Coronavirus as a possible cause of severe acute respiratory syndrome

BACKGROUND

An outbreak of severe acute respiratory syndrome (SARS) has been reported in Hong Kong. We investigated the viral cause and clinical presentation among 50 patients.

METHODS

We analysed case notes and microbiological findings for 50 patients with SARS, representing more than five separate epidemiologically linked transmission clusters. We defined the clinical presentation and risk factors associated with severe disease and investigated the causal agents by chest radiography and laboratory testing of nasopharyngeal aspirates and sera samples. We compared the laboratory findings with those submitted for microbiological investigation of other diseases from patients whose identity was masked.

FINDINGS

Patients' age ranged from 23 to 74 years. Fever, chills, myalgia, and cough were the most frequent complaints. When compared with chest radiographic changes, respiratory symptoms and auscultatory findings were disproportionally mild. Patients who were household contacts of other infected people and had older age, lymphopenia, and liver dysfunction were associated with severe disease. A virus belonging to the family Coronaviridae was isolated from two patients. By use of serological and reverse-transcriptase PCR specific for this virus, 45 of 50 patients with SARS, but no controls, had evidence of infection with this virus.

INTERPRETATION

A coronavirus was isolated from patients with SARS that might be the primary agent associated with this disease. Serological and molecular tests specific for the virus permitted a definitive laboratory diagnosis to be made and allowed further investigation to define whether other cofactors play a part in disease progression.

Intermittent peripheral tissue ischemia during coronary ischemia reduces myocardial infarction through a KATP-dependent mechanism: first demonstration of remote ischemic perconditioning

Remote ischemic preconditioning reduces myocardial infarction (MI) in animal models. We tested the hypothesis that the systemic protection thus induced is effective when ischemic preconditioning is administered during ischemia (PerC) and before reperfusion and examined the role of the K(+)-dependent ATP (K(ATP)) channel. Twenty 20-kg pigs were randomized (10 in each group) to 40 min of left anterior descending coronary artery occlusion with 120 min of reperfusion. PerC consisted of four 5-min cycles of lower limb ischemia by tourniquet during left anterior descending coronary artery occlusion. Left ventricular (LV) function was assessed by a conductance catheter and extent of infarction by tetrazolium staining. The extent of MI was significantly reduced by PerC (60.4 +/- 14.3 vs. 38.3 +/- 15.4%, P = 0.004) and associated with improved functional indexes. The increase in the time constant of diastolic relaxation was significantly attenuated by PerC compared with control in ischemia and reperfusion (P = 0.01 and 0.04, respectively). At 120 min of reperfusion, preload-recruitable stroke work declined 38 +/- 6% and 3 +/- 5% in control and PerC, respectively (P = 0.001). The force-frequency relation was significantly depressed at 120 min of reperfusion in both groups, but optimal heart rate was significantly lower in the control group (P = 0.04). There were fewer malignant arrhythmias with PerC during reperfusion (P = 0.02). These protective effects of PerC were abolished by glibenclamide. Intermittent limb ischemia during myocardial ischemia reduces MI, preserves global systolic and diastolic function, and protects against arrhythmia during the reperfusion phase through a K(ATP) channel-dependent mechanism. Understanding this process may have important therapeutic implications for a range of ischemia-reperfusion syndromes.

