The Pore Size of Non-Graminaceous Plant Cell Walls Is Rapidly Decreased by Borate Ester Cross-Linking of the Pectic Polysaccharide Rhamnogalacturonan II

The walls of suspension-cultured Chenopodium album L. cells grown continually for more than 1 year on B-deficient medium contained monomeric rhamnogalacturonan II (mRG-II) but not the borate ester cross-linked RG II dimer (dRG-II-B). The walls of these cells had an increased size limit for dextran permeation, which is a measure of wall pore size. Adding boric acid to growing B-deficient cells resulted in B binding to the wall, the formation of dRG-II-B from mRG-II, and a reduction in wall pore size within 10 min. The wall pore size of denatured B-grown cells was increased by treatment at pH </= 2.0 or by treatment with Ca(2+)-chelating agents. The acid-mediated increase in wall pore size was prevented by boric acid alone at pH 2.0 and by boric acid together with Ca(2+), but not by Na(+) or Mg(2+) ions at pH 1.5. The Ca(2+)-chelator-mediated increase in pore size was partially reduced by boric acid. Our results suggest that B-mediated cross-linking of RG-II in the walls of living plant cells generates a pectin network with a decreased size exclusion limit for polymers. The formation, stability, and possible functions of a borate ester cross-linked pectic network in the primary walls of nongraminaceous plant cells are discussed.

Uterine artery Doppler velocimetry in pregnant women with hypertension

Uterine and umbilical artery velocimetry was carried out on 71 women with hypertensive disorders in pregnancy. Three categories of hypertensive disease were diagnosed: chronic hypertension, preeclampsia, and chronic hypertension with superimposed preeclampsia. Clinical classifications describe the severity of disease effectively, primarily because the classification is based on the appearance of abnormal physical or laboratory findings. Doppler velocimetry of the uterine arteries shows that normal pregnancy occurs when the systolic/diastolic ratio is less than or equal to 2.6. When the ratio exceeds this level and there is a notch in the waveform, the pregnancy is complicated by stillbirth, premature birth, intrauterine growth retardation, and maternal preeclampsia. The positive and negative predictive value of the examination is 93% and 91%, respectively. It appears that this new technology will be an essential ingredient of optimum pregnancy surveillance.

Umbilical velocity wave ratios in human pregnancy

Umbilical artery velocity waves were measured in the fetuses from 130 pregnant women. One hundred eighty-five determinations were carried out from the fourteenth to the fortieth weeks of pregnancy. Detection of waveforms was carried out on an Angioscan Doppler spectrum analyzer. The umbilical artery velocity waves can be differentiated from other fetal signals by recognition of the pattern. The systolic peak of the velocity wave was divided by the end-diastolic value, thereby giving an S/D ratio. The use of a ratio overcomes the obstacle of not knowing the angle between the incident beam and the direction of motion. The umbilical velocity wave S/D ratio in normal pregnancies declines from 2.8 to 2.2 from 25 to 41 weeks. In pregnancies which result in a small-for-gestational age (SGA) fetus, the ratio is significantly higher, showing an average level of 3.8 at 29 weeks and declining to 3.0 at 40 weeks. Abnormal umbilical velocity wave values are seen in an SGA fetus, unexplained fetal death, poorly controlled diabetes mellitus, and a twin transfusion syndrome. Application of this technique has the potential of being an important aid in prenatal care.

Umbilical artery velocity waveforms and intrauterine growth retardation

A continuous-wave Doppler unit was used to obtain umbilical artery velocity waveforms and to calculate the peak-systolic/diastolic ratio, a reflection of vascular resistance distal to the point of measurement. A total of 587 examinations were performed on 189 women between 18 to 42 weeks' gestation. The neonates were divided in four groups based on their centile birth weight: less than 25%, 25% to 50%, 51% to 75%, and greater than 75% for that gestational age. In all four groups the placental vascular resistance as reflected by the systolic/diastolic ratio fell progressively from the 24 weeks onward. In the lower weight group, placental vascular resistance between 31 to 39 weeks' gestation was higher than in the other three groups (p less than 0.05). For measurements taken between 31 and 39 weeks' gestation we calculated the predictive value of this test in identifying the small-for-gestational age fetus. A ratio of greater than or equal to 3 was defined as abnormal. For the entire population tested, sensitivity was 78% and the specificity was 83%. The predictive value of a positive test was 49%, but when hypertension was present, it was 66%. These findings may prove useful in identifying and managing pregnancies at risk for intrauterine growth retardation.

