Folic acid supplementation in postmenopausal women with hot flushes: phase III randomised double-blind placebo-controlled trial

OBJECTIVE

To assess whether folic acid supplementation ameliorates hot flushes.

DESIGN

Double-blind, placebo-controlled randomised trial.

SETTING

Nine hospitals in England.

POPULATION

Postmenopausal women experiencing ≥50 hot flushes weekly.

METHODS

Women (n = 164) were randomly assigned in a 1:1 ratio to receive folic acid 5 mg tablet or placebo daily for 12 weeks. Participants recorded frequency and severity of hot flushes in a Sloan Diary daily and completed Greene Climacteric and Utian Quality of Life (UQoL) Scales at 4-week intervals.

MAIN OUTCOME MEASURES

The change in daily Hot Flush Score at week 12 from randomisation based on Sloan Diary Composite Score B calculation.

RESULTS

Data of 143 (87%) women were available for the primary outcome. The mean change (SD) in Hot Flush Score at week 12 was -6.98 (10.30) and -4.57 (9.46) for folic acid and placebo group, respectively. The difference between groups in the mean change was -2.41 (95% CI -5.68 to 0.87) (P = 0.149) and in the adjusted mean change -2.61 (95% CI -5.72 to 0.49) (P = 0.098). Analysis of secondary outcomes indicated an increased benefit in the folic acid group regarding changes in total and emotional UQoL scores at week 8 when compared with placebo. The difference in the mean change from baseline was 5.22 (95% CI 1.16-9.28) and 1.88 (95% CI 0.23-3.52) for total and emotional score, respectively.

CONCLUSIONS

The study was not able to demonstrate that folic acid had a statistically significant greater benefit in reducing Hot Flush Score over 12 weeks in postmenopausal women when compared with placebo.

TWEETABLE ABSTRACT

Folic acid may ameliorate hot flushes in postmenopausal women but confirmation is required from a larger study.

Referral and Resource Utilization Among Food Insecure Families Identified in a Pediatric Medical Setting

OBJECTIVE

Despite increased routine screening for food insecurity (FI) in pediatric medical settings, the uptake of offered food resources after FI identification is not well understood. We aimed to 1) describe utilization of referral and supplemental resources and 2) identify characteristics associated with utilization.

METHODS

We linked hospital screening and Electronic Medical Record data to Hunger Free Colorado (HFC) referral data for patients 0 to 18 years who were screened in the emergency department (ED), inpatient, or outpatient setting from January 2017 to December 2018. Among FI families, we compared patient demographic and clinical variables based on acceptance of HFC referral and connection to a food resource using Pearson's chi-square, Wilcoxon rank sum, and Poisson regression.

RESULTS

Of 1952 patients with FI, 371 (19%) accepted a referral to HFC and of these 228 (61%) were connected to a food resource. In adjusted analyses, families screened in the ED (adjusted relative risks [aRR] 1.96, confidence interval [CI]: 1.57-2.44) and inpatient (aRR 1.74, CI: 1.20-2.53) settings more often pursued referral to HFC than those screened in Child Health Clinic, while those screened in Special Care Clinic less often pursued referral (aRR 0.24, CI: 0.14-0.41). Families with 3 or more people in the home were more likely to be connected to resources (aRR 2.67, CI: 1.42-5.04).

CONCLUSIONS

Only a small proportion of families with FI identified in a medical setting are ultimately connected to food resources. Higher rates of HFC referral among ED and inpatient families suggest that increased screening efforts in these settings may be warranted.

Engaging Medical Students in Leadership Development

Leadership development plays a critical role in preparing collaborative, systems-based physicians. Medical schools across the globe have dedicated significant effort towards programming for medical student leadership development. Students report a variety of existing leadership opportunities, ranging from formal didactics to leadership positions within the community. Students identify lack of time, funding, and the hierarchy of medicine as significant barriers for engaging in leadership opportunities. Students favor a formal leadership curriculum coupled with hands-on opportunities to practice leadership skills. In order to train medical students to be engaged physician leaders, it is imperative to foster practical opportunities for leadership development.

