737 STOOLS FOR STOOLS - COMBINING MEDICAL AND CONSERVATIVE TREATMENTS TO REDUCE CONSTIPATION IN THE ELDERLY INPATIENT POPULATION

Introduction

Constipation is a common cause of morbidity in the elderly. Its management is particularly challenging in the inpatient population, where many factors exacerbate constipation. We describe a Quality Improvement Project to reduce the rates of constipation on a female Medicine for the Elderly ward.

Aims

Our aim was to increase bowel chart documentation (nursing and doctor entries) and increase patient frequency of bowel motions to at least once every two days. In particular we focused on conservative measures such as the use of footstools to optimise posture when using commodes and toilets [R Hari Krishnan, Proc Inst Mech Eng H, 2019, 233(4):464–475].

Method

• Weekly monitoring of ward inpatients. • Measurements taken were: days since last bowel motion, laxatives prescribed, bowel chart and ward round documentation, and episodes of diarrhoea over the past week. • One episode of diarrhoea was defined as 3 motions of type 6 or type 7 stool in 24 hours. • A new intervention was introduced every two weeks, over a total of 2 months. Interventions: 1. Recording bowel motions at the daily ‘Board Round’ Multi-Disciplinary Meeting. 2. Ward staff education sessions. 3. Footstools for use with commodes and toilets. 4. High-fibre foods to patients with constipation.

Results

Level of constipation was successfully reduced, with 100% patients moving bowels every 2 days from a baseline of 68%. Ward round and bowel chart documentation improved to 100% and 93.3% respectively (from 41.3% and 33.3%). However, incidence of diarrhoea increased from 0 episodes/week to 8 episodes/week, with laxative prescriptions similarly increased from 50% to 86%.

Conclusion

Constipation improved with our interventions, but at the unintended cost of laxative-associated diarrhoea. Our next steps will be to reduce laxative prescriptions in favour of conservative measures, in order to reduce episodes of loose stool while maintaining our improved constipation rates.

Hybrid solid-state SPECT/CT left atrial innervation imaging for identification of left atrial ganglionated plexi: Technique and validation in patients with atrial fibrillation

BACKGROUND

Ablating left atrial (LA) ganglionated plexi (GP), identified invasively by high-frequency stimulation (HFS) during pulmonary vein isolation (PVI), may reduce atrial fibrillation (AF) recurrence. 123I-metaiodobenzylguanidine (123I-mIBG) solid-state SPECT LA innervation imaging (LAII) has the spatial resolution to detect LAGP non-invasively but this has never been demonstrated in clinical practice.

METHODS

20 prospective patients with paroxysmal AF scheduled for PVI underwent 123I-mIBG LAII. High-resolution tomograms, reconstructed where possible using cardiorespiratory gating, were co-registered with pre-PVI cardiac CT. Location and reader confidence (1 [low] to 3 [high]) in discrete 123I-mIBG LA uptake areas (DUAs) were recorded and correlated with HFS.

RESULTS

A total of 73 DUAs were identified, of which 59 (81%) were HFS positive (HFS +). HFS + likelihood increased with reader confidence (92% [score 3]). 64% of HFS-negative DUAs occurred over the lateral and inferior LA. Cardiorespiratory gating reduced the number of DUAs per patient (4 vs 7, P = .001) but improved: HFS + predictive value (76% vs 49%); reader confidence (2 vs 1, P = .02); and inter-observer, intra-observer, and inter-study agreement (κ = 0.84 vs 0.68; 0.82 vs 0.74; 0.64 vs 0.53 respectively).

CONCLUSIONS

123I-mIBG SPECT/CT LAII accurately and reproducibly identifies GPs verified by HFS, particularly when reconstructed with cardiorespiratory gating.