Child maltreatment, other trauma exposure, and posttraumatic symptomatology among children with oppositional defiant and attention deficit hyperactivity disorders

Consecutive child psychiatric outpatient admissions with disruptive behavior or adjustment disorders were assessed by validated instruments for trauma exposure and posttraumatic stress disorder (PTSD) symptoms and other psychopathology. Four reliably diagnosed groups were defined in a retrospective case-control design: Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), comorbid ADHD-ODD, and adjustment disorder controls. ODD and (although to a lesser extent) ADHD were associated with a history of physical or sexual maltreatment. PTSD symptoms were most severe if (a) ADHD and maltreatment co-occurred or (b) ODD and accident/illness trauma co-occurred. The association between ODD and PTSD Criterion D (hyperarousal/hypervigilance) symptoms remained after controlling for overlapping symptoms, but the association of ADHD with PTSD symptoms was largely due to an overlapping symptom. These findings suggest that screening for maltreatment, other trauma, and PTSD symptoms may enhance prevention, treatment, and research concerning childhood disruptive behavior disorders.

The significance of absent end-diastolic velocity in umbilical artery velocity waveforms

Doppler umbilical artery velocimetry has been used to study high-risk pregnancies. The most extreme waveform abnormality is the absence of end-diastolic velocity. To examine the significance of this finding, events outcome was evaluated in 161 women studied between 31 and 36 weeks. Ten had absence of end-diastolic velocity. When compared with fetuses with normal and less severely abnormal waveforms, there was a higher incidence of intrauterine growth retardation, pregnancy-induced hypertension, cesarean section for fetal distress, neonatal intensive care unit admission, and low Apgar scores. Average birth weight and gestational age at delivery were lower. Five other fetuses with absence of end-diastolic velocity were identified that were delivered between 27 and 30 weeks, making a total of 15 patients with absence of end-diastolic velocity. Of 12 patients monitored, 11 had an abnormal fetal heart rate pattern. Four fetuses had lethal anomalies. There were eight perinatal deaths. Acute or chronic hypoxia was evident in all fetuses with absence of end-diastolic velocity. Absent end-diastolic velocity represents a unique and severe fetal condition that cannot be identified by present surveillance methods and requires a Doppler study for diagnosis.

Predicting posttraumatic stress after hospitalization for pediatric injury

OBJECTIVE

To determine the prevalence and predictors of posttraumatic stress disorder (PTSD) in children after hospitalizations for accidental injuries.

METHOD

Forty-eight children (aged 7-17 years) and their parents were assessed during hospitalization with measures of children's prior traumatization, prior psychopathology, injury severity, parental acute distress, and child acute distress. At outpatient follow-up at least 1 month later, children were evaluated for current PTSD diagnosis and PTSD symptomatology (PTSDS) by a child structured interview and for PTSDS by a parent questionnaire.

RESULTS

A total of 12.5% had the full syndrome of PTSD at follow-up, and an additional 16.7% had partial (sub-syndromal) PTSD. Full PTSD was associated with a higher level of prior psychopathology, higher parental acute distress, and higher rates of prior sexual abuse, compared with partial or no PTSD. Prior psychopathology, parental distress, and, to a lesser extent, children's acute distress as reported by parents and breadth of prior traumatization, predicted subsequent PTSDS.

CONCLUSIONS

Full or partial PTSD is relatively common in youths 1 month or more after hospitalization for injuries. Parents' acute distress as well as children's prior psychopathology, prior traumatization, and acute distress may be useful predictors of such injured children's subsequent PTSD or PTSDS.

