Growth Hormone, Atherosclerosis and Peripheral Arterial Disease: Exploring the Spectrum from Acromegaly to Growth Hormone Deficiency

Growth hormone (GH) and insulin-like growth factor 1 (IGF-1) are increasingly recognised for their role in cardiovascular (CV) physiology. The GH-IGF-1 axis plays an essential role in the development of the CV system as well as in the complex molecular network that regulates cardiac and endothelial structure and function. A considerable correlation between GH levels and CV mortality exists even among individuals in the general population without a notable deviation in the GHIGF- 1 axis functioning. In addition, over the last decades, evidence has demonstrated that pathologic conditions involving the GH-IGF-1 axis, as seen in GH excess to GH deficiency, are associated with an increased risk for CV morbidity and mortality. A significant part of that risk can be attributed to several accompanying comorbidities. In both conditions, disease control is associated with a consistent improvement of CV risk factors, reduction of CV mortality, and achievement of standardised mortality ratio similar to that of the general population. Data on the prevalence of peripheral arterial disease in patients with acromegaly or growth hormone deficiency and the effects of GH and IGF-1 levels on the disease progression is limited. In this review, we will consider the pivotal role of the GH-IGF-1 axis on CV system function, as well as the far-reaching consequences that arise when disorders within this axis occur, particularly in relation to the atherosclerosis process.

Predictors of long-term atrial fibrillation recurrence after catheter ablation: non-linear analytical approach for individualized prognostic stratification

Background

Recurrences are common in patients with atrial fibrillation (AF) during long-term follow-up after catheter ablation (CA) for pulmonary vein isolation (PVI). Recently, machine learning (ML) models identifying non-linear relationships among various patient parameters have been applied for prognostic stratification in different cardiac diseases.

Aim

This is a retrospective study aimed to determine whether ML-based models can identify non-linear relationships in individual clinical baseline characteristics and CT-quantified volumetric parameters of epicardial fat tissue (EFT) to aid in prognosing outcome of catheter ablation for PVI in patients with paroxysmal AF.

Methods

A cohort of 92 patients (median age 60.2 [51.9–64.0]; 74% male) with paroxysmal AF (a single persistent AF episode was accepted) undergoing catheter ablation targeting PVI was analysed. All patients underwent cardiac CT imaging and were fitted with implantable loop recorder (ILR) prior to CA. For PVI, radiofrequency CA with electro-anatomical mapping was used in 79 patients, cryoballoon ablation in 13 patients. AF recurrence, defined as AF burden >0.1% after the blanking period (90 days), was continuously assessed by ILR. Feature selection on 23 baseline parameters was performed using random forest models (XGBoostRegressor). Mean absolute Shapley values (|mSHAP| – Shapley Additive expLanations) were used to quantify the relative discriminative power of analysed parameters.

Results

During a follow-up of 3-years, AF recurrence was detected in 58 (63%) patients, 29 (50%) of them underwent a repeat ablation. Five most important predictors of AF recurrence during 3-year follow-up were upper epicardial fat volume, BMI, baseline AF burden, age and pericardial volume (lower segment) (Fig. 1). Upper EFT volume was twice as important for males than females (0.44 and 0.21 |mSHAP| respectively). For a patient with no AF recurrence, low age (41 years) and low upper EFT volume (13.2 ml) were the most important drivers predicting positive ablation outcome (Fig. 2A). In contrast, in a patient with AF recurrence post CA, an above-average EFT volume of 55.5 ml and a high BMI had the most significant net contribution for predicting his failed CA outcome (Fig. 2B).

Conclusion

Non-linear ML analysis applied to our limited cohort of patients with paroxysmal AF undergoing CA suggests: i) a significant association of high EFT volume with ILR determined AF recurrence during a 3-year follow-up; ii) potential role of such analyses for a more granular and highly individualized prediction of outcome of planned CA. However, these results need further testing, and validation in prospective trials.

Funding Acknowledgement

Type of funding sources: None.

High epicardial fat volume is associated with atrial fibrillation recurrences after catheter ablation

Background

Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation therapy for atrial fibrillation (AF). However, even with important technological improvements, AF recurrences are common in long-term follow-up. Recently, epicardial fat tissue (EFT) has been proposed as a potential AF modulator promoting and sustaining atrial arrhythmogenic milieu.

Aim

In this retrospective single-centre study, we sought to evaluate the association between CT-quantified EFT volume and long-term primary PVI outcome assed by means of continuous ECG monitoring with implantable loop recorders (ILR) in paroxysmal AF patients.