Engaging Medical Students in Leadership Development

Leadership development plays a critical role in preparing collaborative, systems-based physicians. Medical schools across the globe have dedicated significant effort towards programming for medical student leadership development. Students report a variety of existing leadership opportunities, ranging from formal didactics to leadership positions within the community. Students identify lack of time, funding, and the hierarchy of medicine as significant barriers for engaging in leadership opportunities. Students favor a formal leadership curriculum coupled with hands-on opportunities to practice leadership skills. In order to train medical students to be engaged physician leaders, it is imperative to foster practical opportunities for leadership development.

A Student-Led National Conference on Leadership: Broadening the Medical Student Role

This article was migrated. The article was marked as recommended. Students have traditionally held a singular role in medical education - the learner. This narrow view neglects students unique perspective and ability to shape the future of medical education. In recognizing the need for deliberate leadership skill development and networking opportunities for medical student leaders, the American Medical Association (AMA) supported the first AMA Accelerating Change in Medical Education Student-Led Conference on Leadership in Medical Education. A planning committee of 19 students from seven medical schools collaborated to develop this conference, which took place on August 4-5, 2017 at the University of Michigan, Ann Arbor. The primary goal of the conference was for students to learn about leadership skills, connect with other student leaders, feel empowered to lead change, and continue to lead from their roles as students. Attendees participated in a variety of workshops and presentations focused on developing practical leadership skills. In addition, students formed multi-institutional teams to participate on in the MedEd Impact Challenge, attempting to address issues in medical education such as leadership curriculum development, wellness, and culture change. Post-conference surveys showed an overwhelming majority of students connected with other student leaders, shared ideas, developed collaborations, and felt empowered to enact change. Looking forward, we believe that similar student-led conferences focused on broadening the medical student role would provide avenues for positive change in medical education.

Double bubble, double trouble

Duodenal atresia (DA) is not uncommon, either as an isolated anomaly or associated with trisomy 21, malrotation, or cardiac anomalies. It may be diagnosed on antenatal ultrasound by a "double-bubble" sign, which typically persists after birth on a plain abdominal radiograph. DA as a familial association is rare but has been reported with or without other associated anomalies. We report DA in two siblings of nonconsanguineous parents, one case occurring with an annular pancreas in association with gestational diabetes. These two cases suggest possible genetic and environmental components in the aetiology of this anomaly.

Bacterial vaginosis in climacteric and menopausal women

The objective was to determine how frequently an abnormal vaginal flora occurred in women attending a menopause clinic and whether any abnormality might be related to a particular risk factor. Women completed a questionnaire on their gynaecological, sexual and medical history. Whether they were perimenopausal or postmenopausal was determined on the basis of symptomatology, duration of amenorrhoea and on a follicle-stimulating hormone (FSH) assay when clinically indicated. A speculum examination of the vagina was undertaken, at which time a smear of vaginal secretion was Gram stained and the bacterial flora graded as follows: grade 1, normal; grade 2, intermediate, and grade 3, bacterial vaginosis (BV). Of 100 women examined, 44 had grade 1 flora, 17 had grade 2 flora and 18 had BV. An apparent absence of, or very scanty, vaginal bacteria in which grading was not possible was found in 21 women. Women with BV had had more sexual partners than the others, but otherwise there were no discernible factors associated with the occurrence of BV. Women with vaginal atrophy were more likely to have an apparent absence of vaginal bacteria, but a few had BV.

Compliance with estrogen replacement therapy: current issues

Compliance is now considered to be a major issue in the clinical arena of the menopause and hormone replacement management. Recently, the terminology has evolved to intimate a closer working relationship between the woman and her clinician, but still varies from country to country, as do uptake and continuation rates. The literature is conflicting, some papers demonstrating an improvement in the situation in recent years, others striking a more pessimistic note. Certainly, trends can be identified. Factors are emerging that will positively influence long-term adherence, and most studies are consistent in the reasons women quote for cessation of therapy. The gulf between medical and feminist literature is wide, but we should examine women's viewpoints to enhance the profession's understanding of why the perception is one of unnecessary medicalization. Market research allows an insight into women's requirements and we should learn from other countries, cultures and professions. There is an increasing emphasis on communication skills. Counselling and information-giving have been recognized to be the key to developing a working relationship with the patient, but education for the physician is also necessary if accurate, individualized risk-benefit assessments and patient profiling are to be effective. Finally, a wider range of treatment options enhance individualization for the woman.

