Prenatal Coffin-Siris Syndrome: Expanding the Phenotypic and Genotypic Spectrum of the Disease

Coffin-Siris syndrome is an autosomal dominant disorder with neurological, cardiovascular, and gastrointestinal symptoms. Patients with Coffin-Siris syndrome typically have variable degree of developmental delay or intellectual disability, muscular hypotonia, dysmorphic facial features, sparse scalp hair, but otherwise hirsutism and fifth digit nail or distal phalanx hypoplasia or aplasia. Coffin-Siris syndrome is caused by pathogenic variants in 12 different genes including SMARCB1 and ARID1A. Pathogenic SMARCB1 gene variants cause Coffin-Siris syndrome 3 whereas pathogenic ARID1A gene variants cause Coffin-Siris syndrome 2. Here, we present two prenatal Coffin-Siris syndrome cases with autosomal dominant pathogenic variants: SMARCB1 gene c.1066_1067del, p.(Leu356AspfsTer4) variant, and a novel ARID1A gene c.1920+3_1920+6del variant. The prenatal phenotype in Coffin-Siris syndrome has been rarely described. This article widens the phenotypic spectrum of prenatal Coffin-Siris syndrome with severely hypoplastic right ventricle with VSD and truncus arteriosus type III, persisting left superior and inferior caval vein, bilateral olfactory nerve aplasia, and hypoplastic thymus. A detailed clinical description of the patients with ultrasound, MRI, and post mortem pictures of the affected fetuses showing the wide phenotypic spectrum of the disease is presented.

Gestational anemia and maternal antenatal and postpartum psychological distress in a prospective FinnBrain Birth Cohort Study

BACKGROUND

Gestational anemia, most commonly caused by iron deficiency, may increase the risk of maternal anxiety and depression and have a potentially far-reaching impact on mother's and newborn's health. Several mechanisms, such as effects of iron deficiency on cerebral neurotransmitter metabolism, have been suggested. None of the earlier studies have assessed the association between gestational anemia and depression, anxiety and pregnancy-related anxiety simultaneously.

METHODS

Women, participating in the FinnBrain Birth Cohort Study and attending maternity welfare clinics in Turku, whose hemoglobin (Hb) values during pregnancy were available were included in this study (n = 1273). The study group consisted of 301 women with Hb levels < 11.0 g/dL at any time during pregnancy, and 972 women with Hb ≥ 11.0 g/dL were included in the control group. Symptoms of depression, anxiety, and pregnancy-related anxiety were assessed using the Edinburgh Postnatal Depression Scale (EPDS), Symptom Checklist-90 (SCL), and Pregnancy-Related Anxiety Questionnaire (PRAQ) questionnaires at 14, 24, and 34 gestational weeks, and EPDS and SCL were also performed 3 and 6 months postpartum.

RESULTS

Gestational anemia was not associated with an increased risk of depression either prenatally or postpartum when the analyses were adjusted for maternal age at birth, parity, smoking during pregnancy, maternal education, and gestational age. However, a weak connection was found between gestational anemia and prenatal anxiety in the early pregnancy. Furthermore, the analysis between women with Hb < 10.0 g/dL and those with Hb ≥ 10.0 g/dL showed an association between gestational anemia and anxiety in the late pregnancy, but otherwise no difference in psychological distress was found.

CONCLUSIONS

No evidence supporting the association between gestational anemia and antenatal or postpartum depression was found. However, a weak connection between gestational anemia and antenatal anxiety was observed. This finding needs further investigation to establish timing and investigate causality.

Gestational iron deficiency anemia is associated with preterm birth, fetal growth restriction, and postpartum infections

OBJECTIVES

Gestational IDA has been linked to adverse maternal and neonatal outcomes, but the impact of iron supplementation on outcome measures remains unclear. Our objective was to assess the effects of gestational IDA on pregnancy outcomes and compare outcomes in pregnancies treated with either oral or intravenous iron supplementation.

METHODS

We evaluated maternal and neonatal outcomes in 215 pregnancies complicated with gestational IDA (Hb<100 g/L) and delivered in our tertiary unit between January 2016 and October 2018. All pregnancies from the same period served as a reference group (n=11,545). 163 anemic mothers received oral iron supplementation, and 52 mothers received intravenous iron supplementation.

RESULTS

Gestational IDA was associated with an increased risk of preterm birth (10.2% vs. 6.1%, p=0.009) and fetal growth restriction (FGR) (1.9% vs. 0.3%, p=0.006). The gestational IDA group that received intravenous iron supplementation had a greater increase in Hb levels compared to those who received oral medication (18.0 g/L vs. 10.0 g/L, p<0.001), but no statistically significant differences in maternal and neonatal outcomes were detected.

CONCLUSIONS

Compared to the reference group, prematurity, FGR, postpartum infections, and extended hospital stays were more common among mothers with gestational IDA, causing an additional burden on the families and the healthcare system.

Transcriptomic and Phenotypic Analyses of the Sigma B-Dependent Characteristics and the Synergism between Sigma B and Sigma L in Listeria monocytogenes EGD-e

Numerous gene expression and stress adaptation responses in L. monocytogenes are regulated through alternative sigma factors σ^B and σ^L. Stress response phenotypes and transcriptomes were compared between L. monocytogenes EGD-e and its ΔsigB and ΔsigBL mutants. Targeted growth phenotypic analysis revealed that the ΔsigB and ΔsigBL mutants are impaired during growth under cold and organic-acid stress conditions. Phenotypic microarrays revealed increased sensitivity in both mutants to various antimicrobial compounds. Genes de-regulated in these two mutants were identified by genome-wide transcriptome analysis during exponential growth in BHI. The ΔsigB and ΔsigBL strains repressed 198 and 254 genes, respectively, compared to the parent EGD-e strain at 3 °C, whereas 86 and 139 genes, respectively, were repressed in these mutants during growth at 37 °C. Genes repressed in these mutants are involved in various cellular functions including transcription regulation, energy metabolism and nutrient transport functions, and viral-associated processes. Exposure to cold stress induced a significant increase in σ^B and σ^L co-dependent genes of L. monocytogenes EGD-e since most (62%) of the down-regulated genes uncovered at 3 °C were detected in the ΔsigBL double-deletion mutant but not in ΔsigB or ΔsigL single-deletion mutants. Overall, the current study provides an expanded insight into σ^B and σ^L phenotypic roles and functional interactions in L. monocytogenes. Besides previously known σ^B- and σ^L-dependent genes, the transcriptomes defined in ΔsigB and ΔsigBL mutants reveal several new genes that are positively regulated by σ^B alone, as well as those co-regulated through σ^B- and σ^L-dependent mechanisms during L. monocytogenes growth under optimal and cold-stress temperature conditions.