Methods

A cohort of 92 patients (median age 60.2 [IQR 51.9–64.0]; 74% male) with paroxysmal AF (a single persistent AF episode was accepted) undergoing catheter ablation targeted at PVI was analysed. Prior to CA all patients underwent cardiac CT imaging with subsequent implantation of implantable loop recorder (ILR). Radiofrequency CA ablation with electro-anatomical mapping for PVI was used in 79 patients, balloon cryoablation was used in 13 patients. Verified complete PVI was defined as procedural endpoint. EFT volume was semi-automatically segmented and quantified on contrast enhanced CT studies. AF recurrence, defined as AF burden >0.1% after the blanking period (90 days), was continuously assessed by ILR. Kaplan-Meier analysis of AF recurrence-free survival at 1-year, 2-year and 3-year follow-up periods compared patients stratified into EFT volume tertiles.

Results

During a median follow-up of 52.6 months [IQR 43–64], AF recurrence was detected in 58 (63%) patients, 29 (50%) of them underwent a repeat ablation. Patients in high, mid, and low total EFT volume tertiles had a median time to late AF recurrence of 154, 373, and 284 days (Fig. 1A). At a 1-year follow-up, patients in the high EFT volume tertile had the worst AF ablation outcome (p=0.023). However, this difference gradually faded-out and became non-significant at 2 and 3 years. ROC analysis revealed an EFT of 95 ml as an optimal cut-off (p=0.002) for expected arrhythmia recurrence post acutely successful PVI (Fig. 1B).

Conclusion

EFT volume quantification in a relatively homogenous, continuously monitored cohort of patients undergoing catheter ablation for paroxysmal AF revealed a significant association between AF recurrence at 1 year post ablation and volume of epicardial fat. These results suggest a possible role of epicardial adipose tissue as an adverse pro-fibrillatory factor. Identified EFT volume cut-offs have to be validated prospectively on a larger and balanced patient population.

Funding Acknowledgement

Type of funding sources: None.

Deep learning for mortality prediction in patients with a de-novo or worsened heart failure

Background

Heart failure (HF) is a heterogenous syndrome with complex pathophysiology. Biomarkers and clinical risk scores often fail to provide optimal patient-level precision in the prognostic stratification. As utilizing single observational timepoint, they do not capture the entire care pathway with variations in individual patient management. Electronic patient records provide an opportunity to develop new artificial intelligence (AI) strategies for comprehensive prognostic re-stratification reflecting diagnostic and therapeutic management.

Purpose

We sought to use deep artificial intelligence (AI) and develop an unbiased predictive algorithm for all-cause mortality in a cohort of patients hospitalized with a de novo or worsened HF.

Methods

In a cohort of 2449 HF patients hospitalized between 2011–2017, we utilized 151 451 patient exams from 422 parameters. They included clinical phenotyping, medication, ECG, laboratory, echocardiography, catheterization data or percutaneous and surgical interventions gathered on a routine clinical basis reflecting standard of care as captured in individual electronic records. The AI model development consisted of 101 iterations of repeated random subsampling splits into balanced training and validation sets.

Results

AI models yielded performance ranging from 0.83 to 0.89 AUC on the outcome-balanced validation set in predicting all-cause mortality at 30-, 90-, 180-, 360- and 720-day time-limits (Figure 1). The primary endpoint, 1-year mortality prediction model, recorded an 0.85 AUC accuracy. We observed stable model performance across all HF phenotypes: HFpEF 0.83 AUC, HFmrEF 0.85 AUC and HFrEF 0.86 AUC, respectively).

Conclusion

Our findings present a novel, patient-level, AI-based risk prediction of all-cause mortality in heart failure with a robust accuracy across its phenotypes. This suggests the potential of AI based predictive models in a point-of-care approach to guide clinical risk stratification.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): VZW Cardiovascular Research Center Aalst

Substrate Supporting Disc Method for Confirmed Detection of Total Coliforms and E. coli in all Foods: Collaborative Study

The Coli Complete® substrate supporting disc (SSD) method for simultaneous confirmed total coliform count and Escherichia coli determination in all foods was compared with AOAC most probable number (MPN) methods, 966.23 and 966.24. Twenty-nine laboratories participated in this collaborative study in which 6 food types were analyzed. Four food types, raw ground beef, pork sausage, raw liquid milk, and nut meats, were naturally contaminated with coliform bacteria. Two foods, dry egg and fresh frozen vegetables, were seeded with coliforms. Three food types, ground beef, raw liquid milk, and pork sausage, were naturally contaminated with E. coli. Although pork sausage was naturally contaminated, the level was very low (<10/50 g); therefore, additional E. coli were inoculated into 1 lot of this food type. Three food types, nut meats, dry egg, and fresh frozen vegetables, were inoculated with E. coli. For naturally contaminated samples, duplicate determinations were made on 3 separate lots for each food type. For inoculated samples, low, medium, and high contamination levels plus uninoculated control samples were examined in duplicate. Data were analyzed separately for total coliform bacteria and for E. coli. Mean log MPN counts were determined by the SSD method and the appropriate AOAC MPN method. Results were then analyzed for repeatability, reproducibility, and mean log MPN statistical equivalence. Results were statistically equivalent for all total coliform levels in all food types except frozen vegetable and raw nut meat uninoculated control samples and 1 lot of pork sausage where the SSD method produced statistically significant greater numbers. For the E. coli determinations, results were statistically equivalent across all samples and all levels for each food type. The SSD method has been adopted first action by AOAC International for confirmed detection of total coliforms and E. coli in all foods.