Roles of Sox4 in central nervous system development

The transcription factor-encoding gene, Sox4, is expressed in a wide range of tissues and has been shown to be functionally involved in heart, B-cell and reproductive system development. Sox4 shows a high degree of sequence homology with another group C Sox gene, Sox11, which is predominantly expressed in the CNS. Since the expression of Sox4 in the CNS has not been described we have carried out such a study. Sox4 and Sox11 expression increased simultaneously in the same early differentiating cells of the developing CNS except in the external granule layer of the cerebellum where Sox11 expression preceded that of Sox4. As development proceeded, their expression always appeared to relate to the maturational stage of the cell population, with Sox11 expression more transient than Sox4, except in the spinal cord where the reverse was true. Sox4 knock-out mice have been shown to die of a heart defect half way through gestation with no observable CNS phenotype. Our more detailed analysis showed no abnormality in the spatial restriction of expression of Sox2, Sox11, Mash1, neurogenin1 or neurogenin2, although the level of expression of Sox11 and Mash1 appeared a little different from the wild-type, implying that Sox4 might indeed have a functional role in CNS development. However, since Sox4 and Sox11 expression is so similar, we propose that Sox11 might compensate for the loss of Sox4 function in the CNS such that the phenotype is extremely mild in the Sox4 null mutant.

Chick sox10, a transcription factor expressed in both early neural crest cells and central nervous system

Human SOX10 and mouse Sox10 have been cloned and shown to be expressed in the neural crest derivatives that contribute to formation of the peripheral nervous system during embryogenesis. Mutations in Sox10 have been identified as a cause of the Dominant megacolon mouse and Waardenburg-Shah syndrome in human, both of which include defects in the enteric nervous system and pigmentation (and in the latter, sometimes hearing). We have cloned a chick Sox10 ortholog (cSox10) in order to study its role in neural crest cell development. This cDNA reveals a 1383 bp open reading frame encoding 461 amino acids which is highly conserved with human SOX10 and mouse Sox10. In situ hybridization showed cSox10 is expressed in migrating neural crest cells just after the zinc finger transcription factor Slug, but is lost as cells undergo neuronal differentiation in ganglia of the peripheral nervous system. In addition, cSox10 is expressed in the developing otic vesicle, the developing central nervous system and pineal gland.

Gastric emptying rate in the elderly: implications for drug therapy

The effect of the aging process on gastric emptying was studied in 11 elderly subjects (mean age, 77) and in 7 young healthy volunteers (mean age, 26). Gastric emptying rates were assessed by a modified sequential scinti-scanning technique after administration of the nonabsorbable chelated radiopharmaceutical 99mTc-DTPA. The rate of emptying, expressed as half-time (T 1/2e) in minutes, was significantly longer (p less than 0.001) in the elderly subjects (mean apparent T 1/2e = 123.23 min) compared to the young healthy volunteers (mean apparent T 1/2e = 49.69 min). Clinical implications of these findings are discussed, particularly with respect to the rate and extent of drug absorption in elderly persons.

Complications of an abdominal stoma: an analysis of 322 stomas

This paper reports a series of 316 patients with 322 stomas, of which 156 were end-sigmoid colostomies (48.5%) and 123 urological ileal conduits (38.2%). An overall complication rate of 66.8% was detected, with parastomal herniation rate, stenotic rate, and prolapse rate of 31.1, 10.2 and 6.8%, respectively. Complications were detected much later in a urological stoma than in a colostomy. Patients bearing an abdominal stoma should be followed up stringently. The creation of an abdominal stoma should not be regarded as a minor surgical procedure. Certain stomas, such as loop transverse colostomy, should be avoided whenever possible.

Identification of cystic fibrosis transmembrane conductance regulator channel-lining residues in and flanking the M6 membrane-spanning segment

The cystic fibrosis transmembrane conductance regulator (CFTR) forms a chloride channel that is regulated by phosphorylation and ATP binding. Work by others suggested that some residues in the sixth transmembrane segment (M6) might be exposed in the channel and play a role in ion conduction and selectivity. To identify the residues in M6 that are exposed in the channel and the secondary structure of M6, we used the substituted cysteine accessibility method. We mutated to cysteine, one at a time, 24 consecutive residues in and flanking the M6 segment and expressed these mutants in Xenopus oocytes. We determined the accessibility of the engineered cysteines to charged, lipophobic, sulfhydryl-specific methanethiosulfonate (MTS) reagents applied extracellularly. The cysteines substituted for Ile331, Leu333, Arg334, Lys335, Phe337, Ser341, Ile344, Arg347, Thr351, Arg352, and Gln353 reacted with the MTS reagents, and we infer that they are exposed on the water-accessible surface of the protein. From the pattern of the exposed residues we infer that the secondary structure of the M6 segment includes both alpha-helical and extended regions. The diameter of the channel from the extracellular end to the level of Gln353 must be at least 6 A to allow the MTS reagents to reach these residues.

