Fourteen-year follow-up of speech/language-impaired and control children: psychiatric outcome

OBJECTIVE

To examine the association between early childhood speech and language disorders and young adult psychiatric disorders.

METHOD

In a longitudinal community study conducted in the Ottawa-Carleton region of Ontario, Canada, interviewers administered structured psychiatric interviews to age 19 participants who were originally identified as speech-impaired only, language-impaired, or nonimpaired at age 5. The first stage of the study took place in 1982 when participants were 5 years old, and the latest stage of the study took place between 1995 and 1997 when participants had a mean age of 19 years. This report examines the association between early childhood speech/language status and young adult psychiatric outcome.

RESULTS

Children with early language impairment had significantly higher rates of anxiety disorder in young adulthood compared with nonimpaired children. The majority of participants with anxiety disorders had a diagnosis of social phobia. Trends were found toward associations between language impairment and overall and antisocial personality disorder rates. Males from the language-impaired group had significantly higher rates of antisocial personality disorder compared with males from the control group. Age of onset and comorbidity did not differ by speech/language status. The majority of participants with a disorder had more than one.

CONCLUSIONS

Results support the association between early childhood speech and language functioning and young adult psychiatric disorder over a 14-year period. This association underscores the importance of effective and early interventions.

Fourteen-year follow-up of children with and without speech/language impairments: speech/language stability and outcomes

This report concerns the speech and language outcomes of young adults (N = 242) who participated in a 14-year, prospective, longitudinal study of a community sample of children with (n = 114) and without (n = 128) speech and/or language impairments. Participants were initially identified at age 5 and subsequently followed at ages 12 and 19. Direct assessments were conducted in multiple domains (communicative, cognitive, academic, behavioral, and psychiatric) at all three time periods. Major findings included (a) high rates of continued communication difficulties in those with a history of impairment; (b) considerable stability in language performance over time; (c) better long-term outcomes for those with initial speech impairments than for those with language impairments; and (d) more favorable prognoses for those with specific language impairments than for those with impairments secondary to sensory, structural, neurological, or cognitive deficits. These general conclusions held when either a liberal or a more stringent criterion for language impairment was employed. Some of these findings are consistent with those from earlier follow-up studies, which used less optimal methods. Thus, the present replication and extension of these findings with a sound methodology enables greater confidence in their use for prognostic, planning, and research purposes.

Long-term outcomes after moderate to severe traumatic brain injury

OBJECTIVE

This research examined the long-term outcomes of rehabilitation patients with moderate to severe traumatic brain injury (TBI).

DESIGN

Retrospective cohort study.

SETTING AND SUBJECTS

We examined consecutive records of persons with moderate to severe traumatic brain injury who were discharged from a large rehabilitation hospital in Pennsylvania from 1973 to 1989. We interviewed consenting participants (n = 306) up to 24 years post-injury.

MAIN OUTCOME MEASURES

Self-rated health, activity limitations, employment, living arrangements, marital status, Community Integration Questionnaire, and use of rehabilitation services.

RESULTS

Participants were most limited in activities such as managing money and shopping. Twenty-nine per cent of our participants were working full time. There were significant relationships between activity limitations and residual cognitive impairment at follow-up. Self-rated health was correlated with most instrumental activities of daily living.

CONCLUSION

Our findings document health and function in a large post acute TBI population and implications for rehabilitation are discussed.

The use of the Tobit model for analyzing measures of health status

Self-reported health status is often measured using psychometric or utility indices that provide a score intended to summarize an individual's health. Measurements of health status can be subject to a ceiling effect. Frequently, researchers want to examine relationships between determinants of health and measures of health status. Regression methods that ignore the presence of a ceiling effect, or of censoring in the health status measurements can produce biased coefficient estimates. The Tobit regression model is a frequently used tool for modeling censored variables in econometrics research. The authors carried out a Monte-Carlo simulation study to contrast the performance of the Tobit model for censored data with that of ordinary least squares (OLS) regression. It was demonstrated that in the presence of a ceiling effect, if the conditional distribution of the measure of health status had uniform variance, then the coefficient estimates from the Tobit model have superior performance compared with estimates from OLS regression. However, if the conditional distribution had non-uniform variance, then the Tobit model performed at least as poorly as the OLS model.