The efficacy of misoprostol vaginal insert compared with oral misoprostol in the induction of labor of nulliparous women: A randomized national multicenter trial

INTRODUCTION

Our objective was to compare the efficacy of a 200-μg misoprostol vaginal insert vs oral misoprostol regarding the cesarean section rate and the time interval to vaginal delivery in nulliparous women with unfavorable cervix.

MATERIAL AND METHODS

In this prospective multicenter trial, 283 nulliparous women at term with Bishop score <6 were randomized to induction of labor with either a misoprostol vaginal insert (n = 140) or oral misoprostol (n = 143). In the oral misoprostol group, a 50-μg dose of oral misoprostol was administered every 4 hours up to three times during the first day; during the second day, the dose was increased to 100-μg every 4 hours up to three times during the first day, if necessary. Primary outcome was the cesarean section rate. Secondary outcomes were the time from induction of labor to vaginal delivery, the rate of other induction methods needed, labor augmentation with oxytocin and/or amniotomy, use of tocolytics and adverse neonatal and maternal events.

RESULTS

In the misoprostol vaginal insert group, median time to vaginal delivery was shorter (24.5 hours vs 44.2 hours, P < 0.001), whereas no difference was found in the cesarean section rate (33.8% vs 29.6%, odds ratio [OR] 1.21, 95% confidence interval [CI] 0.66-1.91, P = 0.67). Other induction methods and labor augmentation with oxytocin and/or amniotomy were less frequent in the misoprostol vaginal insert group (OR 0.32, 95% CI 0.18-0.59 and OR 0.56, 95% CI 0.32-0.99, respectively). Need for tocolysis and meconium-stained amniotic fluid were more common in the misoprostol vaginal insert group (OR 3.63, 95% CI 1.12-11.79 and OR 2.38, 95% CI 1.32-4.29, respectively). Maternal and neonatal adverse events did not differ between groups.

CONCLUSIONS

Misoprostol vaginal insert proved to shorten the time to vaginal delivery and to reduce the use of other methods of labor induction and augmentation, but it did not reduce the cesarean section rate compared with oral misoprostol. The benefit of more rapid delivery associated with misoprostol vaginal insert should be weighed against the greater risks for uterine hyperstimulation and meconium-stained amniotic fluid.

Gelatine matrix with human thrombin decreases blood loss in adolescents undergoing posterior spinal fusion for idiopathic scoliosis: a multicentre, randomised clinical trial

AIMS

In a multicentre, randomised study of adolescents undergoing posterior spinal fusion for idiopathic scoliosis, we investigated the effect of adding gelatine matrix with human thrombin to the standard surgical methods of controlling blood loss.

PATIENTS AND METHODS

Patients in the intervention group (n = 30) were randomised to receive a minimum of two and a maximum of four units of gelatine matrix with thrombin in addition to conventional surgical methods of achieving haemostasis. Only conventional surgical methods were used in the control group (n = 30). We measured the intra-operative and total blood loss (intra-operative blood loss plus post-operative drain output).

RESULTS

Each additional hour of operating time increased the intra-operative blood loss by 356.9 ml (p < 0.001) and the total blood loss by 430.5 ml (p < 0.001). Multiple linear regression analysis showed that the intervention significantly decreased the intra-operative (-171 ml, p = 0.025) and total blood loss (-177 ml, p = 0.027). The decrease in haemoglobin concentration from the day before the operation to the second post-operative day was significantly smaller in the intervention group (-6 g/l, p = 0.013) than in the control group.

CONCLUSION

The addition of gelatine matrix with human thrombin to conventional methods of achieving haemostasis reduces both the intra-operative blood loss and the decrease in haemoglobin concentration post-operatively in adolescents undergoing posterior spinal fusion for idiopathic scoliosis.

TAKE HOME MESSAGE

A randomised clinical trial showed that gelatine matrix with human thrombin decreases intra-operative blood loss by 30% when added to traditional surgical haemostatic methods in adolescents undergoing posterior spinal fusion for idiopathic scoliosis.

Neuropeptide Y in the noradrenergic neurones induces obesity and inhibits sympathetic tone in mice

AIM

Neuropeptide Y (NPY) co-localized with noradrenaline in central and sympathetic nervous systems seems to play a role in the control of energy metabolism. In this study, the aim was to elucidate the effects and pathophysiological mechanisms of increased NPY in catecholaminergic neurones on accumulation of body adiposity.

METHODS

Transgenic mice overexpressing NPY under the dopamine-beta-hydroxylase promoter (OE-NPY(DβH) ) and wild-type control mice were followed for body weight gain and body fat content. Food intake, energy expenditure, physical activity, body temperature, serum lipid content and markers of glucose homoeostasis were monitored. Thermogenic and lipolytic responses in adipose tissues, and urine catecholamine and tissue catecholamine synthesizing enzyme levels were analysed as indices of sympathetic tone.

RESULTS

Homozygous OE-NPY(DβH) mice showed significant obesity accompanied with impaired glucose tolerance and insulin resistance. Increased adiposity was explained by neither increased food intake or fat absorption nor by decreased total energy expenditure or physical activity. Adipocyte hypertrophy and decreased circulating lipid levels suggested decreased lipolysis and increased lipid uptake. Brown adipose tissue thermogenic capacity was decreased and brown adipocytes filled with lipids. Enhanced response to adrenergic stimuli, downregulation of catecholamine synthesizing enzyme expressions in the brainstem and lower adrenaline excretion supported the notion of low basal catecholaminergic activity.

