Isolation of a partial candidate gene for Menkes disease by positional cloning

Menkes disease is an X-linked recessive disorder of copper metabolism resulting in death in early infancy. The gene has been mapped to band Xq13 based, in part, on a translocation breakpoint in a female with the disease, which was found to lie within 300 kilobases (kb) of the PGK-1 locus, allowing the isolation of a YAC clone spanning the breakpoint. Phage subclones from the breakpoint region were isolated and used to screen cDNA libraries. cDNA clones were found which detect an 8 kb transcript from normal individuals but show diminished or absent hybridization in Menkes disease patients. Partial sequence of the cDNA shows a unique open reading frame containing putative metal binding motifs which have been found in heavy metal resistance genes in bacteria. This gene is a strong candidate for the Menkes disease gene.

Diffuse cortical dysplasia, or the 'double cortex' syndrome: the clinical and epileptic spectrum in 10 patients

Diffuse neuronal migration disorders associated with epilepsy can now be recognized by modern neuroimaging techniques, particularly high-resolution MRI. We report 10 patients with a recently described MRI picture of continuous or generalized band heterotopia underlying the cortical mantle, giving the appearance of a "double cortex." They have epilepsy, and almost all have mental retardation. The epileptic disorder varies in nature and degree of severity. Patients may present with infantile spasms, a Lennox-Gastaut syndrome, or other forms of secondary generalized or multifocal epilepsy. Response to medical treatment is variable. Callosotomy may lead to considerable reduction of drop attacks, present in 60%. Mental retardation is usually mild or moderate, and only rarely severe. It correlates with the type of epileptic syndrome, and is greater in patients with more disorganized cortex overlying the heterotopia. Recognition of this entity by MRI is important for appropriate diagnosis of the epileptic disorder, planning of therapeutic strategy, and prognosis.

Epidemiology of and surveillance for postpartum infections

We screened automated ambulatory medical records, hospital and emergency room claims, and pharmacy records of 2,826 health maintenance organization (HMO) members who gave birth over a 30-month period. Full-text ambulatory records were reviewed for the 30-day postpartum period to confirm infection status for a weighted sample of cases. The overall postpartum infection rate was 6.0%, with rates of 7.4% following cesarean section and 5.5% following vaginal delivery. Rehospitalization; cesarean delivery; antistaphylococcal antibiotics; diagnosis codes for mastitis, endometritis, and wound infection; and ambulatory blood or wound cultures were important predictors of infection. Use of automated information routinely collected by HMOs and insurers allows efficient identification of postpartum infections not detected by conventional surveillance.

Subdural haematoma and effusion in infancy: an epidemiological study

AIM

To determine incidence, aetiology, and clinical features of subdural haematoma and effusion (SDH/E) in infancy throughout the British Isles.

METHODS

Cases were notified to the British Paediatric Surveillance Unit over 12 months by paediatricians, neurosurgeons, and paediatric and forensic pathologists.

RESULTS

A total of 186 infants (121 boys, 65 girls) aged 0-2 years were identified. Annual incidence of SDH/E for the UK and Republic of Ireland is 12.54/100,000 aged 0-2 (95% CI 10.3 to 14.62) and 24.1/100,000 aged 0-1 (95% CI 20.89 to 28.18). A total of 106 infants suffered non-accidental head injury (NAHI), 7 accidental head injury, 26 a perinatal cause, 7 a non-traumatic medical condition, 23 meningitis, and in 17 the cause was undetermined; 35 infants died. Significant differences were found in injury pattern, body weight, and Townsend score between NAHI and SDH/E from other cause. There were fewer diagnostic investigations in non-NAHI cases. Delay in diagnosis of greater than a week occurred in 48/181.

CONCLUSION

SDH/E is a significant cause of morbidity and mortality in infancy. NAHI is the predominant cause of SDH/E. SDH/E can present in a non-specific and varied way and must be considered in any infant who is unwell. Determining the cause of the SDH/E in some cases continues to present a diagnostic challenge.