Intraoperative fibreoptic bronchoscopy during neonatal tracheo-oesophageal fistula ligation and oesophageal atresia repair

Maintenance of adequate ventilation under anaesthesia can be difficult during identification and ligation of congenital tracheo-oesophageal fistula with repair of oesophageal atresia. Anaesthesia may also be complicated by problems associated with prematurity, pre-existing aspiration pneumonitis, and difficulty positioning the endotracheal tube to prevent inflation of the stomach with increased risk of aspiration and diaphragmatic splinting. Even intubation of the fistula and gastric rupture may occur. Two neonatal cases are presented where use of a 2.2 mm neonatal bronchoscope passed through a 3.0 mm ID tracheal tube facilitated surgical identification of the fistula, diagnosis of fistula intubation and other airway problems intraoperatively.

British-Asian women's views on and attitudes towards menopause and hormone replacement therapy

OBJECTIVE

To establish an understanding of the views and values of Asian women living in the UK but of Indian subcontinent origin, in relation to the menopause and hormone replacement therapy (HRT): hopefully this will allow the development of strategies for increasing HRT uptake and long-term adherence.

METHOD

This was a postal, structured questionnaire survey, completed anonymously by British-Asian women who expressed their opinions and knowledge about the menopause and HRT, including their views on service provision.

RESULTS

Some 70% of women were in the age range 40-59 years; 74.5% had some education. In all 82% declared that they understood the menopause, and 77% thought that the menopause was a natural phenomenon. Over 75% were interested in seeking a medical opinion for management of the menopause. Of the women surveyed, 33% (n = 88) felt happy about and 46% (n = 123) felt frightened by the menopause.

CONCLUSIONS

The results suggest an overwhelming demand for information and the need for special clinics run by female doctors who can communicate in the women's own language. Fears and concerns are similar to those of the Caucasian population.

Small bowel injuries in children

OBJECTIVE

To determine the common features of small bowel injury (SBI) in childhood and the consequences of delayed diagnosis.

METHODOLOGY

A retrospective case review was performed of children with traumatic SBI between January 1988 and November 1999.

RESULTS

Twenty-eight patients were identified with SBI. Road trauma accounted for 71% of them. Tachycardia was present on admission in 82% of patients with SBI including all but one of the intestinal perforations. SBI was associated with a Chance fracture of the lumbar spine in three patients (11%). An abdominal computed tomography scan with intravenous contrast was abnormal in all patients with a perforation or mesenteric tear. Diagnosis was delayed in six patients, one of whom died as a result of sepsis from a small bowel perforation.

CONCLUSIONS

Persistent tachycardia with an appropriate mechanism of injury following blunt abdominal trauma requires active exclusion of SBI. Delayed diagnosis is associated with significant morbidity and mortality.

Adverse outcome of congenital diaphragmatic hernia is determined by diaphragmatic agenesis, not by antenatal diagnosis

BACKGROUND/PURPOSE

The authors studied their congenital diaphragmatic hernia (CDH) cases retrospectively to ascertain if classical CDH and diaphragmatic agenesis (DA) have separate clinical manifestations, whether antenatally diagnosed cases behave differently from those not diagnosed antenatally, and if antenatal diagnosis before 25 weeks carries a worse prognosis.

METHODS

The authors performed a retrospective review of 23 infants with CDH treated at their institution between January 1996 and March 1999. The patients were divided into 3 groups that were analyzed: DA and classical CDH, antenatally diagnosed and nonantenatally diagnosed, and antenatally diagnosed before 25 weeks and after 25 weeks.

RESULTS

There were 8 cases of DA and 11 cases of classical CDH. Four infants died without operation and could not be classified. Neonates with DA had significantly longer mean duration of preoperative stabilization compared with classical CDH (5.25+/-2.76 days v 1.36+/-1.0 days) and postoperative mechanical ventilatory support (15.7+/-3.0 days v 4.9+/-3.0 days). Fifty percent of DA patients died; all classical CDH patients survived. Twelve cases were diagnosed antenatally, 6 before 25 weeks' gestation. Antenatally diagnosed cases had no statistically significant difference in mortality rates from those not diagnosed antenatally; 50% of those diagnosed before 25 weeks survived.