Perspectives for integrating human and environmental exposure assessments

Integrated Risk Assessment (IRA) has been defined by the EU FP7 HEROIC Coordination action as "the mutual exploitation of Environmental Risk Assessment for Human Health Risk Assessment and vice versa in order to coherently and more efficiently characterize an overall risk to humans and the environment for better informing the risk analysis process" (Wilks et al., 2015). Since exposure assessment and hazard characterization are the pillars of risk assessment, integrating Environmental Exposure assessment (EEA) and Human Exposure assessment (HEA) is a major component of an IRA framework. EEA and HEA typically pursue different targets, protection goals and timeframe. However, human and wildlife species also share the same environment and they similarly inhale air and ingest water and food through often similar overlapping pathways of exposure. Fate models used in EEA and HEA to predict the chemicals distribution among physical and biological media are essentially based on common properties of chemicals, and internal concentration estimations are largely based on inter-species (i.e. biota-to-human) extrapolations. Also, both EEA and HEA are challenged by increasing scientific complexity and resources constraints. Altogether, these points create the need for a better exploitation of all currently existing data, experimental approaches and modeling tools and it is assumed that a more integrated approach of both EEA and HEA may be part of the solution. Based on the outcome of an Expert Workshop on Extrapolations in Integrated Exposure Assessment organized by the HEROIC project in January 2014, this paper identifies perspectives and recommendations to better harmonize and extrapolate exposure assessment data, models and methods between Human Health and Environmental Risk Assessments to support the further development and promotion of the concept of IRA. Ultimately, these recommendations may feed into guidance showing when and how to apply IRA in the regulatory decision-making process for chemicals.

A critical review of frameworks used for evaluating reliability and relevance of (eco)toxicity data: Perspectives for an integrated eco-human decision-making framework

Considerable efforts have been invested so far to evaluate and rank the quality and relevance of (eco)toxicity data for their use in regulatory risk assessment to assess chemical hazards. Many frameworks have been developed to improve robustness and transparency in the evaluation of reliability and relevance of individual tests, but these frameworks typically focus on either environmental risk assessment (ERA) or human health risk assessment (HHRA), and there is little cross talk between them. There is a need to develop a common approach that would support a more consistent, transparent and robust evaluation and weighting of the evidence across ERA and HHRA. This paper explores the applicability of existing Data Quality Assessment (DQA) frameworks for integrating environmental toxicity hazard data into human health assessments and vice versa. We performed a comparative analysis of the strengths and weaknesses of eleven frameworks for evaluating reliability and/or relevance of toxicity and ecotoxicity hazard data. We found that a frequent shortcoming is the lack of a clear separation between reliability and relevance criteria. A further gaps and needs analysis revealed that none of the reviewed frameworks satisfy the needs of a common eco-human DQA system. Based on our analysis, some key characteristics, perspectives and recommendations are identified and discussed for building a common DQA system as part of a future integrated eco-human decision-making framework. This work lays the basis for developing a common DQA system to support the further development and promotion of Integrated Risk Assessment.

Rosuvastatin vs. protease inhibitor switching for hypercholesterolaemia: a randomized trial

OBJECTIVES

The aim of the study was to compare the efficacy and safety of rosuvastatin initiation with those of switching of ritonavir-boosted protease inhibitors (PI/rs) in HIV-1-infected adults with hypercholesterolaemia and increased cardiovascular risk scores.

METHODS

In this open-label, multicentre study, HIV-1-infected adults on PI/r-based therapy with viral load < 50 HIV-1 RNA copies/mL, fasting total cholesterol ≥ 5.5 mmol/L (both for ≥ 6 months) and elevated cardiovascular risk (Framingham score ≥ 8% or diabetes or family history), and not on lipid-lowering therapy, were randomized to open-label rosuvastatin 10 mg/day or to PI/r switching, both with standardized diet/exercise advice. The primary endpoint was change in total cholesterol at week 12 (intention to treat).