Standardization of thromboelastography: a report from the TEG-ROTEM working group

Laboratory evaluation of bleeding disorders has been performed with the standard clotting assays such as the PT and PTT for several decades. Our improved understanding of the process of blood coagulation has now revealed the important role played by the cellular elements such as platelets, monocytes and red blood cells. The need for a test that can assess clotting in a more 'global' manner, beyond the initiation of clot formation, has led to greater interest in assays such as thrombin generation and thromboelastography. Even though there are several publications using thromboelastography it remains a research tool as the methodology is not standardized. In an attempt to show reproducibility and consistency using thromboelastography, a group of investigators from different countries joined hands to form the TEG-ROTEM Working Group. Two studies were performed using PRP and FVIII deficient plasma and an intrinsic pathway activator. This article summarizes the results of the first international effort at standardization of thromboelastography. Both of the instruments using this technology (TEG(®) and ROTEM(®)) were used. Nine laboratories from countries around the globe participated in this effort. The results showed a significant inter-laboratory variance with CV's greater than 10%. Although these results were not satisfactory, this has been the first effort to standardize this methodology and significant work remains to be done to improve reliability and reproducibility. These studies were performed on PRP and the results may be more reliable when preformed on whole blood samples. We believe that it is important to continue this work so that we may investigate the usefulness and potential applications of thromboelastography in the evaluation of bleeding and thrombosis.

Fetal brain grafts induce recovery of learning deficits and connectivity in rats with gustatory neocortex lesion

Three groups of rats showing disrupted taste aversion due to gustatory neocortex lesions, were studied. One group received a transplant of homotopic cortical tissue, another of heterotopic tectal tissue, obtained from 17-day-old fetuses. The third group remained without transplant as a lesioned control group. Comparisons of the taste aversion scores before and after graft, revealed that cortical grafted animals significantly improved the taste aversion, whereas those which received tectal grafts, and the cortical-lesioned controls did not. Moreover, results with horseradish peroxidase (HRP) histochemistry revealed that the homotopic, but not the heterotopic, brain transplants were able to re-establish connections with amygdala and with the ventromedial nucleus of the thalamus areas who normally kept connectivity with the gustatory neocortex. These results support the hypothesis that fetal brain transplants can reestablish cognitive functions, as well as connectivity with its host tissue.

The effect of early dexamethasone administration on bronchopulmonary dysplasia in preterm infants with respiratory distress syndrome

OBJECTIVES

This study was carried to evaluate the effect of early administration of dexamethasone on the incidence of bronchopulmonary dysplasia (BPD) and/or death in surfactant-treated preterm infants with respiratory distress syndrome (RDS).

STUDY DESIGN

In a multicenter, double-blind, placebo-controlled trial, 109 preterm infants with RDS and birth weights between 700 and 1600 gm, who were treated with mechanical ventilation and surfactant, were randomly assigned before 36 hours of life to receive dexamethasone (n = 55) or placebo (n = 54) for 12 days.

RESULTS

There were no differences in the incidence of BPD and/or death between groups. However, fewer patients in the dexamethasone group were oxygen-dependent at 36 weeks after conception (8% vs 33%, p < 0.05). The dexamethasone group had a lower incidence of necrotizing enterocolitis (0% vs 9%, p < 0.05). The incidence of arterial hypertension, hyperglycemia, and sepsis was not affected by the treatment. Basal and poststimulation serum cortisol levels did not differ between groups.

CONCLUSION

The administration of dexamethasone early in the course of RDS does not decrease the incidence of BPD and/or death in preterm infants. However, dexamethasone may reduce oxygen dependency at 36 weeks after conception.