Housing choice and community success for individuals with serious and persistent mental illness

Consumer choice is a central principle of psychosocial rehabilitation and supported housing approaches. This study assessed level of housing choice and the relationship of choice to community success in supported housing demonstration projects in five states. Assessment of level of choice about housing revealed very limited housing options and a high degree of influence from service providers over housing choice. Despite few options, most respondents liked their housing option(s) and felt they had enough information to make a good housing decision. The relationship of choice to community success over time demonstrated that choice was positively related to housing satisfaction, residential stability, and psychological well-being. Discussion focuses on implications of the findings for mental health services and public policy.

Early manifestations and spectrum of recipient twin cardiomyopathy in twin-twin transfusion syndrome: relation to Quintero stage

OBJECTIVES

To examine cardiac structural and functional changes in twin-twin transfusion syndrome (TTTS), relative to Quintero stage, as a means of evaluating the spectrum of cardiomyopathy in TTTS.

METHODS

This was a cross-sectional, retrospective study of 42 consecutive cases of TTTS referred to a single fetal therapy center. Quintero stages were assigned by standard criteria. Presence of ventricular hypertrophy, cardiomegaly, atrioventricular valve regurgitation (AVVR), ventricular systolic dysfunction and right ventricular outflow tract obstruction on fetal echocardiography were noted. The Doppler myocardial performance index (MPI), an index of global ventricular function, was calculated for both ventricles in subjects with adequate Doppler data. We compared cardiac changes across Quintero stages.

RESULTS

There was no cardiomyopathy observed in donor twins. The majority of subjects presented at Quintero Stage I (n = 14), II (n = 14) or III (n = 11), with fewer at Stages IV (n = 2) or V (n = 1). As early as Quintero Stages I and II, a significant proportion of recipient twins had ventricular hypertrophy (17/28, 61%), AVVR (6/28, 21%) or quantitative abnormalities in either right (12/24, 50%) or left (14/24, 58%) ventricular function. Increasing prevalence of biventricular systolic dysfunction and cardiomegaly accompanied advancing Quintero stage.

CONCLUSIONS

Changes in cardiac structure and function not reflected in Quintero staging occur in recipient twins early in the evolution of TTTS. Incorporation of cardiac findings into assessment of TTTS severity may prove useful in stratification of risk and treatment selection.

Efficient identification of postdischarge surgical site infections: use of automated pharmacy dispensing information, administrative data, and medical record information

Although most surgical site infections (SSIs) occur after hospital discharge, there is no efficient way to identify them. The utility of automated claims and electronic medical record data for this purpose was assessed in a cohort of 4086 nonobstetric procedures following which 96 postdischarge SSIs occurred. Coded diagnoses, tests, and treatments were assessed by use of recursive partitioning, with 10-fold cross-validation, and logistic regression with bootstrap resampling. Specific codes and combinations of codes identified a subset of 2% of all procedures among which 74% of SSIs had occurred. Accepting a specificity of 92% improved the sensitivity from 74% to 92%. Use of only hospital discharge diagnosis codes plus pharmacy dispensing data had sensitivity of 77% and specificity of 94%. All of these performance characteristics were better than questionnaire responses from patients or surgeons. Thus, information routinely collected by health care systems can be the basis of an efficient, largely passive, surveillance system for postdischarge SSIs.

Female gender associates with increased duration of intubation and length of stay after coronary artery surgery. CABG Clinical Benchmarking Database Participants

BACKGROUND

Females have worse outcome than do males after coronary artery bypass grafting; however, gender effects on length of stay (LOS) outcomes, such as duration of intubation or intensive care unit (ICU) LOS, have not been evaluated previously. The authors hypothesized that adjustment for pertinent preoperative covariates would eliminate any significant effect of gender on duration of intubation, LOS in the ICU after extubation, total ICU LOS, postoperative (exclusive of ICU) LOS, or total postoperative LOS.