Is mean platelet volume a good predictor of sustained response to one year infliximab therapy in pediatric patients with Crohn's disease?

Over the past years, there is a growing number of newly diagnosed pediatric patients with Crohn's disease (CD). Severe course of CD often requires biological treatment with Infliximab (IFX). Loss of response to biological treatment is a major problem. Mean platelet volume (MPV) was reported as a good marker of sustained response to IFX therapy in adults. This study is to determine whether MPV measured prior to IFX therapy and a er its third dose can be used as a predictive marker of sustained response to biological therapy in children with severe course of CD. 43 pediatric patients with CD who underwent IFX therapy were enrolled into this study. The clinical response was evaluated after the third dose and after one year of IFX treatment (sustained response). The MPV values at baseline and week 14 were compared to the patients with good response to IFX to those with loss of the response. During 52-week IFX therapy, 2 out of 43 patients enrolled in the study did not achieve primary response a er the third dose, another 18 children lost their response to the above therapy a er one year. There was no significant association between baseline and 14th week values of MPV between patients with the sustained response to those with loss of response. In opposite to adult patients, MPV cannot be regarded as predictive factor of sustained response to IFX treatment in pediatric patients.

Spelling in oral deaf and hearing dyslexic children: A comparison of phonologically plausible errors

A written single word spelling to dictation test and a single word reading test were given to 68 severe-profoundly oral deaf 10-11-year-old children and 20 hearing children with a diagnosis of dyslexia. The literacy scores of the deaf children and the hearing children with dyslexia were lower than expected for children of their age and did not differ from each other. Three quarters of the spelling errors of hearing children with dyslexia compared with just over half the errors of the oral deaf group were phonologically plausible. Expressive vocabulary and speech intelligibility predicted the percentage of phonologically plausible errors in the deaf group only. Implications of findings for the phonological decoding self-teaching model and for supporting literacy development are discussed.

RUPERT: a Device for Robotic Upper Extremity Repetitive Therapy

We report the development and initial evaluation of a device for robotic assisted upper extremity repetitive therapy (RUPERT). Intense repetitive physical therapies provided by individualized interaction between the patient and a rehabilitation specialist to overcome upper extremity impairment after stroke are beneficial, however, they are expensive and difficult to evaluate quantitatively and objectively. The need is urgent and growing for a low cost, safe and easy to use robotic device to assist the patient and the therapist to fully achieve the potential benefit of task-based repetitive physical therapies. We designed a pneumatic muscle (PM) driven therapeutic device, the RUPERT, that is wearable and provides assistive forces required to move the arm during performance of several critical tasks of daily living. The robot has four degrees of freedom at shoulder, elbow and wrist. The sensors feedback position and force information for quantitative evaluation of task performance. It has the potential of providing a take-home method of supplementing therapy. The device can also provide real-time, objective assessment of functional improvement of therapy.

A manner of characterizing the development of countries

An attempt is made to characterize the socio-economic state and the temporal evolution of countries by the use of labor force distribution data on a multidimensional phase plot so that the development of a country is represented by an evolutionary track of a phase point. The evolutionary tracks of several countries are examined, and the phase points of many countries are compared. Snowflake diagrams, which make easy comparison of the socio-economic character of various countries, have also been developed.

Characterization and Inheritance of a New Source of Resistance to Fusarium oxysporum f. sp. melonis Race 1.2 in Cucumis melo

Four physiological races (0, 1, 2, and 1.2) of Fusarium oxysporum f. sp. melonis, causal agent of Fusarium wilt in melons, have been described. Whereas resistance against each of the races 0, 1, and 2 is encoded by a single dominant R-gene, resistance against the fourth race, FOM 1.2, is polygenically inherited and was recently characterized in the cultivar Isabelle. In the present study, we report on an independently derived source of resistance to race 1.2, the Israeli breeding line BIZ. The disease response of BIZ seedlings was compared with two susceptible genotypes, Line 33 and PI 414723, and the partially resistant genotype, Isabelle, at increasing concentrations of inoculum. BIZ exhibited near-complete resistance to race 1.2, even at inoculum levels of 10⁶ spores per ml and root wounding, indicating that such resistance is stronger than that in Isabelle. Although in previous studies the F₁ hybrids between BIZ and the sensitive lines displayed full resistance in the field, in the present study they were susceptible under artificial inoculation conditions that involve high inoculum concentrations of 10⁶ spores per ml and root wounding; under intermediate inoculum levels (10⁵ and 5 × 10⁵ spores per ml) they were partially resistant. Segregation of the resistance response in the F₂ and back-cross-1 progeny from a cross between BIZ and PI 414723 supported a model in which two complementary, recessive genes are required to obtain full resistance. While the fungus was shown to colonize root tissue of both resistant and susceptible lines, colonization was markedly lower in the resistant plants, and the fungus was nearly absent from upper stem segments.