Development of uterine artery compliance in pregnancy as detected by Doppler ultrasound

Uterine artery velocimetry was performed by means of a continuous-wave Doppler ultrasound. Serial studies were done on 12 nonpregnant and 79 normal pregnant women. Measurements were made on both uterine arteries and averaged. From the proliferative phase of the menstrual cycle through 40 weeks of pregnancy, four developmental phases are described. These changes are based on the calculation of the systolic-diastolic ratio and the disappearance of the early diastolic notch in the velocity wave. The ratio after 26 weeks averaged 2 +/- 0.3. These data provide a foundation for the study of pregnancies in which these normal evolutionary changes do not occur.

The clinical significance of Doppler umbilical artery velocimetry in the small for gestational age fetus

Fifty-four women who were delivered of small for gestational age infants were studied antenatally by serially continuous-wave Doppler velocimetry. Outcomes were compared in the normal and abnormal systolic/diastolic ratio groups. Seventy-eight percent had an abnormal systolic/diastolic ratio. The group with an elevated systolic/diastolic ratio had a significantly higher incidence of abnormal fetal heart rate, pregnancy-induced hypertension, oligohydramnios, cesarean section for fetal distress, and admission into the neonatal intensive care unit. One third of the newborns required intermittent positive pressure ventilation. Average birth weight and gestational age at delivery were significantly lower and there were six perinatal deaths in the group with an elevated systolic/diastolic ratio and none in the group with a normal systolic/diastolic ratio. These data suggest that the small for gestational age fetus with normal umbilical artery velocimetry is at significantly lower risk than are those with abnormal ratios. This implies that management of the small for gestational age fetus may now be aided by a functional classification based on the umbilical artery velocity waveform.

A classification of hypertension in pregnancy based on Doppler velocimetry

We studied 136 pregnant women with hypertension with Doppler velocimetry of the uterine and umbilical arteries. The patients were classified into four groups according to the values of the systolic/diastolic ratios. The first group had normal ratios in both the umbilical and uterine arteries. The second group had elevated umbilical ratios and normal ratios in the uterine arteries. The third group had elevated uterine artery systolic/diastolic ratios with normal umbilical artery values, and the fourth group had elevated systolic/diastolic ratios in both vessels. Women in the group with normal ratios in both the umbilical and uterine arteries were delivered of infants with a birth weight (mean +/- SD) of 3261 +/- 522 gm and gestational age of 39 +/- 2 weeks. The values for the three groups with abnormal velocimetry were: those with elevated umbilical ratios and normal ratios in the uterine arteries: body weight = 2098 +/- 811 gm, gestational age = 35.7 +/- 3.2 weeks; those with elevated uterine artery ratios with normal umbilical artery values: 2464 +/- 722 gm, gestational age = 36.3 +/- 3 weeks; and those with elevated systolic/diastolic ratios in both vessels: body weight = 1627 +/- 697 gm, gestational age = 33.3 +/- 2.7 weeks (p less than 0.01; p less than 0.001). There were 27 small for gestational age infants delivered during this study. Doppler velocimetry studies were abnormal in 26 of them (96%). Results show that Doppler-derived vascular patterns correlate well with normal and adverse perinatal outcome. A description of the uterine and umbilical systolic/diastolic ratios should be part of the clinical evaluation of all pregnant women with hypertension. This should lead to better treatment protocols and improved clinical outcome.