METHODS

Patients undergoing elective or urgent primary coronary artery bypass grafting surgery at 51 academic health centers in 1995 and 1997 were studied. Unique multivariable statistical models were developed for duration of intubation, ICU LOS after extubation, total ICU LOS, and postoperative (exclusive of ICU and total) LOS to test for independent associations with gender. Preoperative but not intraoperative or postoperative variables were included in the model. P> or =0.01 was considered significant.

RESULTS

All LOSs were of significantly longer duration in females than in males in both the 1995 (n = 1,064) and 1997 (n = 910) data collections. After covariate adjustment, female sex remained associated with significantly longer duration ICU LOS and total postoperative LOS in both the 1995 (female:male ratios 1.30:1 and 1.13:1, respectively) and the 1997 (female:male ratios 1.19:1 and 1.12:1, respectively) data sets. After covariate adjustment, duration of intubation and ICU LOS after extubation were of significantly longer duration in women than men in 1995 (female:male ratios 1.22:1 and 1.39:1, respectively), but the differences were not significant in 1997.

CONCLUSIONS

Even in the context of accelerated recovery programs, these analyses show that female sex has powerful associations with increased LOS intervals for coronary artery bypass grafting surgery, even after adjustment for preoperative covariates. These effects could result from differences in the ways in which men and women respond to coronary artery disease, anesthesia, and coronary artery bypass grafting surgery, or to bias on the part of healthcare workers.

Variable phenotype including Leigh syndrome with a 9185T>C mutation in the MTATP6 gene

We describe 15 members of a Caucasian family with an apparently homoplasmic T-->C mutation at nucleotide position 9185 (9185T>C) in the mtDNA encoded MTATP6 (ATPase 6) gene. The clinical phenotype is extremely variable and includes late-onset Leigh syndrome (LS), isolated demyelinating peripheral neuropathy and neurogenic muscle weakness, ataxia and retinitis pigmentosa (NARP). Following recent reports of this same mutation in a single case and in a family with late-onset LS and NARP-like features, our paper emphasises the role of MTATP6 in LS and expands the associated clinical phenotype further.

Heterogeneous Reaction Probabilities, Solubilities, and the Physical State of Cold Volcanic Aerosols

On 19 January 1992, heterogeneous loss of HNO(3), ClNO(3), and HCl was observed in part of the Mount Pinatubo volcanic cloud that had cooled as a result of forced ascent. Portions of the volcanic cloud froze near 191 kelvin. The reaction probability of ClNO(3) and the solubility of HNO(3) were close to laboratory measurements on liquid sulfuric acid. The magnitude of the observed loss of HCl suggests that it underwent a heterogeneous reaction. Such reactions could lead to substantial loss of HCl on background sulfuric acid particles and so be important for polar ozone loss.

COL4A1 mutations associated with a characteristic pattern of intracranial calcification

Intracranial calcification (ICC) is a relatively common radiological finding in children undergoing investigation for neurological disorders. Many causes are recognised, and ICC is often regarded as a non-specific sign.From an ongoing study of ICC, we identified 5 patients with characteristic radiological features, in whom a mutation in the COL4A1 gene was found.All patients had CT and MR imaging. MR images demonstrated features of periventricular leukomalacia with irregular dilatation of the lateral ventricles with or without porencephaly, loss of hemispheric white matter volume, and high signal on T2 and FLAIR sequences within periventricular and deep white matter. Calcification was apparent on MR in 4 patients. CT scans demonstrated spot and linear calcification in the subependymal region and around areas of porencephaly. Calcification was also visible in the deep cerebral white matter and basal ganglia. 1 patient showed calcification in the central pons.ICC occurs in COL4A1-related disease. The radiological features are distinct from other conditions demonstrating recognisable patterns of ICC, such as congenital cytomegalovirus infection and Aicardi-Goutiéres syndrome. In the absence of a known risk factor for periventricular leukomalacia, the presence of these radio-logical findings should suggest the possibility of COL4A1-related disease.