Evaluation of sporadic cases of odontogenic keratocysts in multicentric study

The aim of this retrospective study was to report frequency of sporadic odontogenic keratocysts (sOKC) according to the age and gender, as well as location (mandible, maxilla, soft tissues, and maxillary sinus). Four hundred and twenty nine sOKC confirmed pathohistologically in a period from 1965-1998 were included in this study. The average age of patients with sOKC was 43.11 (age range 10-91), in males 42.06 and in females 44.72 years. More frequently sOKC were found in males (60.61%) in comparison to the females (39.39%). Therefore, ratio between males and females was 1.5:1. Diagnosis of sOKC is usually established in patients aged 21-30 (18.88%), in males usually aged between 21-30 (23.46%), and in females aged between 11-20 (18.93%). sOKC are more frequent in males according to the age groups, except between age 61-70 where sOKC were more frequent in females. Most frequently, sOKC occurred in the mandible 70.16%, 12.35% of sOKC were found in the maxilla, 12.82% in soft tissues and 4.66% in the maxillary sinuses.

The 2.4-A crystal structure of the penicillin-resistant penicillin-binding protein PBP5fm from Enterococcus faecium in complex with benzylpenicillin

Penicillin-binding proteins (PBPs) are membrane proteins involved in the final stages of peptidoglycan synthesis and represent the targets of beta-lactam antibiotics. Enterococci are naturally resistant to these antibiotics because they produce a PBP, named PBP5fm in Enterococcus faecium, with low-level affinity for beta-lactams. We report here the crystal structure of the acyl-enzyme complex of PBP5fm with benzylpenicillin at a resolution of 2.4 A. A characteristic of the active site, which distinguishes PBP5fm from other PBPs of known structure, is the topology of the loop 451-465 defining the left edge of the cavity. The residue Arg464, involved in a salt bridge with the residue Asp481, confers a greater rigidity to the PBP5fm active site. In addition, the presence of the Val465 residue, which points into the active site, reducing its accessibility, could account for the low affinity of PBP5fm for beta-lactam. This loop is common to PBPs of low affinity, such as PBP2a from Staphylococcus aureus and PBP3 from Bacillus subtilis. Moreover, the insertion of a serine after residue 466 in the most resistant strains underlines even more the determining role of this loop in the recognition of the substrates.

Spinal cord stimulation facilitates functional walking in a chronic, incomplete spinal cord injured

DESIGN

This paper describes a treatment paradigm to facilitate functional gait in a quadriplegic, ASIA C spinal cord injured (SCI), wheelchair-dependent subject who presented with some large fiber sensation, sub-functional motor strength in all lower limb muscles, and moderate spasticity. The study utilizes partial weight bearing therapy (PWBT) followed by epidural spinal cord stimulation (ESCS) with the assumption that both treatments would be necessary to elicit a well organized, near effortless functional gait with a walker. Function is defined in terms of accomplishing task-specific activities in the home and community.

OBJECTIVES

To demonstrate the feasibility and benefits of combined PWBT and ESCS therapies aimed at promoting functional gait in a wheelchair-dependent ASIA C SCI subject.

SETTING

The Clinical Neurobiology and Bioengineering Research Laboratories at Good Samaritan Regional Medical Center, Phoenix, Arizona, USA, and the Department of Bioengineering, Arizona State University, Tempe, Arizona, USA.

METHODS

The study began with the application of PWBT. The subject walked on the treadmill until a plateau in gait rhythm generation was reached. Subsequently, ESCS, applied to the lumbar enlargement, was utilized to facilitate PWBT and, later, over-ground walking for a standard distance of 15 m. Gait performance was analyzed by measuring average speed, stepping symmetry, sense of effort, physical work capacity, and whole body metabolic activity.

RESULTS

PWBT led to improved stereotypic stepping patterns associated with markedly reduced spasticity, but was insufficient for over-ground walking in terms of safety, energy cost, and fatigue. ESCS with PWBT generated immediate improvement in the subject's gait rhythm when appropriate stimulation parameters were used. When compared to the non-stimulated condition, over-ground walking with ESCS across a 15 m distance was featured by a reduction in time and energy cost of walking, sense of effort, and a feeling of 'lightness' in the legs. After a few months of training, performance in speed, endurance, and metabolic responses gradually converged with/without ESCS at this short distance, suggesting a learned response to these conditions. However, at longer distances (eg, 50-250 m), performance with ESCS was considerably superior. The subject was able to perform multiple functional tasks within the home and community with ESCS.