Uterine and umbilical artery velocimetry during normal labor

Twelve normal parturients were studied with a continuous wave Doppler unit to assess changes in uterine and umbilical velocity waveforms during labor. The analysis of these waveforms included the peak systolic/end-diastolic ratio and the evaluation of a diastolic notch. Each woman served as her own control, and all fetal heart rate tracings were normal. In latent phase labor and intact membranes, the umbilical artery systolic/end diastolic ratios before, during, and after a contraction were 2 +/- 0.2, 2 +/- 0.3 and 1.95 +/- 0.3 (N.S.). Similar results were obtained in the active phase, after rupture of membranes, or during oxytocin stimulation. This stability of the fetal cardiovascular system ensures an uninterrupted gas exchange process during the contractions (on the fetal side), enabling the great majority of term fetuses to tolerate labor with minimal if any metabolic changes. The uterine artery end-diastolic velocity fell progressively during the contraction, reaching 0 when the intrauterine pressure exceeded 35 mm Hg. Despite intrauterine pressure of greater than 60 mm Hg, the diastolic notch did not appear. Thus at term, the umbilical artery velocity waveform does not change over a wide range of uterine pressures. The changes seen in the uterine artery waveforms suggest that the end-diastolic component is primarily determined by changes in the arcuate and spiral arteries, both of which are affected during the uterine contraction.

Surveillance of twin pregnancy with umbilical arterial velocimetry

A continuous-wave Doppler system and a spectrum analyzer provide the tools for the measurement of systolic-diastolic velocity wave ratios in the umbilical arteries. In twins, each umbilical cord can be studied without imaging the fetuses. Results were tabulated by taking the average difference in the ratios between each fetus and plotting these values against the neonatal weight differences. In 43 twin pregnancies, the data revealed that ratio differences between fetuses that averaged 0.4 or more was predictive of a weight difference of greater than 349 gm. The sensitivity was 73% and specificity 82%. Two cases of twin transfusion syndrome were recognized by the simultaneous presence of high- and low-resistance values.

Acute stress disorder symptomatology during hospitalization for pediatric injury

OBJECTIVE

To examine and identify predictors of acute stress disorder (ASD) and ASD symptomatology (ASDS) in children hospitalized for injuries.

METHOD

Fifty-four youths were assessed while hospitalized for injuries. Dependent variables were parent and nurse ratings of children's ASDS. Independent variables included children's prior trauma exposure and behavior problems, injury severity and permanence, brain injury, injury or death to family/friend(s), parental distress, and child reports of the injury/hospitalization experience as meeting criterion A for ASD.

RESULTS

A total of 92.6% of children felt the current experience met criterion A, compared with 64.8% of parents. According to parent questionnaires, 4 subjects (7.4%) met DSM-IV criteria for ASD while another 12 (22.2%) had clinically significant but subsyndromal ASDS. Children's ASDS, as reported by parents, correlated highly with parental distress and ratings of children's prior psychopathology, and modestly with injury severity and family/friend(s) injured or killed. Nurses' ratings of children's ASDS correlated strictly with injury- and accident-related variables, and not with parent ratings of children's ASDS.

CONCLUSIONS

Children perceive injuries and hospitalizations as stressful. ASDS is widely though divergently reported by parents and nurses in children hospitalized for injury. Parental distress, children's prior psychopathology, and injury-related factors may be useful predictors of children's postinjury ASDS.

A high-throughput screening for mammalian cell death effectors identifies the mitochondrial phosphate carrier as a regulator of cytochrome c release

Functional annotation of complex genomes requires the development of novel experimental platforms with increased capacity. Here, we describe a high-throughput system designed to identify cDNAs whose overexpression induces morphologically distinct cell death modalities. The methodology incorporates two robotized steps, and relies on coexpression of library clones with GFP to reveal the morphological features presented by the dying cells. By using this system we screened 135 000 cDNA clones and obtained 90 independent molecules. Interestingly, three death categories were identified, namely; apoptotic, vacuolated and autophagic. Among the pro-apoptotic clones, we found four members of the mitochondrial carrier family: the phosphate and adenine nucleotide (type 3) transporters, and the mitochondrial carrier homologs (MTCHs) 1 and 2. Expression of these molecules induced cytochrome c release and caspase-9-dependent death. One of them, the phosphate carrier, was able to interact with members of the permeability transition pore complex ANT1 and VDAC1, and its binding to ANT1 was stabilized in the presence of apoptotic activators. Depletion of this carrier by siRNA delayed cytochrome c mobilization and apoptosis. These results attribute a previously undescribed apoptotic function to the phosphate carrier and, more generally, suggest that a common property of various mitochondrial transporters was exploited during evolution to regulate apoptosis.