Retinoid-induced hypertriglyceridemia in rats is mediated by retinoic acid receptors

Retinoids in clinical use today are known to induce hypertriglyceridemia as one of their major side effects. The purpose of the present study was to determine, in an appropriate animal model, if retinoid-induced hypertriglyceridemia is mediated by retinoic acid receptors (RARs) and/or by retinoid X receptors (RXRs). Oral gavage of male Fischer rats with 13-cis-retinoic acid for 6 days caused a rapid and sustained increase in serum triglycerides that was reversible within 4 days posttreatment. In subsequent experiments, rats were treated by gavage once daily for 3 days with various retinoids, and serum triglyceride levels were determined 24 hr after the last treatment without fasting. All-trans- and 13-cis-retinoic acid, which can be converted to both RAR and RXR agonists, and 9-cis-retinoic acid, an RAR/RXR pan-agonist, caused dose-dependent increases in serum triglycerides at doses that did not cause weight loss or mucocutaneous toxicity. Ro 13-6298 and AGN 190121, two RAR-specific agonists, caused dose-dependent increases in serum triglycerides, although Ro 13-6298 only induced hypertriglyceridemia at weight-suppressive doses. Two RXR-selective agonists, LG100268 and AGN 191701, failed to induce hypertriglyceridemia or weight loss up to the highest doses tested. A structural isomer of AGN 190121 that does not activate RARs or RXRs, AGN 190727, did not induce hypertriglyceridemia. Hypertriglyceridemia induced by AGN 190121 was significantly inhibited by cotreatment with an RAR-selective antagonist, AGN 193109. Taken together, these data provide strong evidence that retinoid-induced hypertriglyceridemia is mediated, at least in part, by RARs. These data also suggest that RXR-specific agonists may have reduced potential to induce hypertriglyceridemia relative to RAR-active retinoids.

Pathways to suicidality across ethnic groups in Canadian adults: the possible role of social stress

BACKGROUND

Ethnicity is an important determinant of mental health outcomes including suicidality (i.e. suicidal ideation and suicide attempt). Understanding ethnic differences in the pathways to suicidality is important for suicide prevention efforts in ethnically diverse populations. These pathways can be conceptualized within a social stress framework.

METHOD

The study examines ethnic differences in the pathways to suicidality in Canada within a social stress framework. Using data from the Canadian Community Health Survey Cycle 1.1 (CCHS 1.1) and path analysis, we examined the hypotheses that variations in (1) socio-economic status (SES), (2) sense of community belonging (SCB), (3) SES and SCB combined, and (4) SES, SCB and clinical factors combined can explain ethnic differences in suicidality.

RESULTS

Francophone whites and Aboriginals were more likely to report suicidality compared to Anglophone whites whereas visible minorities and Foreign-born whites were least likely. Disadvantages in income, income and education, income and its combined effect with depression and alcohol dependence/abuse led to high rates even among the low-risk visible minority group. Indirect pathways for Asians differed from that of Blacks and South Asians, specifically through SCB. With the exception of SCB, Aboriginals were most disadvantaged, which exacerbated their risk for suicidality. However, their strong SCB buffered the risk for suicidality across pathways. Disadvantages in education, income and SCB were associated with the high risk for suicidality in Francophone whites.

CONCLUSIONS

Francophone whites and Aboriginals had higher odds of suicidality compared to Anglophone whites; however, some pathways differed, indicating the need for targeted program planning and prevention efforts.

Synthesis and biological activity of high-affinity retinoic acid receptor antagonists

This article reports the synthesis and biological activity of new high affinity retinioic acid receptor (RAR) antagonists. The effect of introducing heteroatoms in the bicyclic ring system of the potent dihydronaphthalene RAR antagonist 8, and the variation of the pendant aromatic group on the ability of these compounds to function as RAR antagonists is discussed. The use of binding, transcriptional, and in vivo assays revealed that the 2,2-dimethylthiochromene analogue 59, and the 2,2-dimethylchromene derivative 85, were the most effective in blocking retinoid agonist induced activity.

Antifactor Xa levels vs. activated partial thromboplastin time for monitoring unfractionated heparin. A pilot study

WHAT IS KNOWN AND OBJECTIVES

The two most common methods for monitoring unfractionated heparin (UFH) infusion are the activated partial thromboplastin time (aPTT) and the antifactor Xa heparin assay (anti-Xa). The purpose of this study is to compare the performance of an aPTT protocol vs. an anti-Xa protocol in adult patients as defined by the time to reach therapeutic range, the percentage of time the values were within the goal range and the number of times laboratory monitoring was conducted. We then analysed the discordance between paired values of anti-Xa and aPTT.