Locating the anion-selectivity filter of the cystic fibrosis transmembrane conductance regulator (CFTR) chloride channel

The cystic fibrosis transmembrane conductance regulator forms an anion-selective channel; the site and mechanism of charge selectivity is unknown. We previously reported that cysteines substituted, one at a time, for Ile331, Leu333, Arg334, Lys335, Phe337, Ser341, Ile344, Arg347, Thr351, Arg352, and Gln353, in and flanking the sixth membrane-spanning segment (M6), reacted with charged, sulfhydryl-specific, methanethiosulfonate (MTS) reagents. We inferred that these residues are on the water-accessible surface of the protein and may line the ion channel. We have now measured the voltage-dependence of the reaction rates of the MTS reagents with the accessible, engineering cysteines. By comparing the reaction rates of negatively and positively charged MTS reagents with these cysteines, we measured the extent of anion selectivity from the extracellular end of the channel to eight of the accessible residues. We show that the major site determining anion vs. cation selectivity is near the cytoplasmic end of the channel; it favors anions by approximately 25-fold and may involve the residues Arg347 and Arg 352. From the voltage dependence of the reaction rates, we calculated the electrical distance to the accessible residues. For the residues from Leu333 to Ser341 the electrical distance is not significantly different than zero; it is significantly different than zero for the residues Thr351 to Gln353. The maximum electrical distance measured was 0.6 suggesting that the channel extends more cytoplasmically and may include residues flanking the cytoplasmic end of the M6 segment. Furthermore, the electrical distance calculations indicate that R352C is closer to the extracellular end of the channel than either of the adjacent residues. We speculate that the cytoplasmic end of the M6 segment may loop back into the channel narrowing the lumen and thereby forming both the major resistance to current flow and the anion-selectivity filter.

Surgical treatment of parastomal hernia complicating sigmoid colostomies

PURPOSE

Parastomal hernia is a common late complication of colostomy. Surgical approach to the repair of parastomal hernia is controversial. Results of surgical treatment are disappointing. The aim of this study was to assess the outcome of surgical treatment of parastomal hernia.

METHOD

This article reports a retrospective review of those patients who had undergone a surgical treatment of parastomal hernia complicating sigmoid colostomy. The indications, surgical procedures, complications, and outcome were carefully studied.

RESULTS

There were 43 surgical treatments of parastomal hernia. Sixteen underwent simple local repair; 25 stomas were relocated, and 2 were locally repaired with mesh. Overall recurrence was 18 of 40 (45 percent). Recurrences for fascial repair and stoma relocation were 6 of 13 (46 percent) and 10 of 25 (40 percent), respectively. Stoma relocation could be accomplished without formal laparotomy in 19 of 25 cases. Incisional hernia occurred in only 2 of these 25 relocations.

CONCLUSION

Fascial repair alone can be performed for symptomatic small hernias because of its advantage of minimal morbidity. Stoma relocation without formal laparotomy can be advocated for larger hernias. A combination of local resite together with mesh reinforcement may be the alternative for further improvement of results.

Quantification of plasma beta-catenin mRNA in colorectal cancer and adenoma patients

PURPOSE

Colorectal cancer is an important cause of cancer deaths. Here, we focused our investigation on the beta-catenin gene which is implicated in colorectal carcinogenesis and tested whether beta-catenin mRNA is detectable in the plasma of colorectal carcinoma and adenoma patients using quantitative reverse transcriptase-PCR.