CONCLUSION

We propose that ESCS augments the use-dependent plasticity created by PWBT and may be a valuable adjunct to post-SCI treadmill training in ASIA C subjects. We also conclude that ESCS elicits greater activation of an oxidative motor unit pool, thereby reducing the subject's sense of effort and energetic cost of walking.

Characterization of OXA-29 from Legionella (Fluoribacter) gormanii: molecular class D beta-lactamase with unusual properties

A class D beta-lactamase determinant was isolated from the genome of Legionella (Fluoribacter) gormanii ATCC 33297(T). The enzyme, named OXA-29, is quite divergent from other class D beta-lactamases, being more similar (33 to 43% amino acid identity) to those of groups III (OXA-1) and IV (OXA-9, OXA-12, OXA-18, and OXA-22) than to other class D enzymes (21 to 24% sequence identity). Phylogenetic analysis confirmed the closer ancestry of OXA-29 with members of the former groups. The OXA-29 enzyme was purified from an Escherichia coli strain overexpressing the gene via a T7-based expression system by a single ion-exchange chromatography step on S-Sepharose. The mature enzyme consists of a 28.5-kDa polypeptide and exhibits an isoelectric pH of >9. Analysis of the kinetic parameters of OXA-29 revealed efficient activity (k(cat)/K(m) ratios of >10(5) M(-1) x s(-1)) for several penam compounds (oxacillin, methicillin, penicillin G, ampicillin, carbenicillin, and piperacillin) and also for cefazolin and nitrocefin. Oxyimino cephalosporins and aztreonam were also hydrolyzed, although less efficiently (k(cat)/K(m) ratios of around 10(3) M(-1) x s(-1)). Carbapenems were neither hydrolyzed nor inhibitory. OXA-29 was inhibited by BRL 42715 (50% inhibitory concentration [IC(50)], 0.44 microM) and by tazobactam (IC(50), 3.2 microM), but not by clavulanate. It was also unusually resistant to chloride ions (IC(50), >100 mM). Unlike OXA-10, OXA-29 was apparently found as a dimer both in diluted solutions and in the presence of EDTA. Its activity was either unaffected or inhibited by divalent cations. OXA-29 is a new class D beta-lactamase that exhibits some unusual properties likely reflecting original structural and mechanistic features.

How government policy decisions affect seniors' quality of life: findings from a participatory policy study carried out in Toronto, Canada

Toronto seniors explored how government policy decisions were influencing their health and well-being. In this participatory policy study, emphasis was upon the lay and critical knowledge of highly informed seniors. Focus groups and interviews revealed that all three levels of governments were seen as not listening to seniors' voices. In nine key policy areas identified as influencing seniors' quality of life--hearing seniors' voices, housing, acute illness care, long-term care, income supports, transportation and mobility, promoting healthy lifestyles, access to information, and hearing voices from cultural communities--many concerns were raised. The gap between government rhetoric and government action on seniors' issues merits public health attention.

Modified fetal biophysical profile in the assessment of perinatal outcome

The aim of the study is the evaluation of variables of the biophysical profile in the assessment of perinatal outcome. The prospective study included 87 pregnant women with singleton pregnancy in the 28th to 42nd week of gestation with clinically and ultrasonically verified fetal growth retardation, where the fetal biophysical profile was assessed antenatally. Through the factor analysis of biophysical profile variables we obtained values indicating the contribution of individual variables to the predictability of perinatal outcome. 70% of the patients were examined in 15 minutes according to the principles of modified biophysical profile. The most sensitive variable of the biophysical profile in the prediction of perinatal outcome was the amniotic fluid volume, followed by fetal breathing movements, non-stress test and fetal movements, while the lowest prediction value was assigned to the fetal tone. The modified biophysical profiles need to be perfected on a larger number of pregnant women, which would advance the predictability of this method in detection of hypoxically endangered fetuses.

The 2000 Canadian recommendations for the management of hypertension: Part one--therapy

OBJECTIVE

To provide updated, evidence-based recommendations for the therapy of hypertension in adults.

OPTIONS

For patients with hypertension, there are a number of lifestyle manoeuvres and antihypertensive agents that may control blood pressure. Randomized trials evaluating first- line therapy with thiazides, beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors, calcium channel blockers, alpha-blockers, centrally acting agents or angiotensin II receptor antagonists were reviewed.

OUTCOMES

The health outcomes considered were changes in blood pressure, cardiovascular morbidity, and cardiovascular and/or all-cause mortality rates. Economic outcomes were not considered due to insufficient evidence.

EVIDENCE

Medline searches were conducted from the period of the last revision of the Canadian Recommendations for the Management of Hypertension (May 1998 to October 2000). Reference lists were scanned, experts were polled, and the personal files of the subgroup members and authors were used to identify other studies. All relevant articles were reviewed and appraised, using prespecified levels of evidence, by content experts and methodological experts.