METHODS

This was a single-centre prospective cohort pilot study conducted from 1 September 2013 to 31 May 2014.

RESULTS

Eighty-five patients were treated with UFH infusion, aPTT monitoring (n = 48), anti-Xa monitoring (n = 37). The number of times aPTT and anti-Xa values were ordered was (median, IQR) 14 (2-34) vs 7 (2-76); P = 0·23. The time to reach therapeutic range in hours was (mean, SD) 22 (20) aPTT vs 15 (13) anti-Xa; P = 0·08. Therapeutic range (>50-100% of the time) was achieved in only 5 (10%) patients in the aPTT group vs. 21 (57%) in the anti-Xa group; P < 0·01. Supratherapeutic values (>50-100%) were observed in 38 (78%) patients in the aPTT group vs. 14 (38%) in the anti-Xa group; P < 0·01. The discordance between aPTT and anti-Xa was evaluated using 234 paired values from 37 patients. There was discordance between anti-Xa and aPTT values 57% of the time. Two patients had bleeding complications requiring blood transfusion or discontinuation of post-pilot protocol.

WHAT IS NEW AND CONCLUSION

Utilizing an anti-Xa protocol to monitor heparin infusion showed favourable results compared with utilizing an aPTT protocol by maintaining values within the therapeutic goal range. The most common discordant pattern in our study was a disproportionate prolongation of aPTT to anti-Xa values. Patients with discordant values presenting with high aPTT to normal anti-Xa values may have an increased risk of bleeding complications.

Adolescent substance use disorders: findings from a 14-year follow-up of speech/language-impaired and control children

Intervening on the development of adolescent addiction requires an understanding of the role of precursors. In a community sample of youth with and without early childhood speech/language (S/L) impairments, 12.7% of participants had a substance use disorder (SUD). Among these participants, 42.0% met criteria for more than 1 SUD. Interestingly, rates of SUDs did not differ by S/L status. However, S/L-impaired participants did show greater psychiatric comorbidity and poorer functioning. A total of 80% of S/L participants with SUDs had a concurrent diagnosis of antisocial personality disorder, compared with 43.8% of SUDs controls. In a logistic regression analysis, we found age 5 mother-rated problem behavior scores and an interaction between S/L status and teacher-rated conduct problem scores were predictive of SUDs. High conduct scores were predictive of SUDs development among control participants but not among S/L-impaired participants. First substance use and initial SUDs symptoms suggest that a window of opportunity exists to reach these troubled young people before they spiral into addiction.

Associations between bacterial communities of house dust and infant gut

The human gut is host to a diverse and abundant community of bacteria that influence health and disease susceptibility. This community develops in infancy, and its composition is strongly influenced by environmental factors, notably perinatal anthropogenic exposures such as delivery mode (Cesarean vs. vaginal) and feeding method (breast vs. formula); however, the built environment as a possible source of exposure has not been considered. Here we report on a preliminary investigation of the associations between bacteria in house dust and the nascent fecal microbiota from 20 subjects from the Canadian Healthy Infant Longitudinal Development (CHILD) Study using high-throughput sequence analysis of portions of the 16S rRNA gene. Despite significant differences between the dust and fecal microbiota revealed by Nonmetric Multidimensional Scaling (NMDS) analysis, permutation analysis confirmed that 14 bacterial OTUs representing the classes Actinobacteria (3), Bacilli (3), Clostridia (6) and Gammaproteobacteria (2) co-occurred at a significantly higher frequency in matched dust-stool pairs than in randomly permuted pairs, indicating an association between these dust and stool communities. These associations could indicate a role for the indoor environment in shaping the nascent gut microbiota, but future studies will be needed to confirm that our findings do not solely reflect a reverse pathway. Although pet ownership was strongly associated with the presence of certain genera in the dust for dogs (Agrococcus, Carnobacterium, Exiguobacterium, Herbaspirillum, Leifsonia and Neisseria) and cats (Escherichia), no clear patterns were observed in the NMDS-resolved stool community profiles as a function of pet ownership.