RESULTS

There were 43 participants (23 on rosuvastatin). Baseline characteristics were: mean [± standard deviation (SD)] age 55 (8.5) years, 42 (98%) male, 41 (95%) white race, and mean (± SD) total cholesterol 6.2 (1.2) mmol/L. At enrolment, PI/rs were lopinavir/ritonavir (n = 22; 51%), atazanavir/ritonavir (n = 12; 28%) and darunavir/ritonavir (n = 9; 21%). The commonest PI/r substitutes were raltegravir (n = 9; 45%) and rilpivirine (n = 4; 20%). All participants were adherent through to week 12. Rosuvastatin yielded greater declines than PI/r switching in total (- 21.4% vs. - 8.7%, respectively; P = 0.003) and low-density lipoprotein (- 29.9% vs. - 1.0%, respectively; P < 0.001) cholesterol, but smaller declines in very low-density lipoprotein cholesterol and triglycerides (P < 0.01). Cholesterol lowering was greater in participants on atazanavir/ritonavir or once-daily darunavir/ritonavir (vs. lopinavir/ritonavir). More study drug-related adverse events (mostly grade 1 nausea/diarrhoea; 10 vs. one, respectively; P = 0.001) occurred with PI/r switching than with rosuvastatin.

CONCLUSIONS

In adults receiving a PI/r, rosuvastatin 10 mg/day for 12 weeks yielded larger decreases in total and low-density lipoprotein cholesterol than PI/r switching, and was better tolerated.

White paper on the promotion of an integrated risk assessment concept in European regulatory frameworks for chemicals

The vision of a sustainable and safe use of chemicals to protect human health, preserve the environment and maintain the ecosystem requires innovative and more holistic approaches to risk assessment (RA) in order to better inform decision making. Integrated risk assessment (IRA) has been proposed as a solution to current scientific, societal and policy needs. It is defined as the mutual exploitation of environmental risk assessment (ERA) for human health risk assessment (HHRA) and vice versa in order to coherently and more efficiently characterize an overall risk to humans and the environment for better informing the risk analysis process. Extrapolating between species which are relevant for HHRA and ERA requires a detailed understanding of pathways of toxicity/modes of action (MoA) for the various toxicological endpoints. Significant scientific advances, changes in chemical legislation, and increasing environmental consciousness have created a favourable scientific and regulatory environment to develop and promote the concept and vision of IRA. An initial proof of concept is needed to foster the incorporation of IRA approaches into different chemical sectorial regulations and demonstrate their reliability for regulatory purposes. More familiarity and confidence with IRA will ultimately contribute to an overall reduction in in vivo toxicity testing requirements. However, significant progress will only be made if long-term support for MoA-related research is secured. In the short term, further exchange and harmonization of RA terminology, models and methodologies across chemical categories and regulatory agencies will support these efforts. Since societal values, public perceptions and cultural factors are of increasing importance for the acceptance of risk analysis and successful implementation of risk mitigation measures, the integration of socio-economic analysis and socio-behavioural considerations into the risk analysis process may help to produce a more effective risk evaluation and consideration of the risks and benefits associated with the use of chemicals.

Simple convergent-nozzle aerosol injector for single-particle diffractive imaging with X-ray free-electron lasers

A major challenge in high-resolution x-ray free-electron laser-based coherent diffractive imaging is the development of aerosol injectors that can efficiently deliver particles to the peak intensity of the focused X-ray beam. Here, we consider the use of a simple convergent-orifice nozzle for producing tightly focused beams of particles. Through optical imaging we show that 0.5 μm particles can be focused to a full-width at half maximum diameter of 4.2 μm, and we demonstrate the use of such a nozzle for injecting viruses into a micro-focused soft-X-ray FEL beam.