EXPERIMENTAL DESIGN

Plasma beta-catenin mRNA was measured from 58 colorectal carcinoma patients, 49 colorectal adenoma patients, and 43 apparently normal subjects using intron-spanning primers and Taqman probes. Five clinicopathological parameters were studied and correlated with plasma beta-catenin mRNA concentration. Additionally, 19 colorectal carcinoma patients after tumor removal were also recruited for plasma beta-catenin mRNA measurement to further demonstrate the clinical usefulness of this test.

RESULTS

beta-catenin mRNA was detected with median concentrations of 8737 (range: 1480-933100), 1218 (range: 541-2254) and 291 (range: 0-1366) copies/ml plasma in colorectal carcinoma, colorectal adenoma, and apparently normal subjects, respectively. Statistical analysis demonstrated that plasma beta-catenin mRNA concentration was correlated to tumor stage but not sex, age, lymph node status, and degree in differentiation. Moreover, plasma beta-catenin mRNA concentration decreased significantly after tumor removal in 16 of 19 (84%) colorectal carcinoma patients.

CONCLUSIONS

We conclude that plasma beta-catenin mRNA may potentially serve as a marker for colorectal cancer.

Cognitive function of patients with nasopharyngeal carcinoma with and without temporal lobe radionecrosis

BACKGROUND

Radiotherapy is the primary treatment for nasopharyngeal carcinoma, and temporal lobe necrosis is observed in about 7% of patients after radiotherapy. Although some studies reported that these patients demonstrated cognitive impairment after radiotherapy, it is still unclear if the cognitive deficits are related to the radiation exposure or the radiation-induced necrosis.

OBJECTIVE

To compare the cognitive function of patients with and without temporal lobe necrosis after radiotherapy for nasopharyngeal carcinoma.

METHODS

A comprehensive neuropsychological battery was administered to 53 patients with nasopharyngeal carcinoma who had completed their radiotherapy at least 1 year previously. As evidenced by magnetic resonance imaging, 31 patients developed necrosis after treatment. Thirty-one age- and education-matched individuals were recruited as normal control subjects.

RESULTS

Whereas the performance of patients without temporal lobe necrosis was similar to that of normal control subjects, patients with temporal lobe necrosis demonstrated significant impairment on tests of verbal (P<.001) and visual memory (range, P<.001 to P =.03), language (range, P<.001 to P =.01), motor ability (P =.02), planning (P =.02), cognitive ability (P =.007), and abstract thinking (range, P =.009 to P =.04). However, the performance of patients with necrosis on tests of general intelligence (range, P =.08 to P =.15), attention (range, P =.06 to P =.55), and visual abilities (range, P =.06 to P =.47) was not significantly different from that of normal control subjects and patients without necrosis.

CONCLUSIONS

Radiotherapy for nasopharyngeal carcinoma seemed to have adverse but insignificant effects on the cognitive functions of the patients. However, for patients who developed temporal lobe necrosis after radiotherapy, memory, language, motor ability, and executive functions were significantly impaired, although their general intelligence remained relatively intact.

Utility of faecal calprotectin in inflammatory bowel disease (IBD): what cut-offs should we apply?

BACKGROUND

Faecal calprotectin (FC), a cytosolic protein released by neutrophils (S100 family) in response to inflammation, is a simple, non-invasive test that can be used to differentiate irritable bowel syndrome (IBS) with inflammatory bowel disease (IBD), where there can be considerable symptom overlap.

AIMS AND METHODS

The aims of the study were (1) to be able to predict the ability of FC to exclude IBD and determine cut-offs when in remission, (2) to investigate the effects of time and temperature on stability of FC and (3) compare three ELISA kits to measure FC: Buhlmann, PhiCal v1 and PhiCal v2. A total of 311 patients with altered bowel habit were tested for FC; 144 with IBS, 148 with IBD and 19 with other organic causes.