CONCLUSION

Increased NPY in catecholaminergic neurones induces obesity that seems to be a result of preferential fat storage. These results support the role of NPY as a direct effector in peripheral tissues and an inhibitor of sympathetic activity in the pathogenesis of obesity.

Upper cervical spine fusion in children with skeletal dysplasia

BACKGROUND

Skeletal dysplasias have been associated with upper cervical instability. Many patients are initially asymptomatic, but the instability may progress to subluxation and dislocation and complications thereof, including death. Surgery is hampered by petite osseous structures and low bone formation rate.

AIM

To review the outcomes of surgical fusion of upper cervical instability in children with rare skeletal dysplasias.

MATERIAL AND METHODS

A retrospective study of eight children with five different rare skeletal dysplasias needing upper cervical instrumented stabilization. Cases were evaluated for clinical, radiologic, and quality-of-life outcomes, with median follow-up time of 5 years.

RESULTS

Six patients underwent posterior, segmental cervical spine instrumentation and fusion (three C1/C2 fusions, three occipitocervical fusions), one anterior cervical instrumented spinal fusion, and one anteroposterior fusion. Autogenous bone grafting was used in all patients, and seven were immobilized using a halo body jacket. Nonunion in occipitocervical fusions was common in these patients (3/8 patients). Rib autograft from occiput to cervical spine with recombinant human BMP-2 was used to salvage nonunions.

CONCLUSIONS

Surgical fixation in the pediatric cervical spine is hampered by fragile posterior structures. A postoperative immobilization by halo vest for 4 months is customary. Selective anterior corpectomy and plate fixation is not recommended in pediatric patients with skeletal dysplasias.

LEVEL OF EVIDENCE

Level 4, Case Series.

Lentivirus-mediated α-melanocyte-stimulating hormone overexpression in the hypothalamus decreases diet induced obesity in mice

Melanocyte stimulating hormone (MSH) derived from the pro-hormone pro-opiomelanocortin (POMC) has potent effects on metabolism and feeding that lead to reduced body weight in the long-term. To determine the individual roles of POMC derived peptides and their sites of action, we created a method for the delivery of single MSH peptides using lentiviral vectors and studied the long-term anti-obesity effects of hypothalamic α-MSH overexpression in mice. An α-MSH lentivirus (LVi-α-MSH-EGFP) vector carrying the N'-terminal part of POMC and the α-MSH sequence was generated and shown to produce bioactive peptide in an in vitro melanin synthesis assay. Stereotaxis was used to deliver the LVi-α-MSH-EGFP or control LVi-EGFP vector to the arcuate nucleus (ARC) of the hypothalamus of male C57Bl/6N mice fed on a high-fat diet. The effects of 6-week-treatment on body weight, food intake, glucose tolerance and organ weights were determined. Additionally, a 14-day pairfeeding study was conducted to assess whether the weight decreasing effect of the LVi-α-MSH-EGFP treatment is dependent on decreased food intake. The 6-week LVi-α-MSH-EGFP treatment reduced weight gain (8.4 ± 0.4 g versus 12.3 ± 0.6 g; P < 0.05), which was statistically significant starting from 1 week after the injections. The weight of mesenteric fat was decreased and glucose tolerance was improved compared to LVi-EGFP treated mice. Food intake was decreased during the first week in the LVi-α-MSH-EGFP treated mice but subsequently increased to the level of LVi-EGFP treated mice. The LVi-EGFP injected control mice gained more weight even when pairfed to the level of food intake by LVi-α-MSH-EGFP treated mice. We demonstrate that gene transfer of α-MSH, a single peptide product of POMC, into the ARC of the hypothalamus, reduces obesity and improves glucose tolerance, and that factors other than decreased food intake also influence the weight decreasing effects of α-MSH overexpression in the ARC. Furthermore, viral MSH vectors delivered stereotaxically provide a novel tool for further exploration of chronic site-specific effects of POMC peptides.

Hybrid versus total pedicle screw instrumentation in patients undergoing surgery for neuromuscular scoliosis: a comparative study with matched cohorts

We compared the clinical, radiological and quality-of-life outcomes between hybrid and total pedicle screw instrumentation in patients undergoing surgery for neuromuscular scoliosis. A matched comparison using prospectively collected data was undertaken. A total of 66 patients underwent posterior or anteroposterior correction and fusion with hybrid (n = 33, mean age at surgery 15.8 years (9.10 to 19.6)) or total pedicle screw instrumentation (n = 33, mean age 14.7 years (7.0 to 20.7)) with a minimum follow-up of two years. The major curve pre-operatively was a mean of 87° (SD 29, 25° to 141°) and 81° (SD 18, 47° to 116°) in the hybrid and total pedicle screw groups, respectively (p = 0.29) and at a minimum of two years it was 33° (SD 20; 2° to 87°) and 20° (SD 12; 1° to 55°), respectively (p = 0.0016). The mean correction of the major curve was 59% (41% to 88%) in the hybrid and 75% (43% to 99%) in the total pedicle screw groups at two-year follow-up (p = 0.0011). The mean operating time was 7.45 hours (SD 2.18) and 6.04 hours (SD 1.71) in the hybrid and total pedicle screw groups, respectively (p = 0.001), and the mean intra-operative blood loss was 3760 ml (SD 2790) and 1785 ml (SD 1110), respectively (p = 0.001). Total pedicle screw instrumentation provided shorter operating times, less blood loss and better correction of the major curve compared with hybrid constructs in patients undergoing surgery for neuromuscular scoliosis.

