example in the paintings of de Kooning. Possible links between these two phenomenon are discussed, and it is suggested that in both instances it may be that if the brain is relieved of a number of functions it can concentrate on the remaining ones. Ways in which this may operate in both groups are reviewed.

Mapping an appropriate health promotion approach for crèches in an informal settlement

BACKGROUND

People living in informal settlements in South Africa experience the double burden of poverty and ill health. Wallacedene, an informal settlement was highlighted in the media as being a socially and otherwise deprived community, with many accompanying health problems.

AIM

It was against this background that this study was conducted to gain a better understanding of the health and oral health status of children attending crèches in Wallacedene. It was designed to inform the mapping of an appropriate approach to develop a health promotion programme for crèches.

METHOD

Baseline data were collected through oral and general health examinations, site observations, a structured questionnaire and interviews with key people working with the children at two crèches.

RESULTS

The results indicate poor oral and general health. Gingival inflammation (82.8%), caries (81.5%), and moderate to abundant plaque deposits (95.7%), fungal infections (33.9%), runny nose (51.4%), lymphadenopathy (45.7%) and itchy skin (5.7%) were found. Caregivers were not well informed about oral health. However, they were enthusiastic to engage in new interventions. The community was impoverished; public health interventions were limited with minimal resources such as health centres and voluntary service providers. The limited resources were not coordinated and did not adequately address the health and educational needs of the children.

CONCLUSION

A multi-sectoral approach focusing on community development is an appropriate approach to address the needs of crèche children in this community.

The practice of polypharmacy involving herbal and prescription medicines in the treatment of diabetes mellitus, hypertension and gastrointestinal disorders in Jamaica

The interference in the metabolism of a drug by another drug, food or other foreign chemical is commonly observed and often leads to clinically significant adverse drug reactions. In Jamaica, there is an extensive use of natural products as medicines, although there is little information on whether natural medicines are used along with prescription medicines, which might increase the likelihood of drug adversities. This current pilot survey was initiated to gain information on the prevalence of such polypharmacy practices. Two concurrent surveys were carried out in Kingston (an urban parish) and Clarendon (a rural parish) in 743 patients above age 14 years with diabetes mellitus, hypertension and gastrointestinal disorders of persons who visited health centres and pharmacies. Patrons visiting these places at various times of the day were informed of the nature of the questionnaire and willing participants with the above disease conditions and who were on prescription medicines were included in the survey. The results indicated that 80% of the respondents reported combining natural products in their treatment along with prescription medicines, with only 13% of those patients informing their physicians of such practices. Such polypharmacy practices were independent of the type of disease among both males and females and was statistically most prevalent (p < 0.001) in the 47-57-year age group. There was a significant association (p < 0.001) between such treatment practices and place of residence with 92% of the rural community engaging in polypharmacy but 70% of the urban did likewise. Therefore, being aware of the prevalence of multiple therapy practices would be especially useful when designing a pharmaco-vigilance system.

Cognitive and neurologic predictors of functional impairment in vascular dementia

OBJECTIVE

The purpose of this study is to investigate associations between executive dysfunction, neuroimaging findings, and functional impairment in patients with vascular dementia (VaD).

METHODS

Twenty-nine VaD patients completed the Dementia Rating Scale and underwent MRI scanning to generate quantitative ratings of subcortical hyperintensities (SH) and cortical volume. Patients' caregivers completed items from the Lawton and Brody Activities of Daily Living Questionnaire, designed to measure instrumental activities of daily living (IADLs). The authors hypothesized that performance on the Initiation/Perseveration (IP) subscale, a measure of executive abilities, and SH would significantly predict levels of IADLs.

RESULTS

A hierarchical multiple-regression analysis revealed that IP and SH accounted for 42% of the variance in IADLs; IP alone accounted for 28%, and SH accounted for 14% beyond the contribution made by IP.