Combined clinical and laboratory testing improves diagnostic accuracy for osteomyelitis in the diabetic foot

The purpose of this investigation was to examine the value of using routinely available clinical and laboratory tests in combination to distinguish osteomyelitis from cellulitis in a diabetic population with mild to moderately infected forefoot ulcers. We conducted a case-control study of 54 diabetic patients with 54 locally infected ulcers admitted to a university-affiliated tertiary-care hospital over a 4.5-year period. A total of 30 clinical and laboratory characteristics obtained at admission were tested for their association with pathology-proven osteomyelitis using logistic regression techniques. Ulcer depth greater than 3 mm (univariate odds ratio 10.4, P = .001) and C-reactive protein greater than 3.2 mg/dL (univariate odds ratio 10.8, P < .001) were the most informative individual clinical and laboratory tests for differentiating osteomyelitis from cellulitis. Adding C-reactive protein also significantly improved upon the accuracy of the study's best clinical testing strategy (area under the curve improved from 0.80 to 0.88, P = .040). Strategies that combined ulcer depth with serum inflammatory markers proved most useful in detecting ulcerated patients with concomitant bone infections (sensitivity 100% [95% CI 89.7%-100%] for both ulcer depth greater than 3 mm or C-reactive protein greater than 3.2 mg/dL, and ulcer depth greater than 3 mm or erythrocyte sedimentation rate greater than 60 mm/h). We conclude that considering clinical and laboratory findings together can significantly improve our diagnostic accuracy for osteomyelitis in the diabetic foot. The specific combination of ulcer depth with serum inflammatory markers appears to be a particularly sensitive strategy that may allow for greater detection of early diabetic osteomyelitis.

LEVEL OF CLINICAL EVIDENCE

3.

The development of fetal acidosis in the presence of an abnormal fetal heart rate tracing. I. The average for gestational age fetus

An abnormal fetal heart rate (FHR) tracing is a sensitive indicator of positivity that disease exists, but the intrinsic predictive value of such a tracing is disappointingly low because of the large number of false positive results. Abnormal FHR tracings, defined as those having a persistent quantitative score of 4 or less, were measured against time and outcome. A baseline fetal scalp blood sample was taken. Twenty fetuses were acidotic at the first blood sample. There were 121 study cases, all of which were greater than 37 weeks' gestational age. All fetuses were average for gestational age. Amniotic fluid was clear, internal FHR tracings were initially normal, and the first pH was normal. A relative acidosis-free interval could be demonstrated during the first 90 to 100 minutes. Following this time period rapid cumulative acidosis was seen, which varied according to the FHR pattern observed. The P50 acidosis values for various patterns were late decelerations, 115 minutes; variable decelerations, 145 minutes; and flat line tracings, 185 minutes.

A comparison of the cerebral uptake and metabolism of labeled glucose and deoxyglucose in vivo in rats

Experimental evidence indicated that: 1) [14C]deoxyglucose-6-phosphate (14C-DG-6-P) in brain (and other rat tissues) did not increase with time after injection of 14C-DG, 2) 14C-DG-6-P in rat brain (and other tissues) did not correlate with glucose metabolism, 3) 14C-DG-6-P in rat brain (and other tissues) had a significant negative correlation with glucose-6-phosphatase activity. Further, arterio-venous studies in rats, in which the cerebral uptake and metabolism of labeled glucose were compared directly with those of labeled DG (and labeled fluorodeoxyglucose, FDG), employing double labeled techniques, showed that DG (and FDG) cannot be used to measure glucose uptake and/or metabolism.

American College of Foot and Ankle Surgeons Clinical Consensus Statement: Diagnosis and Treatment of Adult Acquired Infracalcaneal Heel Pain

Adult acquired inferior calcaneal heel pain is a common pathology seen in a foot and ankle practice. A literature review and expert panel discussion of the most common findings and treatment options are presented. Various diagnostic and treatment modalities are available to the practitioner. It is prudent to combine appropriate history and physical examination findings with patient-specific treatment modalities for optimum success. We present the most common diagnostic tools and treatment options, followed by a discussion of the appropriateness of each based on the published data and experience of the expert panel.