Genes encoding putative DEAD-box RNA helicases in Listeria monocytogenes EGD-e are needed for growth and motility at 3°C

Quantitative RT-PCR revealed that transcripts of all four putative DEAD-box RNA helicase genes of the psychrotrophic pathogen Listeria monocytogenes EGD-e are found at higher levels in organisms grown at 3°C than at 37°C. At 3°C, growth of the three corresponding gene deletion mutants Δlmo0866, Δlmo1450 and Δlmo1722 was clearly restricted. The minimum growth temperatures of the three mutants were also higher than that of the wild-type EGD-e. In addition to inability to grow at 3°C, growth of Δlmo0866 and Δlmo1722 was reduced at 25°C, suggesting special roles of Lmo0866 and Lmo1722 in growth at suboptimal temperatures. Growth of Δlmo1450 was restricted not only at 3°C and 25°C, but also at 37°C, suggesting that Lmo1450 plays a universal role in growth of L. monocytogenes EGD-e. Moreover, cold-sensitive Δlmo0866, Δlmo1450 and Δlmo1722 were impaired in motility. The Δlmo0866 and Δlmo1450 strains were non-motile, while Δlmo1722 showed reduced motility. This study shows that the putative DEAD-box RNA helicase genes lmo0866, lmo1450 and lmo1722 are necessary for cold tolerance and motility of L. monocytogenes EGD-e.

Role of flhA and motA in growth of Listeria monocytogenes at low temperatures

While temperature-dependent induction of flagella is a well-characterized phenomenon in Listeria monocytogenes, the essentiality of increased flagellum production during growth at low temperatures remains unclear. To study this relationship, we compared the relative expression levels of two motility genes, flhA and motA, at 3°C, 25°C and 37°C in L. monocytogenes strain EGD-e by using qRT-PCR, and compared the growth curves, motility, and flagellation between the wild-type and flhA and motA deletion mutants. The relative expression levels of flhA and motA at 3°C were significantly higher than at 37°C (p<0.01). At 3°C, the level of flhA transcripts was also significantly higher than at 25°C (p<0.01). Growth curve analysis showed that at 3°C both the growth rates and maximum optical densities of ΔflhA and ΔmotA strains at 600 nm were significantly lower than those of the wild-type (p<0.001), while no significant differences were observed between the wild-type and the mutants at 37°C, and 25°C. Mutant strains ΔflhA and ΔmotA were nonmotile at all three temperatures. At 25°C, the number of flagellated cells of ΔmotA was notably reduced compared with the wild-type, whereas ΔflhA appeared nonflagellated at all temperatures. The results suggest that flhA and motA play a role in the cold tolerance of L. monocytogenes strain EGD-e, and that motile flagella may be needed for optimal cold stress response of L. monocytogenes.

Effects of strength and endurance training on antioxidant enzyme gene expression and activity in middle-aged men

This study was aimed at investigating the effects of a 21-week period of progressive strength or endurance training on peripheral blood mononuclear cells (PBMC) antioxidant enzyme gene expression and activity in healthy middle-aged untrained men. Strength (n=11) and endurance (n=12) training were performed twice a week, including resistance exercises to activate all the main muscle groups or cycle-ergometer pedaling, respectively. mRNA levels of catalase, glutathione peroxidase (GPx), mitochondrial superoxide dismutase (MnSOD) and cytosolic superoxide dismutase (CuZnSOD) were increased after 21 weeks of strength training, while endurance training induced significant changes only in MnSOD and GPx mRNA levels. CuZnSOD protein content was significantly increased only in strength-trained subjects. The program of strength or endurance exercise training had no significant effects on the activity of any of the antioxidant enzymes. In conclusion, in a middle-aged population, 21 weeks of strength or endurance training was a sufficient stimulus to up-regulate mRNA levels of PBMC antioxidant enzymes, the strength training being a more optimal stimulus. However, the discrepancies between enzyme protein and mRNA levels suggest that the present systematic strength or endurance training period had no beneficial effects on enzymatic antioxidant defense mechanisms in previously untrained middle-aged men.

Crystal-structure-dependent photoluminescence from InP nanowires

The formation and photoluminescence (PL) of InP nanowires grown by metal organic vapour phase epitaxy on InP(111)B substrates, using colloidal gold nanoparticles as catalysts, are investigated. The dependence of the orientation and dimensions of the nanowires on the growth temperature is studied using scanning electron microscopy. Vertically aligned [Formula: see text] oriented nanowires with a mean base diameter in the range 50-150 nm, and a tip diameter of 50 nm, show a PL blue-shift of about 80 meV compared to the substrate. Blue-shift due to quantum confinement is ruled out because of the large diameter of the nanowires. A clear correlation between the orientation of the nanowires on the substrate and the PL peak position is observed. Based on x-ray diffraction and transmission electron microscopy measurements, it is proposed that the as-grown vertically oriented nanowires have crystallized in the wurtzite lattice instead of in the zinc-blende structure, which results in a blue-shifted PL.

Cross-sectional tomograms obtained with four panoramic radiographic units in the assessment of implant site measurements

OBJECTIVES

The aim of this study was to evaluate the ability of four panoramic X-ray units to produce cross-sectional images and to assess the effect of interexaminer and intraexaminer variations on the results.

METHODS

Cross-sectional tomograms of a human cadaver mandible were taken from two edentulous and one dentate area using four different X-ray units: OP-100 Ortho Trans (Instrumentarium Imaging Co, Tuusula, Finland), Proscan (Planmeca Co, Helsinki, Finland), Cranex-Tome and Scanora (Soredex, Orion Co, Espoo, Finland). Four different linear distances were measured from each radiograph. The mandible was then cut into 4 mm thick slices at three marked places. These slices were microradiographed and used as the gold standard for measurements made from each cross-sectional tomogram.

RESULTS

Of all measurements only the thickness of the mandible in the radiographs taken with the OP-100 differed significantly (P < 0.021) from the gold standard. In the interexaminer variation, the agreement was 85% and Kappa index 0.68. In the intraexaminer reproducibility, the agreement was 76.7% and Kappa indices 0.52 and 0.50.

CONCLUSIONS

The X-ray units studied were found to be similar in terms of image performance and the produced images were acceptable for dental implant placement planning. Interexaminer and intraexaminer variations can be large and the main source of error can be the interpreter him or herself.