Characterization of the major matrix degrading metalloproteinase of human corneal stroma. Evidence for an enzyme/inhibitor complex

The human cornea is an avascular, highly organized tissue with the unique property of transparency. While the extracellular matrices of this tissue are composed of a variety of collagen types, proteoglycans and glycoproteins, little is known of the normal degradation and remodeling of these components. We examined the capacity of organ cultured human ocular tissues to produce and secrete metalloproteinases, a family of related enzymes capable of digesting a variety of extracellular matrices. We demonstrated that while enzymatic activities similar to type I collagenase and stromelysin are produced, the predominant activities of the corneal stroma and keratocyte cultures are a 68-kDa gelatinase. In our hands, this enzyme does not appear to be induced significantly by phorbol esters in vitro. In addition, this enzyme appears to be secreted as a complex with a 21-kDa protein that functions as an enzymatic inhibitor. Moreover, the keratocytes also produce a 28-kDa inhibitor which has similar properties to tissue inhibitor of metalloproteinase (TIMP).

Comorbidity of psychiatric and substance use disorders in late adolescence: a cluster analytic approach

Cluster analysis was used to identify subgroups of youths with past-year substance and/or psychiatric disorders (N = 110, mean age 19.0 years). Data for this study came from a community-based, prospective longitudinal investigation of speech/language (S/L) impaired children and matched controls who participated in extensive diagnostic and psychosocial assessments at entry into the study at 5 years of age and again at follow-up. Clustering variables were based on five DSM diagnostic categories assessed at age 19with the University of Michigan Composite International Diagnostic Interview. Using Ward's method, the five binary variables were entered into a hierarchical cluster analysis. An iterative clustering method (K-means) was then used to refine the Ward solution. Finally, a series of analyses of variance (ANOVAs) were run to analyze group differences between clusters on measures of Global Assessment of Functioning (GAF), criminal involvement, anxiety and depressive symptomatology, and frequency of drug use and heavy drinking. The analysis yielded eight replicable cluster groups, which were labeled as follows: (a) anxious (20.9%); (b) anxious drinkers (5.5%); (c) depressed (16.4%); (d) depressed drug abusers (10%); (e) antisocial (16.4%); (f) antisocial drinkers (10%); (g) drug abusers (8.2%); (h) problem drinkers (12.7%). These groups were differentiated by external criteria, thus supporting the validity of our cluster solution. Cluster membership was associated with a history of S/L impairment: A large proportion of the depressed drug abusers and the antisocial cluster group had S/L impairment that was identified at age 5. Clarification of the developmental progress of the youths in these cluster groups can inform our approach to early intervention and treatment.

Cues trained apart compete for behavioral control in rats: convergence with the associative interference literature

Contemporary theories of associative learning require cues be trained in compound for cue competition (interference) to occur. That is, Cues A and X should compete for behavioral control only if training consists of AX-outcome (O) trials and not if each cue is separately paired with O (i.e., X-O and A-O). Research with humans challenges this view by showing that A-O trials interpolated between training and testing of a X-O association impair responding to X (i.e., retroactive interference). In six conditioned suppression studies with rats, the authors demonstrate that two cues trained apart can each interfere with the potential of the other to predict the outcome. The authors conclude that this type of interference (a) reflects a failure to retrieve the target association due to priming at test of the interfering association and (b) is attenuated if the outcome is of high biological significance. These findings parallel previous reports in verbal learning research and suggest that a similar associative structure underlies some types of associations in nonverbal subjects.

Comparison of the analgesic effects of meloxicam and carprofen administered preoperatively to dogs undergoing orthopaedic surgery

Thirty-two dogs undergoing operations to repair a torn cranial cruciate ligament or a fractured long bone were randomly allocated to one of two treatment groups in a study on postoperative pain. Sixteen of the dogs were given 4 mg/kg carprofen and the other 16 were given 0.2 mg/kg meloxicam subcutaneously before the operation. The signs of pain shown by the animals were assessed for 24 hours on a visual analogue scale, a discontinuous scoring system, and a score based on five behavioural and physiological variables. The dogs' heart and respiratory rates and their mean arterial blood pressures were also measured non-invasively at each assessment. Blood samples were taken before the surgery and 24 hours after it, and the concentrations of urea and creatinine were measured in plasma. Both drugs were effective in relieving the signs of pain for up to 24 hours in all the dogs. There were no significant changes in the concentrations of urea and creatinine, and no adverse effects were reported during the postoperative period.