CONCLUSIONS

DA cases require more preoperative preparation and postoperative ventilation and have a bad prognosis compared with classical CDH. Antenatal diagnosis of CDH does not convey a different prognosis. Fifty percent of CDH patients with antenatal diagnosis before 25 weeks survive.

Recurrent necrotizing enterocolitis associated with episodes of supraventricular tachycardia

The case of a 5-month-old baby with congenital heart disease and recurrent episodes of refractory supraventricular tachycardia (SVT) is presented. Severe segmental necrotizing enterocolitis (NEC) developed in the patient after one prolonged episode of SVT that required a limited right hemicolectomy. Further episodes of SVT were associated with recurrence of NEC requiring multiple laparotomies. The pathogenesis and therapeutic implications of this process are discussed in view of the potentially multiple pathological processes involved.

Behaviour of children associated with parental participation during induction of general anaesthesia

OBJECTIVE

To evaluate children's behaviour during induction of general anaesthesia with parental participation.

METHODS

A descriptive observational study in which the behaviour of the children was assessed using a Global Mood Scoring system before and during the induction of general anaesthesia, with their parents participating at induction.

RESULTS

Parental participation in anaesthetic induction was beneficial in avoiding distress at parental separation without the use of preoperative sedation. Negative effects of parental participation were not encountered.

CONCLUSIONS

Parental participation in anaesthetic induction of children can reduce distress at parental separation without any negative consequences. With proper preparation and education, parents should be encouraged to be present during the induction of general anaesthesia.

Polyamine metabolism and growth of neurospora strains lacking Cis-acting control sites in the ornithine decarboxylase gene

Ornithine decarboxylase (ODC) initiates the synthesis of polyamines (putrescine, spermidine, and spermine) and is highly regulated. We wished to know the importance of the control of ODC synthesis to the rates of growth and polyamine synthesis in the fungus, Neurospora crassa. We identified two control sites of the spe-1 gene, encoding ODC. One was an upstream activation region (UAR) and the other was the DNA encoding the long ODC mRNA leader, which governs polyamine-mediated repression of enzyme synthesis. Transformants receiving copies of spe-1 sequences lacking the UAR compensated for the deficiency by derepression or enzyme stabilization; polyamine synthesis was almost normal. A transformant lacking the spe-1 mRNA leader DNA constitutively expressed ODC mRNA and ODC activity, and synthesized excessive putrescine, especially when provided exogenous ornithine. This transformant grew normally and had only mildly elevated pools of spermidine, the major polyamine of this organism. We conclude that ODC activity normally limits polyamine synthesis, and ornithine becomes limiting in the ODC-constitutive strain. In this strain, however, spermidine synthesis remains rigorously limited by another step of the pathway, as yet unidentified. Thus the control of ODC activity in Neurospora is not vital to growth in laboratory culture, and synthesis of toxic levels of spermidine is limited by other mechanisms.

Ornithine decarboxylase gene of Neurospora crassa: isolation, sequence, and polyamine-mediated regulation of its mRNA