The safety climate and its relationship to safety practices, safety of the work environment and occupational accidents in eight wood-processing companies

Employees continuously observe their work environment and the actions of their fellow workers and superiors, and they use such observations as a basis for the creation of cognitive models associated with safety. These models regulate their actions in the workplace and thus have an influence on safety. This study attempts to define the structure of the safety climate as perceived by workers and the correlations between the safety climate, on the one hand, and the safety practices of the company, the safety level of the work environment and occupational accidents on the other. The variables used in this study were the same as those employed in two previous Finnish safety climate studies carried out in the plywood industry, shipyards, the forestry industry, building construction and stevedoring. The safety climate was measured by means of a questionnaire. Workers from four sawmills, two plywood factories and two parquet plants participated. The total number of participants was 508 in 1990 and 548 in 1993. The variables formed four factors, whose contents and reliabilities closely resembled the results obtained in the earlier studies. These results indicate that the structure of the safety climate among Finnish workers is quite stable. The safety climate correlated both with the safety level of the work environment and with the safety practices of the company, but the correlation between the safety climate and the safety of the work environment was stronger. This result differs from those of the previous studies, in which the safety climate was defined specifically in terms of an individual's perceptions of the safety practices of the company and of the behavior of other employees. The two safety climate factors that described a company's attitudes to safety and its safety precautions correlated with the accident rates. The better the safety climate of the company was, the lower was the accident rate. Four companies with an accident rate below the average for the wood-processing industry had a better safety climate than four similar companies with an accident rate above the average.

Conscious sedation and cardiorespiratory safety during colonoscopy

BACKGROUND

Cardiorespiratory events during colonoscopy are common. The effect of sedative premedication on cardiorespiratory parameters during colonoscopy has not been studied in controlled, prospective trials.

METHODS

One hundred eighty patients undergoing colonoscopy were divided into 3 groups: (1) sedation with intravenous midazolam (midazolam group); (2) sedation with intravenous saline (placebo group); and (3) no intravenous cannula (control group). Arterial oxygen saturation (SaO(2)), systolic and diastolic blood pressure and continuous electrocardiogram were recorded prior to, during and after the endoscopic procedure.

RESULTS

Midazolam produced lower SaO(2) values during colonoscopy compared with placebo or control groups (p < 0.001, repeated measures analysis of variance). Systolic and diastolic blood pressure during colonoscopy were lower in the midazolam group than in the placebo group (p < 0.01 and p < 0.05, respectively), but no difference was found between the midazolam and the control groups. Hypotension (systolic blood pressure less than 100 mm Hg) occurred more frequently in the midazolam group (19%) than in the placebo (3%; p < 0.01) or control groups (7%; p < 0.05). ST-segment depression developed in 7% of patients during the recording with no difference between the groups. In 75% of cases ST-depression appeared prior to the endoscopic procedure.

CONCLUSIONS

Premedication with midazolam induced a statistically significant decrease in arterial oxygen saturation and increased the risk for hypotension. However, colonoscopy proved to be a safe procedure both with and without sedation.

Vertical asymmetry of the mandibular ramus and condylar heights measured with a new method from dental panoramic radiographs in patients with psoriatic arthritis

Vertical asymmetry of the mandibular ramus and condylar heights was measured with a new method from dental panoramic radiographs. The study groups consisted of 45 psoriatic arthritis (PA) and 45 control (CO) matched pairs. Vertical asymmetry was calculated with the formula (R - L)/(R + L) x 100. Females showed no statistical significant difference in vertical asymmetry between the PA and CO pairs. In males however, vertical asymmetry showed a statistically significant difference between the PA and CO groups among those aged 35-55 years (P = 0.008). This group included four men with arthritis mutilans, a severe form of psoriatic arthritis.

Analysis of working postures in hammering tasks on building construction sites using the computerized OWAS method

The main objectives of this study were to identify the most problematic postures in hammering tasks performed at building construction sites through application of the computerized OWAS method, and to develop recommendations for improvement of working method and workplaces. Eighteen construction workers, with mean age of 41.6, from three construction companies participated in the field study. The hammering tasks observed during the two-month period included roof boarding, concrete form preparation, clamping support braces, assembling roof frames, roof joisting, shelter form preparation, and fixing fork clamps. Three different types of hammer, including a small Fiskar's hammer, a Fiskar's construction hammer, and a Rocket hammer, were used by the workers. Of all the observations, poor working postures were observed most frequently in roof joisting (12.4% of all observations within the task), followed by concrete form preparation (8.6%), and construction of frames for the roof (7.5%). Overall, out of 593 different postures analysed, a total of 7.8% of postures adopted by the workers during various hammering tasks were classified into OWAS categories III or IV, indicating that these postures should be corrected either soon or immediately. The computerized OWAS method for postural data analysis proved to be a very useful way to reduce postural load of dynamic hammering tasks, and allowed for efficient application of the original OWAS method.

Pharmacokinetics and clinical response of hyoscine plus morphine premedication in connection with cardiopulmonary bypass surgery

Plasma hyoscine and morphine levels and various pharmacodynamic responses have been examined in seven patients scheduled for a coronary-artery bypass graft. Hyoscine 0.006 mg kg-1 and morphine 0.20 mg kg-1 were administered intramuscularly as routine premedication. Surgery was performed using high-dose fentanyl anaesthesia (100 micrograms kg-1). The clinical responses followed were heart rate, blood pressure, subjective sedation and antisialogogue effect. The plasma hyoscine levels were determined by radioreceptor assay, and plasma morphine levels by liquid chromatography, both up to 24 h. The maximum levels of plasma hyoscine (6.6 micrograms l-1) and morphine (158 micrograms l-1) and the time they were reached (13.0 and 9.7 min, respectively) were comparable with the values obtained in earlier studies using young healthy subjects. After the start of cardiopulmonary bypass, significant decreases in plasma levels of both hyoscine and morphine were found. The elimination half-life of hyoscine in the plasma was 2.4 h, which is somewhat greater than obtained in earlier studies with young healthy patients under regional anaesthesia. Elimination of plasma morphine (t1/2el = 3.3 h) was not significantly altered by the procedure. The sedative and antisialogogue effects of the drugs appeared quickly and were significant, but no tachycardia or other side effects were observed. In conclusion, the kinetic properties of both hyoscine and morphine are suitable for routine use as premedicants before cardiac surgery.