A provincial program of blood conservation: The Ontario Transfusion Coordinators (ONTraC)

PURPOSE

Although often life-saving, blood transfusions are associated with significant risk to the patient and escalating costs to the blood system and hospital. Transfusions are often given unnecessarily. Blood conservation represents the use of alternatives to transfusion. The ONTraC program attempts to enhance transfusion practice outside the blood transfusion laboratory, promote blood conservation in surgery patients, and reduce allogeneic red cell use.

METHODS

In the first such large scale program, funding was obtained from the Ontario MOHLTC for a Transfusion Coordinator in 23 Ontario hospitals selected based on blood utilization and geography. At specific time periods, detailed anonymized information was collected in a defined number of all consecutive patients admitted for the three designated surgical procedures: knee arthroplasty (N=approximately 1200 at each time point), abdominal aortic aneurysm (AAA; N=300 at each time) and coronary artery bypass graft (CABG) surgery (N=300 at each time point).

RESULTS

Considerable inter-institutional variation was observed in the proportion of patients and amount of blood transfused. At the 12 month analysis, most, although not all, hospitals had decreased use of allogeneic blood and there was an overall 24% reduction in blood use in patients undergoing knee surgery, 14% in AAA and 23% in CABG. In addition to reduction in proportion of patients transfused, transfused patients received fewer units of allogeneic blood. Patients who did not receive allogeneic transfusions had significantly lower postoperative infection rates (p<0.05) and length of stay (p<0.0001); multivariate analysis showed that allogeneic transfusion was an independent predictor of increased length of stay. Eighteen-month analysis indicates even greater reduction in allogeneic transfusion. The main measures of blood conservation employed were preoperative autologous donation and education, with recent increasing use of erythropoietin and the cell saver. These measures have been demonstrated to be very effective in avoiding allogeneic transfusion.

CONCLUSIONS

The ONTraC have become leaders locally, nationally and internationally in blood conservation. The reduction in allogeneic transfusion associated with the implementation of the ONTraC program represents important savings in costs associated with blood components, hospital stay and work in transfusion laboratories and nursing units, as well as enhancing patient satisfaction and safety.

Altered gelatinolytic activity by keratoconus corneal cells

Keratoconus involves thinning and central protuberance of the cornea, scarring and significantly decreased vision. It is one of the major causes of corneal transplantation in this country, but the etiology of this disorder is unclear. In the present study stromal keratocytes were isolated and cultured from normal and keratoconus human corneas. Consistent with the phenotype of cornea thinning, we observed an increased gelatinolytic activity in keratoconus cultures. Characterization of enzyme properties in these cells suggested that gelatinase (type IV collagenase) was responsible for the majority of proteolytic activity found in this system. This elevated gelatinolytic activity was present in spite of lower amounts of total protein being produced by the keratoconus cultures.