RESULTS

Sensitivity and specificity of FC (with PhiCal v2 kit) to distinguish between functional disorder (IBS) and IBD using cut-off 50 μg/g were 88% and 78%, respectively, with a negative predictive value of 87%. Area under the receiver operating curve was 0.84 (CI 0.78 to 0.90). For those with IBD, FC values below 250 μg/g corresponded with remission of disease with a sensitivity and specificity of 90% and 76%, respectively. Area under the receiver operating curve was 0.93 (CI 0.89 to 0.97). FC was stable once extracted and frozen for up to 2.5 months. Pearson correlation was good between Buhlmann assay and PhiCal v2 (r² = 0.95).

CONCLUSIONS

FC has up to 87% negative predictive value to exclude IBD, and cut-offs less than 250 μg/g had 90% sensitivity to determine remission in IBD. Once frozen, FC is stable and the ELISA monoclonal plates were broadly comparable.

Physiologic and supraphysiologic increases in lipoprotein lipids and apoproteins in late pregnancy and postpartum. Possible markers for the diagnosis of "prelipemia"

A supraphysiologic (greater than 95th percentile) rise in plasma lipids in pregnancy may serve as a marker for "prelipemia" in the same way that gestational diabetes is a marker for prediabetes. To qualify as prelipemic, subjects with an abnormal lipid rise antepartum must return to normal postpartum but may have other identifying characteristics. This paper describes the antepartum-postpartum changes of lipoprotein lipids and apoproteins at 34 to 38 weeks of gestation and 6 and 20 weeks postpartum in 23 subjects with physiologic and six subjects with supraphysiologic plasma lipid increases during pregnancy. These results are compared to measurements in 23 nonpregnant controls matched for weight, age, and race. In subjects with a physiologic antepartum lipid rise, postpartum total triglyceride and very low density lipoprotein (VLDL) lipids (cholesterol and triglyceride) and apo B returned to baseline within 6 weeks. In contrast, low density lipoprotein (LDL) showed a slow postpartum decline in lipids and apo B with elevations remaining at 20 weeks postpartum. High density lipoprotein (HDL) cholesterol concentrations, elevated in pregnancy, remained elevated at 6 weeks postpartum, but fell to baseline by 20 weeks postpartum. HDL triglyceride and apo A-l concentrations, both elevated in pregnancy, returned to baseline by 6 weeks postpartum. A supraphysiologic triglyceride rise in pregnancy was associated with a slower return of total triglycerides and VLDL to baseline, reduced HDL cholesterol ante- and postpartum, atypical changes in LDL cholesterol during pregnancy and postpartum, and evidence of hyperlipidemia among family members. Two subjects with hypercholesterolemia in the nonpregnant state showed no marked exaggeration of total or LDL cholesterol concentrations in pregnancy. The data support the hypothesis that a supraphysiologic rise in plasma triglyceride concentrations in late pregnancy may serve as a marker of prelipemia. Proof of the hypothesis requires further investigation and longer follow-up.

The significance of skull fracture in acute traumatic intracranial hematomas in adolescents: a prospective study

A prospective study was conducted to validate the retrospective finding that adolescents (11 to 15 years old) with skull fractures were prone to develop acute traumatic intracranial hematoma (ICH). Over a 4-year period, 1178 consecutive adolescents attended the emergency room directly, of whom 760 were discharged well and 418 were admitted. All underwent skull x-ray studies. Immediate computerized tomography (CT) scans were performed in patients with Glasgow Coma Scale (GCS) scores of less than 15, in those with radiological and/or clinical evidence of skull fracture, and whenever clinically indicated. Of the 418 admitted patients, only 26 had skull fractures; 13 of these developed ICH. Four patients without skull fracture developed diffuse brain swelling. The remaining 401 patients were discharged after observation periods of up to 48 hours. Of the 13 patients with ICH, 10 had admission GCS scores of 15; however, four deteriorated rapidly and required urgent operation, and four remained stable but were operated on due to their large ICH. Two required conservative treatment only and both made good recovery. Three patients were in coma (GCS score less than or equal to 8) on admission. One patient had an epidural hematoma and made good recovery after surgery. Two developed delayed ICH after operations for associated systemic injuries despite initial CT showing diffuse brain swelling only, and both died despite evacuation of the ICH. Multivariate analysis showed that skull fracture was the only independent significant risk factor in predicting ICH in adolescents (sensitivity of 100% and specificity of 97%). A routine skull x-ray study is therefore mandatory in all head-injured adolescents and, if a skull fracture is detected, immediate CT may be performed for early detection of ICH.