VALUES

A high value was placed on the avoidance of cardiovascular morbidity and mortality.

BENEFITS, HARMS, AND COSTS

Various lifestyle manoeuvres and antihypertensive agents reduce the blood pressure of patients with sustained hypertension. In certain settings, and for specific classes of drugs, blood pressure lowering has been associated with reduced cardiovascular morbidity and/or mortality.

RECOMMENDATIONS

The present document contains detailed recommendations pertaining to all aspects of the therapy of patients with hypertension, including lifestyle modifications proven to lower blood pressure, treatment thresholds, target blood pressures, choice of agents in various settings and strategies to enhance adherence. Lower thresholds for blood pressure treatment are advocated for people with other cardiovascular risk factors or established hypertensive target organ damage. Implicit in the recommendations for therapy is the principle that treatment should be individualized for each patient and the choice of agent should be dictated by coexistent conditions. For the treatment of uncomplicated essential hypertension, thiazides, beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors or calcium channel blockers may be appropriate, depending on individual circumstances.

VALIDATION

All recommendations were graded according to strength of the evidence and voted on by the Canadian Hypertension Recommendations Working Group. Only those recommendations achieving high levels of consensus are reported here. These guidelines will be updated annually.

The communication, speech and gesture of a group of hearing-impaired children

The communication skills, speech and gesture of 20 hearing-impaired children were assessed. The children were all being educated in a school using an oral/aural approach. Assessment result comparison indicated the importance of assessing gesture and speech separately for these children and comparing the use of both skills. More informal and formal assessment of gesture and the tools to complete this task effectively are needed to ensure that these children's communication skills are described accurately.

Improved survival in severe acquired aplastic anemia of childhood

Multi-agent immunosuppressive therapy has produced improved survival for severe acquired aplastic anemia in children. Recently, some investigators have suggested that immunosuppressive therapy may replace bone marrow transplantation as first-line therapy for this disorder. To assess its validity, we compared the outcomes of bone marrow transplantation vs immunosuppressive therapy in one institution from 1987 to 1997. We studied 46 consecutive patients less than 18 years of age who presented between January 1987 and April 1997. Inherited marrow failure syndromes and myelodysplastic syndromes were excluded. Patients received immunosuppressive therapy vs bone marrow transplantation based on availability of HLA-matched donors. The main outcome measures were survival, complete marrow and hematological remission, or partial remission but achieving independence from transfusional support. Twenty patients received multi-agent immunosuppressive therapy (cyclosporine, antithymocyte globulin and methylprednisolone); 11 attained complete remission and three partial remission for a transfusion-independent survival of 70%. Six patients died of infectious and hemorrhagic complications. Twenty-six patients were transplanted and 24 (93%) achieved complete remission; one achieved a PR, 25 remain transfusion independent with a median follow-up of 5.9 years or 70 months. One patient developed AML 34 months after successful transplant and one patient died due to graft failure and complications of transplant. There has been a striking improvement in survival for pediatric patients treated with multi-agent immunosuppression in the last decade. However, transplantation results have also improved and this remains the definitive first-line therapy for severe acquired aplastic anemia in this age group.

The influence of global discourse on lexical ambiguity resolution

The influence of global discourse on the resolution of lexical ambiguity was examined in a series of naming experiments. Two-sentence passages were constructed to bias either the dominant or the subordinate meaning of a homonym that was embedded in a locally ambiguous sentence. The results provided evidence for the immediate (0-msec interstimulus interval) resolution of lexical ambiguity and were subsequently replicated in Experiment 2, in which an 80-msec stimulus onset asynchrony exposure duration was employed for the homonyms. Strong dominant and subordinate biased discourse contexts activated only the contextually appropriate sense of a homonym. In Experiment 3, each sentence of the discourse was presented in isolation. The pattern of activation obtained in Experiments 1 and 2 was found to be contingent on the integration of the two sentences to construct an overall global discourse representation of the text. The results support a context-sensitive model of lexical ambiguity resolution.

[Fetal hypoxia--etiology and pathophysiology of hypoxic damage]

In current perinatology, the prevention of hypoxic damage to the organs, brain in particular, is given special emphasis. The causes of fetal hypoxia include maternal (preuterine), intrauterine, umbilical, placental and fetal causes. Hypoxia and hypoxic lesions occur prenatally in about 80%, and perinatally in 10-20% of cases. Hypoxia/ischemia induce cellular and subcellular responses in the fetal brain. Some of these are membraneous phenomena such as potassium channel activation, enhanced release of excitoxic amino acids aspartate and glutaminate, activation of NMDA receptors, transmembranous calcium ion influx, and membranous lipid peroxidation. Cytosolic events include the formation of free oxygen radicals, release of eicosanoids, prostaglandins, leukotriens and cytokines, enzyme activation, and gene induction.