Mikrowellen-Relaxation von Decylalkohol in Mischung mit unpolaren Flüssigkeiten

An reinem n-Decylalkohol, sowie seinen konzentrierten und verdünnten Lösungen in vier unpolaren Flüssigkeiten wurde zwischen 20 und 60°C die komplexe DK bei 9,4,19,5 und 34,8 GHz gemessen. Wenn man die Anteile abtrennt, die das Hauptabsorptionsgebiet bei diesen Frequenzen noch beiträgt, erhält man ein Mikrowellengebiet anomaler Dispersion, das allein von Prozessen mit Kurzzeitrelaxation herrührt. Dazu gehört eine Verteilung von Relaxationszeiten, die in erster Näherung durch zwei diskrete Werte zu beschreiben ist. Die so erhaltenen charakteristischen Daten — Dispersionsstufe, Relaxationszeit und Aktivierungsenergie — werden von sehr verdünnter Lösung, die nur Einzelmoleküle enthält, bis zur reinen Dipolflüssigkeit verfolgt und geben bei der Diskussion Hinweise auf die zugrundeliegenden molekularen Vorgänge. Danach ist die kürzeste Zeitkonstante der Eigenbewegung von polaren Molekülgruppen zuzuordnen, in verdünnter Lösung allein der OH-Gruppe. Die Dipolorientierung mit längerer Relaxationszeit dagegen hat quantitativ alle Kennzeichen, die von der rotatorischen Bewegung ganzer, starrer oder flexibler Moleküle bekannt sind. Zu ihr müssen bei konzentrierten Mischungen aber noch andere Strukturen beitragen als allein Monomere, wie aus dem Relaxationszeitspektrum des Einzelmoleküls in verdünnter Heptanlösung folgt. Bei Benzol treten durch eine spezifische Wechselwirkung mit der OH-Gruppe erhebliche Verschiebungen in der Relaxationszeit-Verteilung auf, die sich noch bei höheren Alkoholkonzentrationen bemerkbar machen.

Distinct eosinophil cytokine expression patterns in skin diseases - the possible existence of functionally different eosinophil subpopulations

BACKGROUND

The function of eosinophils has been attributed to host defense, immunomodulation, and fibrosis. Although eosinophils are found among infiltrating cells in a broad spectrum of skin diseases, their pathogenic role remains uncertain. This study aimed to analyze the cytokine expression by eosinophils in different skin diseases.

METHODS

Skin specimens from different skin diseases [allergic/reactive, infectious, autoimmune, and tumors/lymphomas (LY)] were stained by antibodies directed to eosinophil cationic protein, cytokines [tumor necrosis factor (TNF)-α, interleukin (IL)-5, IL-6, IL-10, IL-11, IL-13, IL-17, IL-25, IL-33, interferon-γ, transforming growth factor (TGF)-β, and thymic stromal lymphopoietin], eotaxins (CCL11, CCL24, and CCL26), metalloproteinase (MMP)-9 as well as extracellular matrix proteins (tenascin-C and procollagen-3) and then analyzed by laser scanning microscopy.

RESULTS

The number of eosinophils varied considerably in and between disease groups and did not correlate with the numbers of accompanying inflammatory cells. The expression of IL-5, IL-6, IL-11, TGF-β, CCL24, and MMP-9 by eosinophils significantly differed between disease groups. Eosinophils in tumors/LY predominantly expressed IL-6, TGF-β, and CCL24, but not IL-11. On the other hand, in autoimmune diseases, eosinophils largely contributed to MMP-9 production. IL-5-generating eosinophils were particularly obvious in allergic and infectious diseases.

CONCLUSION

In skin diseases, eosinophil expresses a broad spectrum of cytokines. The different cytokine expression patterns suggest distinct functional roles of eosinophils in these diseases that might be related to host defense, immunomodulation, fibrosis, and/or tumor development.

Does the frequency of HIV and STI testing among men who have sex with men in primary care adhere with Australian guidelines?

OBJECTIVES

Australian guidelines recommend annual testing for HIV and sexually transmitted infections (STIs) for all men who have sex with men (MSM) and 3-6 monthly testing for those at higher risk as defined by behavioural criteria. We assessed HIV/STI re-testing rates among MSM attending primary care clinics.

METHODS

We conducted a retrospective follow-up of HIV negative MSM tested for HIV or STIs (chlamydia or syphilis) at four primary care clinics in the 9-month period: April to December 2006. Re-testing rates for these infections were calculated over 18 months. Logistic regression was undertaken to identify predictors of guideline adherence.