Successful hematopoietic reconstitution with transplantation of erythrocyte-depleted allogeneic human umbilical cord blood cells in a child with leukemia

Cord blood, a potent source of hematopoietic stem cells, has been shown to successfully reconstitute hematopoiesis following allogeneic transplantation in a variety of disorders. A major drawback of cord blood has been the risk of transfusion reactions in ABO blood group incompatibility and drastic reduction in the stem cell pool if the cord blood is manipulated to remove red cells prior to cryopreservation or after thawing. This report describes an erythrocyte depletion method employing 3% gelatin-induced erythrocyte sedimentation for the selective removal of red cells from cord blood. The red cell-depleted fraction was shown to be enriched in progenitor cells and in cells secreting hematopoietic cytokines interleukin 3, granulocyte/macrophage colony-stimulating factor, and interleukin 6; a major source for cytokines was from cord T cells. This preparative technique was employed to separate out red cells from cord blood of an infant delivered by cesarean section who had an 8-year-old sibling with leukemia. Histocompatibility testing of cord cells revealed complete matching with the patient. A cord cell transplant of cryopreserved and thawed cells consisting of 4 x 10(7) nucleated cells per kg was administered to the patient following myeloablative chemotherapy. The patient's quick hematologic recovery and 9-month disease-free period to date suggest that 3% gelatin separation of erythrocytes is a simple method that can be successfully used for transplanting cord cells for malignant/nonmalignant diseases.

Concentration of 3', 5' cyclic adenosine monophosphate in ventricular cerebrospinal fluid of patients with prolonged coma after head trauma or intracranial hemorrhage

A previous study showed that cerebrospinal fluid from the lateral ventricle of patients without disturbance of sensorium or intracranial pressure contains 15 to 30 nm 3', 5' cyclic adenosine monophosphate. We measured the concentration of this cyclic nucleotide by radioimmunoassay in cerebrospinal fluid from the lateral ventricle of six patients with prolonged coma (20 days or longer) after head trauma (four), or spontaneous intracranial hemorrhage (two). Coma was graded IV to I in order of decreasing severity. Fluid was removed at intervals of six to 72 hours from a Rickham reservoir placed in the lateral ventricle. Concentration of the cyclic nucleotide (mean +/- S.E.M.) in coma of Grades IV, III, II and I was 2.1 +/- 0.3, 4.6 +/- 0.5, 6.3 +/- 1.4 and 12.5 +/- 2.4 nM respectively. After sensorium became normal, cAMP was 21.0 +/- 1.4 nM. Correlation between grade of coma and concentration was -0.89 (P less than 0.01). Thus, prolonged coma appears to be associated with a disturbance of cyclic AMP metabolism within the central nervous system.

Elevated first trimester PAPP--a is associated with increased risk of placenta accreta

OBJECTIVES

The objective of this article is to determine whether there were differences in first trimester serum analytes between cases of placenta previa with and without accreta.

METHODS

Cases of placenta previa in which the patient had first trimester aneuploidy screening were identified. Pregnancy-associated plasma protein A (PAPP-A) and free beta human chorionic gonadotropin (fbhCG) MoMs were compared with those with an accreta. Accreta cases were also compared with published distributions to determine significance and to develop likelihood ratios based on MoM values.

RESULTS

Eighty-two cases of previa were identified, including 16 with a histological diagnosis of placenta accreta. The median PAPP-A MoM of 1.68 in accreta was significantly greater than that of 0.98 in non-accreta (P = 0.002). For fbhCG, the median MoM was 1.00 and 1.01 in accreta and non-accreta, respectively. Of the 16 patients with accreta, 14 (87.5%, 95% confidence interval: [61.6%, 98.4%]) had PAPP-A MoM above 1.0. Six of 16 (37.5%) accreta cases were above the 90th percentile of the unaffected distribution. The likelihood ratios for accreta were 0.5, 2.0, and 3.0. PAPP-A MoMs were 0.19, 2.11, and 4.27, respectively.