Specific antagonist of retinoid toxicity in mice

AGN 193109 was recently identified as a potent retinoic acid receptor (RAR) antagonist in vitro. The purpose of the present study was to determine if AGN 193109 functions as an RAR antagonist in vivo and thus could prevent and/or treat retinoid toxicity. Female hairless mice were treated topically for 5 consecutive days with the synthetic retinoic acid receptor agonist (E)-4-[2-(5,6,7,8- tetrahydro-5,5,8,8-tetramethyl-2-naphthyl)propen-1-yl]benzoic acid (TTNPB) alone or in the presence of a 1-, 4-, or 16-fold molar excess of AGN 193109. TTNPB caused skin flaking, skin abrasions, and splenomegaly, and these effects were blocked in a dose-dependent fashion by AGN 193109 cotreatment. In the same model, AGN 193109 also decreased topical irritation induced by the natural RAR agonist, all-trans-retinoic acid. To determine if topical AGN 193109 could block toxicity induced by an oral retinoid, mice were treated by gavage with TTNPB (0.75 mumol/kg/day) and topically with 0, 0.3, or 1.2 mumol/kg/day of AGN 193109 for 4 days. TTNPB treatment alone caused cutaneous irritation and weight loss, and these effects were inhibited by AGN 193109 cotreatment. To determine if AGN 193109 could be used to treat preexisting retinoid toxicity, mice were pretreated topically on Days 1-2 with TTNPB (0.72 mumol/kg/day) and then treated topically on Days 3-5 with 0, 1.44, 7.2, or 36.0 mumol/kg of AGN 193109. TTNPB pretreatment caused precipitous weight loss and, in the absence of AGN 193109 intervention, 60% mortality. AGN 193109 treatment at all dose levels significantly accelerated recovery of body weight and prevented death in TTNPB-intoxicated mice. These data demonstrate that AGN 193109 is a potent RAR antagonist and a potential antidote of retinoid intoxication in vivo. In addition to potential clinical applications in the prevention and treatment of retinoid toxicity, AGN 193109 should provide a powerful experimental tool for the elucidation of retinoid biology.

Should sacrospinous ligament fixation for the management of pelvic support defects be part of a residency program procedure? The University of Miami experience

OBJECTIVE

The objective of this article is to determine the safety and effectiveness of transvaginal sacrospinous ligament fixation as part of the management of pelvic support defects in a residency program.

STUDY DESIGN

A retrospective chart review of patients undergoing sacrospinous ligament fixation at the Division of Gynecology, Jackson Memorial Hospital, University of Miami School of Medicine, between July 1990 and December 1995, was performed. Patients with vaginal vault prolapse and uterine prolapse with documented preoperative evaluation were included in this study. Data were obtained using a detailed predetermined flow sheet.

RESULTS

A total of 160 patients was included in the study. All patients underwent right sacrospinous ligament fixation, anterior and posterior colporrhaphy, and perineorrhaphy. In addition, 31 (19%) underwent enterocele repair, 5 (3%) underwent trachelectomy, and 9 (6%) underwent Burch procedure. Complications included fever 13 (8.1%), urinary tract infection 16 (10%), blood loss requiring transfusion 7 (4.3%), sciatic neuralgia 2 (1.2%), and rectovaginal fistula 2 (1.2%). The mean follow-up was 40 months (range 18 to 78 months). The success of the operation was gauged by recurrence. Ninety-four percent of the patients had no evidence of vaginal vault prolapse on follow-up, and 85% had no recurrence of any pelvic support defect. Eleven of the 24 patients with recurrence underwent repeat surgery, whereas 13 opted for conservative management with pessaries.

CONCLUSION

Transvaginal unilateral sacrospinous ligament fixation is a safe and successful operation for the treatment of pelvic support defect and should be an essential component in the training of gynecologic residents.

Are UN peacekeepers at risk for suicide?

Media reports connecting UN peacekeeping duties by Canadian soldiers to their subsequent suicide prompted this study of peacekeeping as suicide risk. In a case-control design we retrospectively compared 66 suicides in the Canadian military between 1990 and 1995 with two control groups: (a) 2,601 controls randomly selected from the electronic military database and (b) 66 matched controls with complete personnel and medical data. We found no increased risk of suicide in peacekeepers except among a subgroup of air force personnel. Here confounding individual factors, isolation from supports, and possibly inadequate preparation for deployment elucidated their suicides. Theater of deployment (e.g., Bosnia) did not affect the suicide rate. Military suicides experienced psychosocial stresses and psychiatric illness more often than their matched controls. We conclude that although peacekeeping per se does not increase overall suicide risk, military life-styles may strain interpersonal relationships, encourage alcohol abuse, and contribute to psychiatric illness and suicide in a minority of vulnerable individuals irrespective of peacekeeping assignment. Careful selection, and preparatory military training that encourages intragroup bonding and mutual support, may protect against suicide risk.

Unusually high prevalence rates of obesity in four Mexican rural communities

OBJECTIVE

To establish the nutritional status of previously studied rural populations.