Linguistic models of F0 use, physiological models of F0 control, and the issue of "mean response time"

This paper evaluates "mean response time" (MRT), a method used in previous studies to relate physiological evidence (recordings of electromyographic activity in the cricothyroid and sternohyoid) to acoustic evidence (fundamental frequency). Rather than averaging over tokens before correlating these signals, we calculated the best response time (RT) for each token, and evaluated the pattern of variability across utterances. Furthermore, rather than correlating over whole utterances, we correlated electromyographic activity (EMG) to fundamental frequency (F0) only over intervals defined in terms of linguistically significant events in the F0 trace, identified using a linguistically motivated model of English intonation. Steep changes in the F0 tended to have better correlation coefficients than shallow ones, which we relate to the physiological model by noting the complex of components contributing to both signal types. Also, the distribution of lead times was easier to interpret when the two tones delimiting the analysis domain had some tight temporal relationship specified by the intonational phonology. Finally, lead times tended to vary as a function of what preceded the target rise or fall. In short, averaging over signals before analysis obscures patterns of variation in the data which may lead to new insights and to new directions for research.

AIDS-related services and training in outpatient mental health care agencies in New York

Directors of 471 outpatient mental health settings in New York State (82.1 percent of 574 settings located in counties with intermediate to high AIDS case rates) completed a survey about HIV and AIDS services, training needs, and barriers to care. Most of the sites served one to ten persons with HIV infection annually and had staff members who were trained in providing at least one HIV-related service. Nonetheless, 84 percent of the respondents reported unmet needs for training. The likelihood of providing certain services was significantly increased in sites that were in urban locations, primarily served clients with comorbid alcohol or other drug use disorders, lacked funds for providing condoms, had staff members who were trained in HIV and AIDS services, identified particular HIV training needs, believed clients needed condoms, and viewed HIV-related services as very important.

Preoperative tumor marker CA125 levels in relation to epithelial ovarian cancer stage

The paper deals with 62 ovarian cancer patients observed from 1988 to 1997. Considering the ovarian cancer stage, the patients were divided in two groups. Group I consisted of 31 patients at the early stage of ovarian carcinoma (FIGO classification I and II), while group II included 31 patients with the advanced disease (FIGO classification III and IV). According to FIGO classification, a majority of group I and group II patients was classified as IA (61.3%) and IIIC, respectively. Ovarian carcinoma of the serous pathohistologic type accounting for 48.4% prevailed in both groups, but there were also endometroid and mucinous types. Sensitivity to CA125 was observed in 93.5% of the group I and in 96.7% of the group II patients. In group I, the mean value of tumor marker CA125 read 262.97 U/ml, median 93 U/ml, ranging from 13-2000 U/ml. In comparison with group I, the mean value of group II tumor marker CA125 was significantly higher reading 1053.81 U/ml, median 365 U/ml, with CA125 levels ranging from 15-9960 U/ml. In relation to patients at the early stage of ovarian cancer, preoperative CA125 serum levels were statistically more significant in the advanced ovarian cancer patients (statistically significant difference p = 0.002). When comparing CA125 levels and tumor differentiation according to Broders, no statistically significant difference was observed in both group I (p = 0.6144) and group II (p = 0.6605). The statistically significant correlation (p = 0.00008) was confirmed between advanced ovarian carcinoma and less differentiated tumors (Broders differentiation III and IV).

Issues in designing an assessment of British Sign Language development

This paper reports on a collaborative project in progress to develop a standardised clinical assessment of British Sign Language development for use with deaf children. The need for such an assessment is highlighted following a survey of professionals working in this area (Herman, in press). The development of the assessment battery will be described in the context of research into the assessment of sign language development. Issues in selection of the standardisation population will be presented. Finally the need for collaboration between different professionals working in this area, in particular the key role of the deaf BSL user will be emphasised.

Effects of early defibrillation by ambulance personnel on short- and long-term outcome of cardiac arrest survival: the Munich experiment

OBJECTIVES

This study evaluates the feasibility of implementing early defibrillation of out-of-hospital cardiac arrest patients for basic life-support providers (EMT-D) in a two-tier emergency system in the city of Munich, Germany.

DESIGN

Retrospective consecutive analysis of all EMT-D attempts during a 5-year initiation phase (1990 to 1994) and prospective follow-up of all cardiac arrest survivors discharged from hospital.

SETTING

A strictly defined inner-city and suburban area of 978 km2 and a residential population of 1,530,000 inhabitants with 22 ICUs in urban hospitals. One dispatching center to alert a two-tier emergency system with 56 EMT-D-staffed ambulances and physician-staffed mobile ICUs stationed at the nearest of nine hospitals.