Weight bias among exercise and nutrition professionals: a systematic review

Obesity affects approximately one-third of American adults. Recent evidence suggests that weight bias may be pervasive among both exercise and nutrition professionals working with adults who have obesity. However, the published literature on this topic is limited. This review aimed to (i) systematically review existing literature examining weight bias among exercise and nutrition professionals; (ii) discuss the implications of this evidence for exercise and nutrition professionals and their clients; (iii) address gaps and limitations of this literature; and (iv) identify future research directions. Of the 31 studies that met the criteria for this review, 20 examined weight bias among exercise professionals, of which 17 (85%) found evidence of weight bias among professionals practicing physical therapy (n = 4), physical education (n = 8) and personal/group fitness training (n = 5). Of 11 studies examining weight bias among nutrition professionals, eight (73%) found evidence of weight bias. These findings demonstrate fairly consistent evidence of weight bias among exercise and nutrition professionals. However, the majority of studies were cross-sectional (90%). Given that weight bias may compromise quality of care and potentially reinforce weight gain and associated negative health consequences in patients with obesity, it is imperative for future work to examine the causes and consequences of weight bias within exercise and nutrition professions using more rigorous study designs.

Do shorter-acting neuromuscular blocking drugs or opioids associate with reduced intensive care unit or hospital lengths of stay after coronary artery bypass grafting? CABG Clinical Benchmarking Data Base Participants

BACKGROUND

The authors hypothesized that shorter-acting opioid and neuromuscular blocking drugs would be associated with reductions in duration of intubation, length of stay (LOS) in the intensive care unit (ICU) after tracheal extubation, or postoperative (exclusive of ICU) LOS, and that shorter durations of intubation would be associated with reduced ICU LOS after extubation and postoperative (exclusive of ICU) LOS.

METHODS

One-thousand ninety-four patients undergoing primary coronary artery bypass graft surgery at 40 academic health centers were studied. Multiple patient-related factors were included in multivariate models for hypothesis testing.

RESULTS

The duration of tracheal intubation, ICU LOS after extubation, and postoperative (exclusive of ICU) LOS all varied significantly by site. There was no difference between vecuronium and pancuronium in duration of intubation, ICU LOS after extubation, or postoperative (exclusive of ICU) LOS. Use of sufentanil rather than fentanyl was associated with a significant (P=0.045) reduction of 1.9 h (95% CI, 0.04 to 4.1 h) in duration of tracheal intubation but had no significant effect on ICU LOS after extubation, total ICU LOS, postoperative (exclusive of ICU) LOS, or total postoperative LOS. The authors' best model predicts a complex association between increasing duration of intubation and both ICU LOS after tracheal extubation and postoperative (exclusive of ICU) LOS, which was associated with an increase in those measures when duration of intubation exceeded 7.3 or 3 h, respectively.

CONCLUSIONS

The LOS measures varied considerably among the institutions. Use of shorter-acting opioid and neuromuscular blocking drugs had no association with ICU LOS after tracheal extubation or with postoperative (exclusive of ICU) LOS. Only when the duration of intubation exceeded threshold values was it associated with increased LOS measures.

Pre-eclampsia is associated with HLA-DR4 sharing between mother and fetus

Full HLA-A,B and DR typing was carried out on 92 women with proteinuric pre-eclampsia, 80 of their husbands and 46 of their babies. The results were compared with corresponding data from 65 normotensive pregnancies involving primiparous women. The frequency of HLA-DR4 was increased in the pre-eclamptic women (RR 3.1; p less than 0.005) and in the babies of pre-eclamptic pregnancies (RR 2.6; p less than 0.03). The strongest association, however, was with sharing of HLA-DR4 between mother and fetus (RR 4.2; p = 0.01). There was no increase in HLA antigen sharing in general between spouses or maternal-fetal pairs in pre-eclampsia. Nor did pre-eclamptic women exhibit increased homozygosity in general at any HLA locus. We conclude that genetic susceptibility to pre-eclampsia depends at least partly on fetomaternal compatibility for a gene or genes associated with HLA-DR4.