DESIGN AND SUBJECTS

A total of 139 households with 245 males and 301 females from four relatively isolated Mexican rural communities were randomly selected to be surveyed in 1996.

RESULTS

Underweight was not a problem in either children or adults. In children <5 y only three (4.2%) were stunted but the age- and sex-specific distributions of body mass index (BMI) in children showed 17% of boys and 19% of girls exceeded the proposed International Obesity Task Force limits for classifying the overweight. Triceps skinfold values were similar to NHANESI values for white USA children. Of the adult men 42% were overweight (BMI 25.0-29.9) and 9% obese; 40% of adult women were overweight and a further 33% obese. Adjusting BMI values with corrected total heights by relating them to measured knee height reduced the BMI of women >50 y by 2.0 units; the male data were essentially unchanged. The prevalence of abdominal obesity in women, based on waist measurements and WHO cut-off points was high with 25% of women having elevated values despite a normal BMI; 43% of the overweight women had substantial increases in waist measurements, indicative of high risk, as did 91% of obese women. The men's waist measurements were greater in relation to both BMI and body fat but the prevalence of values in excess of the suggested sex-specific WHO limits was less than half that of women.

CONCLUSIONS

The high prevalence of overweight and obesity is now evident in poor and relatively isolated rural communities of Mexico.

SPONSORSHIP

The Chronic Disease Office, from the Ministry of Health in Mexico partially financed this study.

Retinoid X receptor agonist elevation of serum triglycerides in rats by potentiation of retinoic acid receptor agonist induction or by action as single agents

Hypertriglyceridemia is a major side-effect of retinoid therapy in humans. We previously reported that agonists for the retinoic acid receptors (RARs), but not the retinoid X receptors (RXRs), elevate serum triglycerides in male Fischer rats, and that, surprisingly, the RAR/RXR pan-agonists 9-cis-retinoic acid and AGN 191659 [(E)-5-[2-(5,6,7,8-tetrahydro-3,5,5,8,8-pentamethyl-2-naphthyl)propen-1-yl]-2-thiophenecarboxylic acid] induce 2- to 3-fold higher levels of serum triglycerides than the RAR-selective agonists alone. We have now demonstrated that hypertriglyceridemia induced by an RAR agonist, AGN 190121 [4-[4-(2',6',6'-trimethylcyclohex-1-enyl)-but-1-yne-3-enyl]benzoic acid], is substantially potentiated by the RXR-selective agonists AGN 191701 [(E) 2-[2-(5,6,7,8-tetrahydro-3,5,5,8,8-pentamethyl-2-naphthyl)propen-1-yl]-4-thiophene-carboxylic acid] and AGN 192849 [(3,5,5,8,8,-pentamethyl-5,6,7,8-tetrahydronaphthalen-2-yl) (5 carboxypyrid-2-yl)sulfide] in a dose-dependent manner. RXR-specific retinoids, as previously reported, had no independent effect on serum triglycerides when tested at 24 hr after final dosing, but did elicit a reversible hypertriglyceridemia at 2.5 and 5 hr. This induction of serum triglycerides could not be blocked by the potent RAR-specific antagonist AGN 193109 [4-[(5,6-dihydro-5,5-dimethyl-8-(4-methylphenyl)-2-naphthalenyl)-ethynyl] benzoic acid]. The RXR ligand-induced hypertriglyceridemia was independent of the effect of feeding or fasting. The relative potencies of RXR-specific retinoids for acute triglyceride elevation (AGN 194204 [3,7-dimethyl-6S,7S-methano-7-[1,1,4,4-tetramethyl-1,2,3,4-tetrahydronaphth-7-yl] 2(E),4(E) heptadienoic acid] > AGN 192849 approximately AGN 191701) approximately correlated with potencies in the activation of the RXR receptors. The RAR/RXR pan-agonist effect included >50% inhibition of total heparin-releasable lipase activity in serum, consistent with inhibition of lipase-mediated triglyceride disposal. These data also indicate that RAR and RXR ligands can act synergistically to induce hypertriglyceridemia through distinct mechanisms of action.