CONCLUSIONS

First trimester PAPP-A levels may be useful in identifying pregnancies at high risk for placenta accreta. Larger studies could incorporate both clinical and biochemical data into a risk algorithm.

Body mass index and achilles tendonitis: a 10-year retrospective analysis

INTRODUCTION

High body mass index (BMI) has been implicated as an etiologic agent in Achilles tendonitis (AT) and may contribute to poorer treatment outcomes. The purpose of this study was to better elucidate the role of BMI in both the development and treatment of AT.

METHODS

A matched case-control (1:1) study design was used. Matching criteria were age, gender, and year of presentation. Consecutive patients who presented with a diagnosis of AT between 2002 and 2011 at a single foot and ankle specialty clinic were identified. Patients who presented with other foot pain at the same clinic served as controls (CG). The AT group was further stratified into treatment responders and nonresponders. The main effect measure for both analyses was an adjusted odds ratio.

RESULTS

A total of 944 patients (472 AT; 472 CG) were included. AT patients had higher BMI than those in the CG (30.2 ± 6.5 vs 25.9 ± 5.3, P < .001). Overweight and obese patients were 2.6 to 6.6 times more likely than those with a normal BMI to present with Achilles tendonitis (P < .001). There was also elevated risk of presenting with AT at higher BMI categories (Mantel-Haenszel χ (2) = 8.074, P = .004). However, only age, not BMI, correlated with having failed conservative treatment among the AT group, with patients older than 65 years at the greatest risk (odds ratio = 2.4, 95% confidence interval = 1.5 to 4.1, P < .001).

CONCLUSION

BMI plays a role in the development of AT but does not appear to influence patient response to conservative treatment.

LEVELS OF EVIDENCE

Prognostic, Level II.

Probing angular correlations in sequential double ionization

We study electron correlation in sequential double ionization of noble gas atoms and HCl in intense, femtosecond laser pulses. We measure the photoelectron angular distributions of Ne+ relative to the first electron in a pump-probe experiment with 8 fs, 800 nm, circularly polarized laser pulses at a peak intensity of a few 10(15)  W/cm2. Using a linear-linear pump-probe setup, we further study He, Ar, and HCl. We find a clear angular correlation between the two ionization steps in the sequential double ionization intensity regime.

American College of Foot and Ankle Surgeons' clinical consensus statement: risk, prevention, and diagnosis of venous thromboembolism disease in foot and ankle surgery and injuries requiring immobilization

The purpose of this document is to provide guidance for physicians regarding the risk, prevention, and diagnosis of venous thromboembolism disease after foot and ankle surgery and while caring for lower extremity injuries that require ankle immobilization. A panel composed of all authors of this document reviewed the published evidence and, through a series of meetings, reached consensus regarding the viewpoints contained herein. We conclude that routine chemical prophylaxis is not warranted; rather, patients should be stratified and have a prevention plan tailored to their individual risk level. An effective venous thromboembolism prevention program is typically multimodal and focuses on addressing any modifiable risk factors, use of mechanical prophylaxis, early mobilization, and careful consideration of the use of chemical prophylaxis. The final decision regarding use and method(s) of prophylaxis adopted should be agreed upon by both the clinician and patient after a discussion of the potential benefits and harms as they relate to the individual. This should take place preferably during the preoperative visit or in the immediate post-injury setting, and it may need to be revisited during the course of care if the patient's risk level changes. Prompt recognition of the signs and symptoms of deep venous thrombosis following surgery or injury is important. Patients suspected of deep venous thrombosis should receive further work-up with either a D-dimer test or duplex venous ultrasound of the symptomatic leg, depending on their pretest probability for the disease. The latter can be determined using a validated clinical decision-making tool (e.g., Well's criteria).

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.