A randomized study of high-dose versus low-dose cis-platinum combined with cyclophosphamide in the treatment of advanced ovarian cancer. Hong Kong Ovarian Carcinoma Study Group

A randomized clinical study of patients with advanced epithelial ovarian cancer after debulking surgery showed that high-dose (120 mg/m2) cis-platinum (DDP) in combination with cyclophosphamide (600 mg/m2) had a significantly higher response and survival rate than the low-dose DDP (60 mg/m2) and cyclophosphamide combination. The 3-year actuarial survival rate of the high-dose group was 60% and that of the low-dose group was 30%. Though moderate to severe marrow toxicity was evident in 80% of the patients in the high-dose group and 40% of the low-dose group, no serious sepsis or death developed as a result of the marrow depression. Mild neurotoxicity was observed in 55% of the patients in the high-dose group and only 20% in the low-dose group. Mild nephrotoxicity was seen in 25 and 17% of patients in the high- and low-dose groups, respectively. It was concluded that the 120 mg/m2 dose DDP and cyclophosphamide combination should be used in the treatment of carcinoma of the ovary in spite of its toxicities. However, it should only be used in institutions with supportive facilities in the management of patients with severe marrow depression.

Clinical significance of cytokeratin 20-positive circulating tumor cells detected by a refined immunomagnetic enrichment assay in colorectal cancer patients

PURPOSE

Current immunomagnetic enrichment method can only detect general epithelial antigens of circulating tumor cells (CTC). Further characterization of the CTCs to provide specific information on the tumor type is not possible. We attempted to overcome this drawback by developing the methodology for using a gastrointestinal-specific anti-cytokeratin (CK) 20 antibody to detect CTCs in colorectal cancer patients' blood.

EXPERIMENTAL DESIGN

The protocol was validated using a colorectal cancer SW480 cell line. The clinical significance of findings in colorectal cancer was investigated by detecting CK20-positive CTCs (pCTC) in patients with colorectal cancer, other common cancers, colorectal adenoma, benign colorectal diseases, and normal subjects. Moreover, the malignant nature of CK20 pCTCs was examined by comparing chromosome 17 aberration patterns with those from the corresponding primary tumors.

RESULTS

The assay successfully showed CK20-positive SW480 cells. When applied in patient samples, the detection rates were 62% (132 colorectal cancer patients; median number = 11 CTCs), 0% (120 patients with other common cancers), 6% (50 colorectal adenoma patients), 0% (120 patients with benign colorectal diseases), and 0% (40 normal subjects). Furthermore, statistical analysis showed that CK20 pCTC numbers were associated with tumor-node-metastasis stage and lymph node status. Using the median CK20 pCTC numbers as the cutoff points, stratified groups of colorectal cancer patients had significant differences in their recurrence, metastasis, and survival. Finally, chromosome 17 aneusomy in 90% of colorectal cancer patients with CK20 pCTCs matched with those from the primary tumors.

CONCLUSIONS

Detection of CK20 pCTCs using the new protocol could generate clinically important information for colorectal cancer patients.