CONCLUSION

Findings indicate that specific cognitive and neuropathological factors are associated with functional impairment in VaD.

Dementia severity and pattern of cognitive performance in vascular dementia

We evaluated the influence of dementia severity on cognitive performance in two groups of individuals with vascular dementia (VaD). Performance on the Mini-Mental State Exam (MMSE) was used to determine dementia severity. Tests of executive function, psychomotor speed, memory, language, and visuospatial function were administered. As expected, individuals with severe VaD (MMSE < 18) performed significantly more poorly than individuals with mild VaD (MMSE > or = 18) on most tests. More important, deficits were evident for both groups in each cognitive domain when compared to normative data. These results indicate that multiple cognitive domains are affected even in mild cases of VaD. Clinicians should be aware that although the presence of "patchy" cognitive deficits may indicate stroke, general cognitive dysfunction may occur in mild cases of VaD.

Race and the decision to refer for coronary revascularization: the effect of physician awareness of patient ethnicity

OBJECTIVES

We sought to assess whether there were differences, relative to racial ethnicity, in coronary revascularization recommendations made by a panel that had no knowledge of the patients' ethnicity.

BACKGROUND

Coronary revascularization is employed less frequently in African American than in white patients. It is unclear whether this utilization pattern is driven by clinical differences between the two populations or by nonclinical factors.

METHODS

Data were reviewed from 938 (26.5% African American, 73.5% white) consecutive cardiac catheterizations done between 1993 and 1995. Revascularization recommendations were made by cardiologists and cardiothoracic surgeons provided with the patients' clinical and angiographic data, but without knowledge of their ethnicity. Revascularization recommendations were compared between African American and white patients and correlated with clinical characteristics.

RESULTS

No difference was noted in the percentage of African American and white patients recommended for revascularization, without reference to whether the recommendation was for percutaneous transluminal coronary angioplasty (PTCA) or for coronary artery bypass graft surgery (CABG) 40 vs. 46%, p = NS). African Americans were recommended more frequently for PTCA (22 vs. 18%, p = NS), whereas CABG was recommended for more white patients (28 vs. 18%, p = 0.002). Significantly fewer African Americans had disease in the left main or left anterior descending coronary artery or in multiple arteries. After adjusting for age, co-morbidity, left ventricular dysfunction and the extent of coronary disease, African Americans were more likely to have a recommendation for PTCA (odds ratio [OR] 1.42, 95% confidence interval [CI] 0.96 to 2.11, p = 0.08) and less likely to have a recommendation for CABG (OR 0.59, 95% CI 0.37 to 0.94, p = 0.02).

CONCLUSIONS

This study suggests that when only clinical factors are considered, the rates of recommendations for revascularization will be similar for white and African American patients; but the type of revascularization procedure may differ by ethnicity and may depend, in part, on clinical factors.

Performance on the Mattis Dementia Rating Scale in patients with vascular dementia: relationships to neuroimaging findings

Impairment on screening measures such as the Mattis Dementia Rating Scale (MDRS) provides evidence of dementia in patients with cerebrovascular disease. However, the relationships between neuroimaging findings and performance on the MDRS in vascular dementia (VD) have not been determined. In the present study, we examined the relationships between subcortical hyperintensity (SH) volume and whole brain volume (WBV) on the subscales and total score of the MDRS. Results revealed that SH accounted for a significant amount of variance on the Initiation/Perseveration and Construction subscales, whereas WBV accounted for a significant amount of variance on the Memory subscale. The total score on the MDRS was found to be significantly related to WBV but not SH. These results suggest that subcortical damage and brain volume account for different aspects of cognitive decline in VD and that overall cognitive impairment may reflect cortical and subcortical involvement.

Factors influencing families' consent for donation of solid organs for transplantation

CONTEXT

Transplantation has become the therapy of choice for patients with organ failure. However, the low rate of consent by families of donor-eligible patients is a major limiting factor in the success of organ transplantation.