METHODS

AH EMT-D cases were identified and data on patients were documented in a standardized manner from patients' records, including the resuscitation protocol in the hospitals to which the patients were referred. For those patients discharged from the hospital, a standardized telephone interview was undertaken with the physician in charge of the patient and with the patient/relative leading to an assessment of the patient's status according to the Glasgow-Pittsburgh cerebral performance categories.

INTERVENTION

None.

RESULTS

During the 5-year initiation phase of the EMT-D program in the two-tier emergency system in Munich, there were 243 resuscitation attempts by EMTs, using the semiautomated defibrillator; 125 patients died immediately on the scene. In 118 patients, spontaneous circulation was reestablished and these patients were admitted to an ICU in 1 of the 22 urban hospitals. Median call-response interval for the EMT-D was 5 min (interquartile range, 3 to 6) and was 10 min (interquartile range, 7 to 13) for the second tier (p < or = 0.0001). In 34 cases (28.8%), EMT-D staff had reestablished spontaneous circulation (ROSC) before the second tier arrived on the scene. Patients with ROSC on the arrival of the second tier were more frequently discharged alive from hospital than were patients without ROSC at that time (p < or = 0.0001). The hospital discharge rate of initially successful resuscitated patients presenting with out-of-hospital ventricular fibrillation was 38.1% (45/118). Overall success rate of all EMT-D attempts was 18.5% (45/243). After a mean follow-up time of 39 (range, 22 to 64) months, 29 (66%) patients were still living. Twenty-five (56.8%) were neurologically not disabled or mildly disabled (CPC 1/2); disability was moderate in 3 (6.8%) patients and was severe in 1 (2.3%) patient. One case was lost to follow-up.

CONCLUSION

The present study demonstrates that the upgrading of basic life support providers with semiautomated defibrillators has a significant benefit for cardiac arrest victims outside the hospital in an urban environment.

[The effect of the presence of the husband during childbirth]

In the course of 1994 a particular number of deliveries were examined in the maternity ward of the Clinical Hospital "Sestre milosrdnice". Randomly a hundred pregnant women were chosen whose husbands were present at the childbirth. The same number of women delivered their babies without their husband's presence. The duration of labor was examined as well as APGAR score, threatening intrauterine asphyxia, uterine inertia, prolonged labor, induced labor, medical analgesia, and the frequency of cesarean section and vacuum extraction. In the group, in which the husband was present, the labor was shorter, the number of threatening intrauterine asphyxia cases and cesarean sections was smaller, but there were more induced deliveries. Contrary to all expectations, the uterine inertia with the administration of oxytocin was comparably present in both groups, the same as medical analgesia. Other above mentioned parameters were also comparably present in both groups. The level of labor analgesia was not examined in particular to avoid the subjective factor, and besides, the aim was to achieve the maximal possible analgesia. The results suggest the importance of husband's presence at childbirth. Apart from being a very important psychosocial factor, reducing the duration of labor as well as the frequency of threatening intrauterine asphyxia and cesarean section, it also directly affects the course and result of labor.

The relative contributions of psychiatric symptoms and AIDS knowledge to HIV risk behaviors among people with severe mental illness

BACKGROUND

This study was designed to determine whether psychiatric symptoms and acquired immunodeficiency syndrome (AIDS) knowledge predict human immunodeficiency virus (HIV) risk behavior among people with severe mental illness.

METHOD

We interviewed 178 psychiatric patients to determine Axis I diagnosis, level of functioning, severity of psychiatric symptoms, knowledge about AIDS, sexual risk behaviors in the previous 6 months, and drug injection since 1978. Severity of psychiatric symptoms was rated on the Positive and Negative Syndrome Scale within the classification of positive, negative, cognitive, excited, and depressed/anxious symptoms.

RESULTS

Ninety-two patients (51.7%) reported being sexually active in the previous 6 months. Of sexually active patients for whom data were available, 44 (47.8%) of 92 had multiple sex partners; 32 (35.2%) of 91 used drugs during sex; 27 (29.7%) of 91 traded sex for drugs, money, or other goods; and 50 (58.1%) of 86 never used condoms. Thirty-one patients (17.5%) had drug-injection histories. The median AIDS knowledge score was 23 (82.1%) of 28. Although AIDS knowledge was negatively correlated with cognitive and negative symptoms and positively correlated with excitement, knowledge alone did not predict any risk behavior. However, when AIDS knowledge was taken together with age and excited symptoms, the odds of being sexually active versus abstinent were three times higher among patients with better AIDS knowledge and twice higher among patients with greater excited symptoms. Having multiple sex partners was nearly three times as likely among patients with greater positive symptoms. Trading sex was more than three times as likely among patients with schizophrenia than among those with other diagnoses and more than five times as likely among those with more excitement symptoms.

CONCLUSION

Patients, particularly those who were sexually active, were well informed about AIDS. Specific psychiatric conditions, including the presence of positive and excited symptoms and a diagnosis of schizophrenia, predicted certain sexual risk behaviors and must be the focus of innovative prevention efforts.