RESULTS

Of the MSM requiring annual HIV testing according to the guidelines, the re-testing rates at 1 y were 35% (762/2163). Among the higher risk MSM, 6-monthly HIV re-testing rates were 15% (283/1862). Within the subgroup who reported 11 or more male sexual partners within the past 6 months, HIV re-testing rates within 6 months were 19%. Independent predictors of HIV re-testing within 6 months in higher-risk MSM were reporting 11 or more male sexual partners in the last 6 months (AOR 3.1, 95% CI 1.8 to 4.8); being born overseas (AOR 2.0, 95% CI 1.2 to 3.4); and previous HIV testing more than 12 months earlier (AOR 3.3, 95% CI 1.9 to 5.5).

CONCLUSION

There is poor adherence to national guidelines that recommend regular re-testing of MSM for STIs, particularly among those at higher risk who require more frequent testing. Clinical strategies are urgently needed to encourage more frequent HIV/STI testing among MSM, especially in the higher risk subgroup.

Serum total 8-iso-prostaglandin F2α: A new and independent predictor of peripheral arterial disease

OBJECTIVE

Circulating 8-iso-prostaglandin F 2alpha (8-iso-PGF 2alpha ) has been proposed as new indicator of oxidative stress, which is involved in the pathophysiologic changes of atherosclerosis. We proposed to test the hypothesis that 8-iso-PGF 2alpha is an independent predictor of symptomatic peripheral arterial disease (PAD).

METHODS

A case-control study in 100 patients with symptomatic PAD and 100 control subjects matched for age, sex, and diabetes mellitus was conducted. Smokers and subjects using lipid-lowering drugs were excluded. Serum total 8-iso-PGF 2alpha was quantified with an enzyme immunoassay.

RESULTS

Median 8-iso-PGF 2alpha was higher in patients with PAD than in control subjects (63 vs 42 pg/mL; P = .001). Logistic regression with hypertension, body mass index, and creatinine, low-density lipoprotein (LDL) cholesterol, triglyceride, high-sensitivity C-reactive protein (hs-CRP), 8-iso-PGF 2alpha , and total homocysteine concentrations as independent variables and case-control status as dependent variable revealed significant odds ratios (OR) for hypertension (OR, 3.74; 95% confidence interval [CI], 1.85-7.53), low-density lipoprotein cholesterol (OR, 1.16, for an increment of 10 mg/dL; 95% CI, 1.07-1.27), high-sensitivity C-reactive protein (OR, 1.02, for an increment of 1 mg/L; 95% CI, 1.00-1.03), and 8-iso-PGF 2alpha (OR, 1.11, for an increment of 10 pg/mL; 95% CI, 1.03-1.20).

CONCLUSIONS

Serum total 8-iso-PGF 2alpha was an independent predictor of PAD in the population studied. This finding supports the hypothesis that 8-iso-PGF 2alpha is a risk marker for PAD. Our results indicate increased systemic oxidative stress in patients with PAD.

A randomized trial of nelfinavir, ritonavir, or delavirdine in combination with saquinavir-SGC and stavudine in treatment-experienced HIV-1-infected patients

PURPOSE

To evaluate the 24-week impact of saquinavir-enhancing antiretroviral therapy on viral replication in patients previously treated with nucleoside analogues with or without prior saquinavir hard-gel capsules (HGC).

METHOD

Patients were randomized in three groups to receive the following: Group 1-nelfinavir (750 mg tid), saquinavir soft-gel capsule (SGC) (800 mg tid), and stavudine (40 mg bid); Group II-ritonavir (400 mg bid), saquinavir-SGC (400 mg bid), and stavudine (40 mg bid); or Group III-delavirdine (400 mg tid), saquinavir-SGC (800 mg tid), and stavudine (40 mg bid). Viral loads, CD4 count, and safety were assessed over a 24-week period with an additional 6-month follow-up.