OBJECTIVE

To explore factors associated with the decision to donate among families of potential solid organ donors.

DESIGN AND SETTING

Data collection via chart reviews, telephone interviews with health care practitioners (HCPs) or organ procurement organization (OPO) staff, and face-to-face interviews with family for all donor-eligible deaths at 9 trauma hospitals in southwestern Pennsylvania and northeastern Ohio from 1994 to 1999.

PARTICIPANTS

Family members, HCPs, and OPO staff involved in the donation decision for 420 donor-eligible patients.

MAIN OUTCOME MEASURE

Factors associated with family decision to donate or not donate organs for transplantation.

RESULTS

A total of 238 of the 420 cases led to organ donation; 182 did not. Univariate analysis revealed numerous factors associated with the donation decision. Multivariable analysis of associated variables revealed that family and patient sociodemographics (ethnicity, patient's age and cause of death) and prior knowledge of the patients' wishes were significantly associated with willingness to donate (adjusted odds ratio [OR], 7.68; 95% confidence interval [CI], 6.55-9.01). Families who discussed more topics and had more conversations about organ donation were more likely to donate (adjusted OR, 5.22; 95% CI, 4.32-6.30), as were families with more contact with OPO staff (adjusted OR, 3.08; 95% CI, 2.63-3.60) and those who experienced an optimal request pattern (adjusted OR, 2.96; 95% CI, 2.58-3.40). Socioemotional and communication variables acted as intervening variables.

CONCLUSIONS

Public education is needed to modify attitudes about organ donation prior to a donation opportunity. Specific steps can be taken by HCPs and OPO staff to maximize the opportunity to persuade families to donate their relatives' organs.

Single photon emission computed tomography, magnetic resonance imaging hyperintensity, and cognitive impairments in patients with vascular dementia

BACKGROUND

The relationship between subcortical hyperintensity (SH) on magnetic resonance imaging (MRI), cortical perfusion on single photon emission computed tomography (SPECT), and cognitive function is not well understood. The authors examined these relationships in individuals with vascular dementia (VaD), paying particular attention to frontal lobe function to determine whether the presence of SH on MRI was associated with frontal hypoperfusion on SPECT, which in turn would be associated with impairments of executive-attention function.

METHODS

Patients with vascular dementia (n = 26) were assessed on neurocognitive tests and brain MRI and SPECT. SH volume was quantified from the axial T2-weighted fluid attenuated inversion recovery MRI. Total counts of activation across voxels for 12 cortical regions of interest were determined from SPECT. Perfusion ratios of both total cortical and frontal activation relative to cerebellum activation were derived, and regression analyses were performed to determine the relationships between cognitive, MRI, and SPECT indices.

RESULTS

SH volume on MRI was significantly associated with frontal lobe perfusion, but not with global cortical perfusion as measured by SPECT. Frontal lobe perfusion did not consistently correlate with performance on measures of executive-attention function, although both total and frontal perfusion ratios were significantly associated with other cognitive functions.

CONCLUSIONS

These results suggest that a functional "disconnection" between the frontal lobes and subcortical structures does not fully account for the magnitude of global cognitive impairment in VaD. Cortical perfusion as measured by SPECT appears to be associated with cognitive performance, but not specifically executive-attention dysfunction. Additional studies are needed to further examine the relationship between subcortical and cortical function in VaD.

Patterns of cigarette smoking and alcohol use among lesbians and bisexual women enrolled in a large health maintenance organization

OBJECTIVES

This study compared the prevalence of cigarette smoking and alcohol use among lesbians and bisexual women with that among heterosexual women.

METHODS

Logistic regression models were created with data from an extensive member health survey at a large health maintenance organization. Sexual orientation was the primary predictor, and alcohol consumption and cigarette smoking were outcomes.

RESULTS

Lesbians and bisexual women younger than 50 years were more likely than heterosexual women to smoke cigarettes and drink heavily. Lesbians and bisexual women aged 20 to 34 reported higher weekly alcohol consumption and less abstinence compared with heterosexual women and older lesbians and bisexual women.