Cerebral function monitoring in paediatric intensive care: useful features for predicting outcome

Neurological integrity in sick children is difficult to assess clinically. The aim of this study was to determine the predictive value of EEG activity recorded with a bedside EEG analysing monitor in an intensive care unit. EEG activity was monitored in 108 children (age range 2 weeks to 16 years, median 1.7 years) considered at risk for cerebral abnormalities with a cerebral function analysing monitor (CFAM). Recordings were evaluated for features of background EEG activity including mean amplitude, frequencies, and symmetry. Electrical seizure activity was quantified if present. Predictive value of the EEG features was evaluated relative to the clinical neurological outcome after one year. Asymmetrical recordings were not seen in any child with a normal outcome. Suppression of background activity was seen in 75% of the children who died. Seizures were present in 68% of children with a poor outcome. Seventeen of the 32 children (65%) who died had prolonged seizures. Absence of seizures and the presence of superimposed fast EEG activity in response to benzodiazepine infusions correlated with good outcome. A combination of two or more predictive EEG features demonstrated >90% specificity and positive predictive likelihood of poor outcome. EEG features provide information about the functional cerebral integrity of sick children. Changes in cerebral activity detected by the CFAM aid decision making by providing such information readily at the bedside in intensive care.

SAGE II aerosol data validation based on retrieved aerosol model size distribution from SAGE II aerosol measurements

This paper describes an investigation of the comprehensive aerosol correlative measurement experiments conducted between November 1984 and July 1986 for satellite measurement program of the Stratospheric Aerosol and Gas Experiment (SAGE II). The correlative sensors involved in the experiments consist of the NASA Ames Research Center impactor/laser probe, the University of Wyoming dustsonde, and the NASA Langley Research Center airborne 14-inch (36 cm) lidar system. The approach of the analysis is to compare the primary aerosol quantities measured by the ground-based instruments with the calculated ones based on the aerosol size distributions retrieved from the SAGE II aerosol extinction measurements. The analysis shows that the aerosol size distributions derived from the SAGE II observations agree qualitatively with the in situ measurements made by the impactor/laser probe. The SAGE II-derived vertical distributions of the ratio N0.15/N0.25 (where Nr is the cumulative aerosol concentration for particle radii greater than r, in micrometers) and the aerosol backscatter profiles at 0.532- and 0.6943-micrometer lidar wavelengths are shown to agree with the dustsonde and the 14-inch (36-cm) lidar observations, with the differences being within the respective uncertainties of the SAGE II and the other instruments.

Potential salvage therapy for inadvertent intrathecal administration of vincristine

Vincristine is an anti-neoplastic agent for intravenous use. Inadvertent intrathecal administration of vincristine tends to follow a predictable clinical sequence of a progressive ascending radiculomyeloencephalopathy, usually fatal in outcome. We report a case of a 10-year-old girl who suffered an inadvertent intrathecal vincristine administration. We have outlined the management strategy used and her consequent neurological progress. She has survived but with a significant neurological deficit. Her outcome is, however, less severe than in previous literature reports; this may in part be attributable to early aggressive neurological management. This case also serves to highlight the tragic consequences of human error when handling chemotherapeutic agents of this nature.

Studies of the human liver insulin receptor in noninsulin-dependent diabetes mellitus

The insulin binding characteristics and the structural components of the insulin receptor were studied in the purified liver plasma membranes from seven patients with noninsulin-dependent diabetes (NIDDM) and seven control subjects. In comparison to the controls, diabetic subjects had a 65% reduction in plasma insulin levels in response to an oral glucose load. Specific insulin binding by liver membranes from diabetic patients was, however, twofold greater than the binding activity by membranes from control subjects. This alteration resulted largely from an increase in the number of insulin receptors and a modest increase in receptor binding affinity. Holo (nonreduced) receptor species of similar molecular weights were detected by an affinity labeling technique in the two membrane preparations and sulfhydryl reduction demonstrated an insulin binding subunit of 125,000 mol wt. Overall, these results show that the hepatic insulin resistance of NIDDM cannot be explained by a deficiency in insulin binding.