Gastric emptying rate and the systemic availability of levodopa in the elderly parkinsonian patient

The gastric emptying rate and systemic availability of levodopa, administered as a single oral dose, was studied in six elderly parkinsonian patients, five elderly nonparkinsonian subjects, and six young healthy volunteers. In both elderly groups, gastric emptying was slowed relative to the young healthy volunteers. The lack of significant differences in the plasma elimination half-life of levodopa among the three groups was accompanied by increased absorption of the drug in the elderly patient groups. These findings are discussed in relation to a possible age-related alteration in the activity of peripheral dopa decarboxylase in the elderly parkinsonian patients.

cSox3 expression and neurogenesis in the epibranchial placodes

Epibranchial placodes are local thickenings of the surface ectoderm, which give rise to sensory neurons of the distal cranial ganglia. The development of these placodes has remained unclear due to the lack of any definitive marker for these structures. We show here that the chick transcription factor, cSox3, is expressed in four lateral patches at the rostral edge of the epibranchial arches and that these mark the epibranchial placodes. These patches of cSox3 expression arise by gradual thinning from broader areas of cSox3 expression with concomitant loss of cSox3 in nonplacodal regions. Cells leaving the epithelial placodes as they initiate neurogenesis, lose cSox3 expression and sequentially express Ngn1, NeuroD, NeuroM, and Phox2a, but do not express Ngn2. This is in contrast to studies in the mouse where it is Ngn2, rather than Ngn1, that is predominantly expressed in epibranchial-derived neuroblasts. Overexpression of cSox3 interferes with normal neuroblast migration and results in changes in ectodermal morphology. Thus, cSox3 provides a useful tool for the study of placode formation, and loss of cSox3 expression appears to be a necessary event in normal neurogenesis from the epibranchial placodes.

The association between higher maternal pre-pregnancy body mass index and increased birth weight, adiposity and inflammation in the newborn

BACKGROUND

Excess adiposity and adiposity-related inflammation are known risk factors for cardiovascular disease in adults; however, little is known regarding the determinants of adiposity-related inflammation at birth.

OBJECTIVES

The aim of this study was to investigate the association between maternal pre-pregnancy BMI and newborn adiposity and inflammation.

METHODS

Paired maternal (28-week gestation) and infant (umbilical cord) blood samples were collected from a population-derived birth cohort (Barwon Infant Study, n = 1074). Data on maternal comorbidities and infant birth anthropomorphic measures were compiled, and infant aortic intima-media thickness was measured by trans-abdominal ultrasound. In a selected subgroup of term infants (n = 161), matched maternal and cord lipids, high-sensitivity C-reactive protein (hsCRP) and maternal soluble CD14 were measured. Analysis was completed by using pairwise correlation and linear regression. Because of their non-normal distribution, pathology blood measures were log transformed prior to analysis.

RESULTS

Maternal pre-pregnancy BMI was positively associated with increased birth weight (mean difference 17.8 g per kg m^-2 , 95% CI 6.6 to 28.9; p = 0.002), newborn mean skin-fold thickness (mean difference 0.1 mm per kg m^-2 , 95% CI 0.0 to 0.1; p < 0.001) and cord blood hsCRP (mean difference of 4.2% increase in hsCRP per kg m^-2 increase in pre-pregnancy BMI, 95% CI 0.6 to 7.7%, p = 0.02), but not cord blood soluble CD14. Inclusion of maternal hsCRP as a covariate attenuated the associations between pre-pregnancy BMI and both newborn skin-fold thickness and cord blood hsCRP.

CONCLUSION

Higher maternal pre-pregnancy BMI is associated with increased newborn adiposity and inflammation. These associations may be partially mediated by maternal inflammation during pregnancy.

Surgical morbidity and mortality in obturator hernia: a 10-year retrospective risk factor evaluation

Obturator hernia is a rare condition occurring predominantly in elderly, thin, female patients and causes significant morbidity and mortality. Due to obscure presenting symptoms and signs, diagnosis and management are often delayed. While previous studies have attributed the high mortality to the delay in diagnosis, current literature remains controversial about this issue. The aim of this study was to identify peri-operative risk factors associated with mortality in patients with obturator hernia at our hospital.

METHODS

We retrospectively reviewed our series of 20 consecutive patients who underwent surgical repair of 21 obturator herniae and examined their clinical characteristics and post-operative outcomes.