CONCLUSIONS

Lesbians and bisexual women aged 20 to 34 years are at risk for alcohol use and cigarette smoking.

Performance on the Hooper Visual Organizational Test in patients diagnosed with subcortical vascular dementia: relation to naming performance

OBJECTIVE

To examine the performance of individuals with vascular dementia (VaD) on the Hooper Visual Organization Test (HVOT) and to determine the influence of naming on HVOT performance in this population.

BACKGROUND

The HVOT is commonly administered to assess visuospatial perception among neurologic patients, but the test requires verbal identification of stimuli as well as spatial ability. Previous studies have examined the influence of naming on the HVOT, but the issue has not been systematically addressed in individuals with subcortical VaD.

METHOD

Individuals with a diagnosis of VaD were administered the HVOT, three additional measures of visuospatial function (Block Design and Picture Completion subtests of the Wechsler Adult Intelligence Scale-Revised, Rey-Osterrieth Complex Figure Test copy trial), and the Boston Naming Test (BNT).

RESULTS

On average, the VaD patients performed poorly compared with normative data on each of the cognitive measures, with the most pronounced deficit evident on the BNT. Regression analyses revealed that more than 60% of the variance in performance on the HVOT was accounted for by performance on the Block Design subtest of the Wechsler Adult Intelligence Scale-Revised; performance on the BNT did not contribute significantly.

CONCLUSIONS

The results suggest that VaD patients perform below expectations on the HVOT and that the measure is robust to naming deficits in this population.

Perceived benefit after participating in positive or negative/neutral heart failure trials: the patients' perspective

BACKGROUND

Clinical trials, the gold standard for the evaluation of new therapeutic strategies, may prove a drug to be beneficial, harmful or neutral according to its effect on the end-point(s) under study.

AIMS

To study the reaction and perspective of the patients participating in a clinical heart failure trial, particularly in relation to whether the trial subsequently proved to be positive, negative or neutral.

METHODS

Anonymous self-completed questionnaire was sent to 78 and returned by 70 consecutive patients 1--6 months after participating in six clinical heart failure trials. The trial was neutral or negative regarding the primary end-point in four (47 patients) of the six studies (MACH-1 trial of mibefradil, REACH trial of bosentan, CASCO trial of calcium sensitizer, ecadotril trial of neutral endopeptidase inhibitor) and positive in two (23 patients) (ICARUS Israel carvedilol study, exercise study of candesartan cilexetil).

RESULTS

Most patients reported subjective global clinical benefit (78% for positive, 74% for negative or neutral trial, NS) after participating in a clinical trial. After adjustment for age, sex, level of education, previous research, perceived comprehension, and treatment allocation (active drug/placebo) in a stepwise regression model, perceived global improvement was greater in older patients (P=0.02), after participation in a positive trial (P=0.05) and in females (P=0.07). The major reason given by the patient for perceived clinical improvement was better follow-up, some believed it was due to change in medication, particularly those who had participated in a positive trial.

CONCLUSIONS

More than 70% of patients participating in clinical trials of new drugs for heart failure reported perceived global improvement. Clinical improvement was greater in, but not limited to, patients who participated in positive trials. These salutary findings support the continued recruitment of patients to clinical heart failure trials.