Analysis and improvement of work postures in the building industry: application of the computerised OWAS method

Awkward work posture is associated with the development of musculo-skeletal disorders. Previous workplace investigations in new building construction have shown that physical work affects workers' health in 46% of jobs. There is, however, a need for detailed analysis of jobs having physical workload and ergonomics problems. OWAS (Ovako Working Posture Analysing System) is a simple observation method for postural analysis, but there has been no study of its use in the building construction industry. The work described here examined (a) the use of the OWAS method to analyse work postures in building construction, (b) the development of a portable computer system for the OWAS method, (c) improvement of work postures identified as poor, and (d) use of the results as part of the ergonomics training programme of the company. Suggestions for work redesign measures are given.

Hazard screening and proposals for prevention by occupational health service: an experiment with job load and hazard analysis at a Finnish construction company

In this study a systematic method for workplace investigation was developed and then tested as part of the regular occupational health care procedures in the building trade. Workplace investigation is a concept which entails the analysis of hazards inherent in the work as well as assessment of their effects on workers' well-being. The aim of this paper is to evaluate the effectiveness of the workplace investigation method. The newly developed method, called Job Load and Hazard Analysis, has the following characteristics: a job analytic approach; the application of group problem-solving; and cooperation between occupational health professionals, occupational safety personnel, and line management. The method comprises the identification of health hazards, their assessment, and conclusions and proposals as to their prevention and follow-up. The method was tested as part of one constructor's actual occupational health care programme, over a 2.5-year period. The method worked well as a central component of preventive occupational health care. It yielded concrete data that could be applied to make the occupational health care programme better suited to preventing the hazards inherent in the building trade. The contents of the occupational health care programme were clearly enhanced, the number of preventive measures increased, and the organizational climate improved; the workers praised the increased emphasis on safety. More research is needed, eg in other production settings and to determine the most effective utilization of the data gathered by the method.

Actions and interactions of psychotropic drugs on human performance and mood: single doses of ORG 3770, amitriptyline, and diazepam

Actions and interactions of two antidepressants and diazepam on human skilled performance and mood were studied in a randomized double-blind cross-over trial with single oral doses of 50 mg amitriptyline (AMI), 15 mg Org 3770 (ORG) and placebo, given alone and in combination with 15 mg diazepam (DZ) to 12 young healthy subjects at one-week intervals. Objective tests (digit substitution, tapping, flicker fusion, Maddox wing, tracking, choice reactions, body sway, memory) and subjective assessments (visual analogue scale) were performed at baseline and 1.5, 3, 4.5 and 6 hours after drug administration. Side-effects were reported, blood pressure and heart rate measured and blood samples taken after each testing run. Placebo was nearly inert on performance and mood. DZ impaired some objective skills and showed sedative effects in the subjective tests. AMI produced sedation and impaired coordination as well as cognitive performance (digit substitution), most clearly at 3 to 4.5 hr. ORG resembled AMI in impairing objective and subjective performance, however, not necessarily in the same tests. Their combined effects with DZ were additive in objective tests but less additive in subjective tests. The drug combinations, but not any single drug, impaired learning acquisition. Plasma concentrations of the drugs given alone were about as expected, without important interactions. We conclude that the combinations of benzodiazepines with the antidepressants used impair skilled performance but may not cause major hazards.

Connective tissue changes of the multifidus muscle in patients with lumbar disc herniation. An immunohistologic study of collagen types I and III and fibronectin

The connective tissue components, Types I and III collagen fibronectin, were immunohistologically analyzed using their specific antibodies for localization and semiquantitative estimation in 24 patients (11 women and 13 men, all under 55 years of age) operated on for herniated lumbar intervertebral disc. Nine cadavers without known back problems (2 women, 7 men) served as controls. In controls, Type I collagen was present in the endo- and perimysial structures of the muscle, more conspiciously in the former. Type III collagen, together with fibronectin, were more abundant in the perimysium than in the endomysium. Thickening of these structures was not evident in the controls. In most patients Types I and III collagen and fibronectin distribution was similar to that of the controls. However, fibrotic changes of both and endo- and perimysial structures involved all Types I and III collagen and fibronectin in ten cases. In two patients an increase in Type I collagen staining intensity in the endomysium was recorded and thickening of the endomysial structures was observed in six patients. There were correlations with the severity of the connective tissue structural changes to atrophy of the muscle and furthermore to disability of the patient in the 1-year postoperative check-up. These findings suggest that if marked fibrosis of the muscle occurs, it can be a factor impairing recovery from the disease during the long-term postoperative course.

Improvement in the occupational health program in a Finnish construction company by means of systematic workplace investigation of job load and hazard analysis

The aim of the present study was to improve an occupational health program by means of systematic workplace investigations. The 8-month study was done at three building sites of one construction firm. The method for workplace investigations was a simple job hazard analysis of chemical hazards, physical hazards, physical work load, mental stress, and risk of injury, each factor being rated on a three-point scale. Information was gathered by observations, interviews, and a worker questionnaire. Occupational health and safety personnel and worker representatives dealt with problems cooperatively. Together they assessed occupational loads and hazards, whereafter the occupational health and safety personnel devised an occupational health care program and proposed preventive measures. The workplace investigation method proved to function well. It improved the occupational health care program, produced an overall analysis of occupational hazards, and dramatically increased the number and quality of proposed preventive measures. The new method was evaluated to be clearly superior to previous practices and was implemented at moderate cost. The study showed that attention to issues of environmental and occupational health can effectively prevent health impairment even in difficult setting such as construction work. More research is needed for effective utilization of information accumulated by systematic workplace investigations.