Ornithine decarboxylase (ODC), which initiates the biosynthesis of the polyamines putrescine, spermidine, and spermine, is encoded by the spe-1 gene of the fungus Neurospora crassa. This gene and its cDNA have been cloned and sequenced. The gene has a single 70-nucleotide intron in the coding sequence. The cDNA, comprising the entire coding region, recognizes a single 2.4-kb mRNA in Northern (RNA) blots. The mRNA transcript, defined by S1 mapping, has an extremely long, 535-base leader without strong secondary-structure features or an upstream reading frame. The translational start of the protein is ambiguous: a Met-Val-Met sequence precedes the Pro known to be the N terminus of the ODC polypeptide. The polypeptide encoded by the N. crassa spe-1 gene (484 amino acids) has 46% amino acid identity with that of Saccharomyces cerevisiae (466 amino acids) and 42% with that of mouse (461 amino acids). Alignment of the longer N. crassa sequence with S. cerevisiae and mouse sequences creates gaps in different sites in the S. cerevisiae and mouse sequences, suggesting that N. crassa ODC is closer to an ancestral form of the enzyme than that of either yeast or mouse ODC. N. crassa ODC, which turns over rapidly in vivo in the presence of polyamines, has two PEST sequences, found in most ODCs and other proteins with rapid turnover. In striking contrast to other eucaryotic organisms, the variation in the rate of ODC synthesis in response to polyamines in N. crassa is largely correlated with proportional changes in the abundance of ODC mRNA. Spermidine is the main effector of repression, while putrescine has a weaker effect. However, putrescine accumulation appears to increase the amount of active ODC that is made from a given amount of ODC mRNA, possibly by improving its translatability. Conversely, prolonged starvation for both putrescine and spermidine leads to the differentially impaired translation of ODC mRNA.

The genetics of polyamine synthesis in Neurospora crassa

New mutations of the polyamine pathway of Neurospora crassa fell into three categories. The majority affected ornithine decarboxylase and lay at the previously defined spe-1 locus. One mutation, JP100, defining the new spe-2 locus, eliminated S-adenosyl-methionine decarboxylase and led to putrescine accumulation. Revertants of this mutation suggested that the locus encodes the enzyme. Two other mutations, LV105 and JP120, defined a third locus, spe-3. Strains with these mutations also accumulated putrescine and were presumed to lack spermidine synthase activity, which catalyzes the formation of spermidine from putrescine and decarboxylated S-adenosylmethionine. The three spe loci lay within about 20 map units of one another on the right arm of Linkage Group V in the order: centromere-spe-2-spe-1-spe-3. The requirement for spermidine for growth was much less in spe-2 and spe-3 mutants than in spe-1 mutants, which do not accumulate putrescine. This suggested that putrescine fulfills many, but not all, of the functions of spermidine, or that high levels of putrescine render spermidine more effective in its essential roles.

Abnormalities of peptide-containing nerve fibers in infantile hypertrophic pyloric stenosis

The distributions of nerve cells and fibers with immunoreactivity for the peptides enkephalin, gastrin-releasing peptide, neuropeptide Y, somatostatin, substance P, and vasoactive intestinal peptide were examined in specimens of myenteric plexus and external muscle from the pylorus of 20 infants with hypertrophic pyloric stenosis. These were compared with peptide distributions in pyloric samples from unaffected infants and adults. In the normal pylorus the circular muscle was richly supplied with fibers reactive for enkephalin, neuropeptide Y, substance P, and vasoactive intestinal peptide. In pyloric stenosis, these immunoreactive fiber bundles were either missing or less than 5% of normal. In contrast, there were reactive cell bodies and nerve fibers in the myenteric plexuses of both normal and affected specimens. In the samples from cases of stenosis, swollen nerve fibers that appeared to be in the process of degeneration were frequently encountered. It is concluded that infantile hypertrophic pyloric stenosis is associated with a loss of peptide immunoreactivity in nerve fibers in the circular muscle, although the same peptides are still revealed in fibers and in nerve cell bodies in the myenteric plexus.

Congenital tracheal stenosis

Twenty-one cases of congenital tracheal stenosis seen at the Royal Alexandra Hospital for Children 1971 through 1980 were reviewed with regard to the clinical features, associated anomalies, endoscopic findings and radiological evaluation. Congenital tracheal stenosis was usually a serious problem often associated with other major anomalies of the respiratory tract, esophagus, or skeleton. There was no set pattern of presentation. The presenting features included: persistent wheeze or stridor, atypical "respiratory distress," and atypical "croup" or "bronchiolitis." Documentation of the nature and extent of the stenosis by endoscopy and, if necessary, tracheobronchogram was important for prognosis and to direct treatment. Congenital tracheal stenosis must be considered in infants who present with atypical respiratory tract obstruction, especially where there is an H-type tracheoesophageal fistula, pulmonary hypoplasia or skeletal abnormalities such as hemivertebrae or a thumb abnormality.