Mutism: elective or selective, and acquired

When a child does not speak, this may be because there is no wish to do so (elective or selective mutism), or the result of lesions in the brain, particularly in the posterior fossa. The characteristics of the former children are described, especially their shyness; and it is emphasized that mild forms are quite common and a definitive diagnosis should only be made if the condition is significantly affecting the child and family. In the case of mutism due to organic causes, the commonest of these is trauma to the cerebellum. Operations on the cerebellum to remove tumours can be followed by mutism, often after an interval of a few days, and it may last for several months or longer, to be followed by dysarthria. Other rarer causes are discussed, and also the differential diagnosis. The so-called posterior fossa syndrome consists of mutism combined with ataxia, cranial nerve palsies, bulbar palsies, hemiparesis, cognitive impairment and emotional lability, but the post-operative symptoms are often dominated by the lack of speech. The most accepted cause for the condition is vascular spasm with involvement of the dentate nucleus and the dentatorubrothalamic tracts to the brain-stem, and subsequently to the cortex. Diaschisis may be involved in causing the loss of higher cerebral functions, and possibly, complicating hydrocephalus. The treatment of elective mutism is reviewed, either using a psychotherapeutic approach or a variety of drugs, or both. These may well be ineffective, and it must be remembered that the condition often resolves on its own. The former treatment must concentrate on the training of social skills and activities of daily life and must be targeted to both the child, the family, and the school. Also, all kinds of punishment and insistence on speech must be discouraged. The drug, which seems to be most effective, is fluoxetine. Discovering more about the causes of mutism due to organic causes may well depend on studies using such techniques as magnetic resonance imaging and single photon emission tomography.

Canavan disease: a review of recent developments

The clinical features, causes and potential treatment of Canavan disease are reviewed. The course of the illness can show considerable variation, and can sometimes be protracted. It has an autosomal recessive mode of inheritance, and is caused by mutations in the gene for aspartoacetylase, localized to the short arm of chromosome 17. The changes in the central nervous system are related to the deficiency of aspartoacyclase which leads to an excess of N-acetylaspartate. Prenatal diagnosis of Canavan disease is possible by the measurement of N-acetylaspartate in the amniotic fluid, but the method of choice is by DNA analysis. If an infant is suspected of having the disease, due to megalencephaly and clinical deterioration, the diagnosis can be confirmed by elevated N-acetylaspartate levels in the urine, blood, and spinal fluid--and in the brain using proton magnetic resonance spectroscopy. Neuroradiological investigations confirm the white matter degeneration. Reports of children with megalencephaly, and similar clinical findings, but with normal metabolic tests, are also considered. Until recently treatment was symptomatic, such as the control of seizures, but now there is a possibility though not yet proven, of using gene therapy with modification of the phenotype of brain cells while bypassing the blood-brain barrier and the ependyma. This seems to be well tolerated, and was associated with biochemical, radiological, and clinical changes. The development of knockout mice for Canavan disease should help in the development of gene transfer vectors to treat Canavan disease and for understanding the pathophysiology.

Friedreich's ataxia and iron metabolism

The possible causes of abnormal iron metabolism in patients with Friedreich's ataxia are considered. Reduced expression of a frataxin homologue in yeast is associated with mitochondrial iron accumulation at the expense of cytosolic iron, and the same phenomenon can be demonstrated in these patients. A decrease in cytosolic iron causes the expression of a high-affinity iron-uptake protein, and therefore Friedreich's ataxia can be considered to be a disease of abnormal intracellular iron distribution. Friedreich's ataxia is of autosomal recessive inheritance, and the gene associated with it has been mapped to chromosome 9. This encodes the protein frataxin which regulates mitochondrial iron transport. The commonest mutation causing this disorder is an expanded GAA repeat in the gene for this protein. Different point mutations may account for some of the variations in the phenotypic features that are often found, and these variations are discussed. These findings have raised therapeutic possibilities in a condition for which previously there was no specific treatment. There are intracellular enzymes which are very sensitive to injury by oxygen-free radicals. Treatment has therefore been tried with ibebenone which acts as a free-radical scavenger, with some evidence of improvement. Iron chelating agents, such as deferoxamine, have also been given, but the finding of normal serum iron and ferritin casts doubt on the rationale of this. However the finding that the accumulation of iron in the mitochondria of the cells in patients with this form of ataxia will cause oxidative stress and cell death, gives hope for more effective treatment in the future, possibly with gene therapy.