RESULTS

Overall mortality rate was 47.6 %. Survivors did not differ from non-survivors in terms of basic demographics and operative parameters (operative time, blood loss and the need for intestinal resection). The use of computed tomography for pre-operative diagnosis was associated with reduced need for bowel resection, but did not result in shorter time to operation or improved morbidity and mortality. Our series demonstrated that early timing of surgery alone did not improve operative outcome. The absence of bowel motion and a high serum urea level at the time of operation were independent factors for mortality.

CONCLUSIONS

Obturator hernia remains a highly lethal surgical emergency. Adequate peri-operative resuscitation may be the key to further improvement in surgical outcomes.

Comparison of the lipoprotein, carbohydrate, and hemostatic effects of phasic oral contraceptives containing desogestrel or levonorgestrel

Desogestrel (DSG) is a less-androgenic progestogen than levonorgestrel (LNG). This difference in androgenicity may be responsible for observed differences in metabolic effects between oral contraceptive (OC) formulations containing almost equivalent estrogen doses but with either DSG or LNG as a progestogen. To test the hypothesis, a prospective 9-month randomized comparison of plasma lipids, glucose, insulin, hemostasis, and sex hormone binding globulin (SHBG) was conducted in 66 healthy women using phasic formulations of OCs containing either DSG (DSG-OC) or LNG (LNG-OC). The study results showed that SHBG increased 3-fold with DSG-OC and 2-fold with LNG-OC. DSG-OC increased HDL-C, HDL(2)-C and HDL(3)-C; LDL-C decreased transiently. LNG-OC decreased HDL(2)-C and increased HDL(3)-C; HDL-C was unchanged and LDL-C decreased transiently. Both formulations increased VLDL-C and triglycerides, more with DSG-OC, but apolipoprotein B levels increased equally. Apo A-I and A-II increased more with DSG-OC than with LNG-OC. Neither formulation altered Lp(a) or fasting glucose and insulin levels. Postprandially, both formulations decreased glucose and increased insulin responses, but to an equivalent degree. Both OCs slightly enhanced procoagulant and profibrinolytic parameters to the same extent except for internally compensating decreases in Factor V and protein S with DSG-OC. In summary, at almost equivalent estrogen doses, a phasic OC containing DSG compared with LNG has a less androgenic effect on lipoproteins and SHBG, similar effects on hemostatic parameters with lower protein S and factor V activity and equivalent effects on carbohydrate metabolism. The lipoprotein, SHBG, and protein S and factor V differences are likely due to the lesser androgenicity of DSG allowing for a greater expression of the dose of estrogen.

Poor outcome of on-site CPR in a multi-level geriatric facility: three and a half years experience at the Baycrest Centre for Geriatric Care

Our objective was to determine the outcome of onsite CPR in elderly patients receiving institutional care who had access to 24-hour on-site full ACLS capability. We used a retrospective chart and CPR protocol review of all patients who received CPR during the study period; these were patients or residents in a multi-level geriatric long-term care facility that provides various degrees of facility-based and ambulatory care. Immediate, short-term, and long-term survivorship were determined and correlated where possible with the category of patient seen (short-term care versus long-term care) and the relationship between the witnessing of the arrest and survival. Of the 41 patients who underwent CPR, there were only four survivors of 60 days or greater. Of these, three subjects were short-term, not long-term care patients of the Centre; they returned to their previous level of function. One fully dependent bed-ridden patient returned to that level of care for a survival period of 100 days. Of the four long-term survivors, three of the arrests were witnessed, and one was indeterminate. No unwitnessed arrests resulted in long-term survival. Our experience suggests that CPR in the elderly long-term care patient is unlikely to be successful even when it is available on-site. Unwitnessed arrests in this population were universally fatal. This information has helped Baycrest Centre for Geriatric Care develop protocols, guidelines, and policies for CPR that are suitable for our population.