Acute and subacute effects of diazepam on human performance: comparison of plain tablet and controlled release capsule

The psychomotor performance of 9 healthy volunteers was measured in a randomized, double-blind, cross-over manner after single doses (Day 1) and one-week maintenance (Day 8) with diazepam given in uncoated tablets (DZ) or in controlled-release capsule (DZ-CR). The performance was measured objectively (simulated driving, digit symbol substitution, Maddox wing, flicker fusion, tapping rate) and subjectively (visual analogue scales, questionnaires) at baseline and 1.5 and 3 hrs after the intake of DZ 15 mg, DZ-CR 20 mg, or placebo. The maintenance dose for diazepam was 10 mg daily. Subjective, but not objective, responses to placebo were evident on Day 1, but not on Day 8. As expected, DZ impaired most objective test performances on Day 1, the strongest effects seen at 1.5 hr. Subjectively it caused drowsiness and impaired performance. These effects were weaker but still significant on Day 8. DZ-CR produced less effects on both objective and subjective measurements on Day 1. It was about inert on Day 8, yet exophoria and subjective muzziness increased after the last dose; the subjects did not experience their performance as impaired. Measurements of plasma benzodiazepine concentrations confirmed the different pharmacokinetic profiles of DZ and DZ-CR due to different rates of absorption, yet characteristic accumulation of diazepam and its active metabolites during maintenance was seen with both formulations. The results suggest that DZ-CR capsule with less acute psychomotor impairment and steady pharmacokinetic profile would well suit to the treatment of anxiety for longer periods.

Acute effects of sertraline, amitriptyline, and placebo on the psychomotor performance of healthy subjects over 50 years of age

A double-blind, placebo-controlled, crossover study in 12 subjects (greater than or equal to 50 years) compared the effects of single oral doses of sertraline (100 mg) and amitriptyline (50 mg) with placebo as assessed by psychomotor function testing. Unlike sertraline and placebo, amitriptyline increased tracking error severity and impaired digit/symbol substitution. Sertraline slightly improved flicker frequency recognition. Both active drugs caused subjective drowsiness, although amitriptyline's effect was greater and of longer duration. Both drugs impaired subjectively assessed performance. Sertraline caused nausea, and amitriptyline, dry mouth; sertraline tended to increase supine systolic blood pressure. The authors conclude that sertraline has a considerably less detrimental effect on psychomotor performance and may have a slight activating effect not found with amitriptyline.

Anxiogenic effect of yohimbine in healthy subjects: comparison with caffeine and antagonism by clonidine and diazepam

Three placebo-controlled double-blind and crossover trials were carried out to analyze the effects of oral yohimbine (YOH) 0.8 mg/kg on mood and performance in 16 healthy students. Subjective assessments (visual analogue scales, side-effects on questionnaire) and objective measurements (digit symbols, flicker fusion, tapping, heterophoria) were done at baseline, and post treatment. YOH shifted the healthy subjects' mood towards feeling panicked, elevated systolic blood pressure and plasma prolactin concentrations, reduced digit symbol substitution, and induced drowsiness and passiveness. Caffeine (CAF) 10 mg/kg raised plasma cortisol and rendered the subjects slightly panicked. Muzziness, clumsiness, tremor, chills and nausea were common after both YOH and CAF. Diazepam (DZ) 0.3 mg/kg given at 60 min antagonized some effects of CAF but failed to antagonize YOH. Clonidine (CLO) 100 micrograms counteracted YOH effects on blood pressure but less the subjective and hormonal effects. CLO 200 micrograms partly antagonized the pressor, sedative but not the hormonal responses of YOH. DZ counteracted YOH effects on plasma cortisol on panic but not on other subjective measures or plasma prolactin. Since CLO did not abolish YOH-induced prolactin increase, it is suggested that these effects of YOH are mediated not only via adrenergic alpha 2-receptors; other mechanisms made important contributions.

Objective and subjective assessments of the effects of flupentixol and benzodiazepines on human psychomotor performance

The aim of this double-blind crossover trial was to compare the objective and subjective effects of flupentixol and lorazepam on human performance, and to reveal possible interactions between flupentixol and diazepam. Twelve healthy students received at 1-week intervals oral single doses of flupentixol 1 mg, flupentixol 2 mg, lorazepam 2.5 mg, placebo, and diazepam 15 mg alone and with flupentixol 1 mg. After the baseline measurements, the drugs were given in capsule form, and the tests were repeated 1.5, 3 and 4.5 h later. Diazepam was given at 1.5 h, to time its peak effect to coincide with that of lorazepam. Drug effects were measured objectively (two tracking tests, digit substitution, letter cancellation, flicker fusion, Maddox wing, tapping, memory) and subjectively (visual analogue scales, questionnaire). Blood samples were taken after each test time. Flupentixol 1 mg did not differ from placebo objectively or subjectively. Flupentixol 2 mg proved nearly inert objectively and on visual analogue scales. Lorazepam impaired objectively measured test performance, the clearest effects occurring at 3 and 4.5 h. It also impaired subjectively assessed performance. Diazepam impaired objective performance less than lorazepam, its effects peaking at 1.5 h after intake. Diazepam caused subjective drowsiness, clumsiness, mental slowness etc. as much as or more than lorazepam. The combination of 1 mg flupentixol and diazepam modified performance as much as diazepam alone. After the administration of 1 mg flupentixol, plasma concentrations were undetectable and levels after 2 mg were hardly detectable. Concentrations of lorazepam exceeded those of diazepam in direct bioassay, but they were much lower when bioassayed after solvent extraction.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined effects of buspirone and diazepam on objective and subjective tests of performance in healthy volunteers

The combined effects on performance of two anxiolytics with different mechanisms of action were evaluated double-blind and crossover in 12 healthy students. Objective (tracking, divided attention, Maddox wing, etc.) and subjective (visual analogue scales and questionnaires) tests were done before and twice after single oral doses. Diazepam (0.15 and 0.30 mg/kg) impaired performance dose relatedly and rendered the subjects drowsy, calm, mentally slow, and clumsy. Buspirone (15 mg) proved inactive in objective tests but matched diazepam (0.30 mg/kg) subjectively. In combinations, buspirone added to the effects of diazepam in Maddox wing and letter cancellation but tended to counteract diazepam effects on divided attention and learning acquisition. Subjectively buspirone prolonged diazepam-induced sedation. Increased calmness caused by diazepam was not affected by concomitant buspirone. It is suggested that combining small doses of buspirone to diazepam does not cause any additional decrement in psychomotor performance. Possible advantages of the diazepam-buspirone combination in therapeutic use are discussed.

The multifidus muscle in patients with lumbar disc herniation. A histochemical and morphometric analysis of intraoperative biopsies

Structural changes in the multifidus muscle were analyzed in 41 patients operated on for herniated intervertebral disc. Twelve cadavers served as controls. The two main findings follow: Both in the patients and in the controls the Type 2 muscle fibers were markedly and selectively smaller than the Type 1 fibers, which were of normal size for striated muscles, and the internal structure of Type 1 fibers showed so-called core-targetoid and/or moth-eaten change. Group atrophy or fiber-type grouping (indicators of denervation and reinnervation) were observed only in a few patients. The selective small size of the Type 2 fibers may indicate atrophy due to relative inactivity of the multifidus muscle both in the patients and in the controls, ie, it does not need to be related to the herniated disc. Definite proof for denervation of the multifidus muscle was not observed, but neither the possibility be excluded. The cause of the core-targetoid and/or moth-eaten changes cannot yet be determined with certainty, because these changes are not specific for any single entity but may be due, for example, to denervation, ischemia, or altered use of the muscles because of pain. In any case, because the changes were significantly more common in the patients than in the controls, they signal for a pathologic condition, the character of which remains to be elucidated.

Acute and subacute actions on human performance and interactions with diazepam of temelastine (SK&F93944) and diphenhydramine

Thirteen healthy subjects participated in a combined acute and subacute double-blind, cross-over trial of two H1-antihistamines diphenhydramine (DPH) and temelastine (SKF) against placebo. The doses were DPH 50 mg b.d. and SKF 100 mg b.d. Objective (digit symbol substitution, flicker fusion, Maddox wing, attention, tracking, choice reaction) and subjective (visual analogue scales, side-effects on questionnaire) tests were done on Days 1, 4 and 5, on each occasion before drug intake and after 90 min and 3 h. On Day 1 DPH caused clear sedation of unpleasant character and impaired flicker fusion, attention and digit symbol substitution. SKF shifted the VAS assessment "drowsy/alert" towards drowsiness at 90 min, without objective impairment. On Day 4 DPH reduced exophoria and impaired flicker fusion without subjective sedation. On Day 5, diazepam 0.3 mg/kg (DZ) given with the other drugs caused subjective sedation of pleasant character and impaired various functions in the objective tests. Neither SKF nor DPH increased the effects of DZ; DPH slightly counteracted the effect of DZ on exophoria. At home, SKF did not differ from placebo while DPH proved sedative. DPH did not improve sleep but caused dry mouth and blurred vision. Measurement of plasma levels of antihistamines on each test day revealed the development of tolerance to antihistamine-induced sedation. The concentration of DZ measured by bioassay was somewhat elevated in the presence of DPH. Since the majority of the performance tests were not influenced by temelastine, it appears to be an acceptable, novel H1-antihistamine for the treatment of allergic disorders.

Dihydroergotamine in the prevention of hypotension associated with extradural anaesthesia

The efficacy of a single dose of dihydroergotamine (DHE) 0.5 mg i.v. in preventing the decrease in arterial pressure resulting from extradural anaesthesia was studied in 47 patients; 24 received DHE and 23 a placebo, in a randomized double-blind manner. Although the decrease in systolic arterial pressure was more pronounced in the placebo group than in the DHE group, the difference was not significant. Diastolic and mean arterial pressures were both significantly lower in the placebo group than in the DHE group during the initial phase of extradural anaesthesia. Administration of DHE did not cause any significant changes in heart rate. In both groups the heart rate decreased significantly during the 5-h period following the induction of extradural anaesthesia. The patients in the placebo group needed additional medication to increase unacceptably low arterial pressures or heart rate more frequently than the patients in the DHE group.

Hydroxyethyl starches, dextran and balanced salt solution in correction of hypotension during epidural anaesthesia

A low molecular weight (Mw 38 000) and a medium molecular weight (Mw 125 000) hydroxyethyl starch and a medium molecular weight dextran (Mw 70 000) solution were compared with a balanced salt solution in 123 patients undergoing operations of the lower extremities in epidural anaesthesia; 500 ml of the studied solutions were infused during 15 min after the injection of the epidural anaesthetic. The need for etilefrine hydrochloride as a vasoconstrictor in correcting hypotensive reactions was recorded. Changes in haemoglobin (Hb), haematocrit (Hct), serum total protein and serum albumin concentrations were measured. The number of patients given etilefrine hydrochloride in the plasma-substitute groups was smaller than in the control group. The differences were, however, not statistically significant. The fall in blood pressure cannot be totally inhibited by administration of 500 ml plasma substitute. According to the differences in Hb, Hct, serum protein and albumin values, the hydroxyethyl starch solutions were significantly more effective plasma substitutes than the balanced salt solution and as effective as dextran. No side-effects attributable to the solutions used were observed.

Dosage of salicylates for children with juvenile rheumatoid arthritis. A prospective clinical trial with three different preparations of acetylsalicylic acid

41 children with juvenile rheumatoid arthritis (JRA) and 6 with postinfectious arthropathies, aged 3--15 years, were treated with acetylsalicylic acid for 14 days during which time the patients were hospitalized. Three different acetylsalicylic acid preparations were used: a microencapsulated form, an enteric-coated form and standard acetylsalicylic acid tablets. Serum salicylate concentrations were measured by Trinder's photometric method. With doses of 90--120 mg/kg/day symptoms of salicylism appeared in about 50% of the cases. Daily doses of 2 g/m2 (not exceeding 70 mg/kg) proved relatively safe in this study, whereas symptoms and signs of intoxication appeared at doses exceeding 3 g/m2/day. In this respect there were no significant differences between the three acetylsalicylic acid preparations used. The results of this study also suggest that the serum salicylate concentrations should not exceed 2000 mumol/l (about 27 mg/100 ml). The symptoms of salicylism correlated closely with serum salicylate levels, which, in turn, correlated well with the dosage in g/m2. Elevation of serum aspartate aminotransferase was noted in 1/3 of the cases. All of these had a dose exceeding 2 g/m2, and the frequency of elevated enzyme activities increased with increasing dosage. In the group receiving enteric coated form of acetylsalicylic acid, there were fewer positive benzidine tests (12%) than in the two other groups (22--28%).