RESULTS

73 patients received randomized therapy; 14 of whom were SQV naïve, with a median baseline viral load of 3.6 log(10) and a CD4 count of 370 cells/mm(3). By 6 months, the median decreases in plasma viral loads were 0.26, 0.71, and 0.29 log(10) copies/mL for groups I, II, and III, respectively. The median increases in CD4 counts, for groups I, II, and III, were 52, 40, and 69 cells/mm(3) at 6 months, respectively. Changes in viral load and CD4 counts at 6 months and 1 year were not significantly different between the treatment groups. More patients discontinued therapy in the ritonavir arm (35%) for drug intolerance or toxicity compared to either the nelfinavir or delavirdine arms (15% and 5%, respectively). In a multivariate analysis, baseline viral load, younger age, and baseline saquinavir resistance were significantly associated with detectable viral load at 24 weeks.

CONCLUSION

The use of antiretroviral agents that pharmacokinetically boost saquinavir levels has a modest benefit in saquinavir-experienced patients.

Photochemical decontamination of red blood cell concentrates with the silicon phthalocyanine PC 4 and red light

Various approaches are being developed for virus inactivation of red blood cell concentrates (RBCC) in order to increase the safety of the blood supply. We have been studying the silicon phthalocyanine Pc 4 for this purpose, a photosensitizer activated with red light. Pc 4 targets the envelope of pathogenic viruses such as HIV. To protect RBC during the process two main approaches are used: (i) inclusion of quenchers of reactive oxygen species produced during the treatment. Tocopherol succinate was found to be most effective for this purpose; (ii) formulation of Pc 4, a lipophilic compound, in liposomes that reduce its binding to RBC but not to viruses. As a light source we used a light emitting diode array emitting at 670-680 nm. An efficient mixing device ensures homogenous light exposure during treatment of intact RBCC. Treatment of 50 ml RBCC with 5 microM Pc 4 and 18 J/cm(2) light results in the inactivation of > or = 5.5 log(10) HIV, > or = 6.3 log(10), VSV and > or = 5 log(10) of PRV and BVDV. The relative sensitivities of these viruses based on the slope of virus kill versus light dose are 1.0, 1.25, 1.5 and 1.9 for HIV, VSV, PRV and BVDV, respectively. To achieve the same level of virus inactivation in 350 ml RBCC, the light dose needed is 40 J/cm(2). HIV actively replicating in CEM cells is as sensitive as cell-free and HIV in latently infected cells is 3-4 times more sensitive. Parasites that can be transmitted by blood transfusion (P. falciparum and T. cruzi) are even more sensitive than viruses. Following treatment, RBCC can be stored for 28 days at 4 degrees C with haemolysis below 1%. Previous studies under less favourable conditions showed that baboon RBC circulated with an acceptable 24 hr recovery and half-life. Genetic toxicological studies of Pc 4 with or without light exposure (mutagenicity in bacteria, mammalian cells in vitro and clastogenicity in vivo) were negative. We conclude that a process using Pc 4 and red light can potentially reduce the risk of transmitting pathogens in RBCC.

Capturing the paradigm shift in HIV treatment: changing attitudes in the choice of combination antiretroviral drugs by high HIV caseload Australian GPs (1996-1997)

The use of combination antiretroviral therapy for HIV infection is a rapidly changing field. To assess the impact of recent studies on prescribing patterns, two surveys of 21 high HIV caseload Australian GPs were undertaken in June 1996 and June 1997 to plot changes in the choice of combination antiviral therapy. Of the 17 GPs who responded to the survey in each year, the number of HIV-infected patients seen at their practices were estimated to be 5,061 in 1996 and 5,912 in 1997. In 1996, 40% of their patients were estimated to be on antiretroviral therapy compared to 60% in 1997 (p < 0.05). In 1996, most GPs preferred using dual combination therapy (59%); whereas in 1997, triple combination therapy was preferred (82%). Between 1996 and 1997, there was a significant change by high caseload Australian GPs in the choice of antiretroviral drugs with many combinations being preferred prior to presentation of efficacy data for those combinations, or recommendation through national guidelines.

Superior mesenteric artery syndrome after segmental instrumentation: a biomechanical analysis

Superior mesenteric artery (SMA) syndrome is a rare complication that occurs after correction of scoliosis. A review of the literature suggests that the incidence of this syndrome may be decreasing, as methods for the correction of scoliosis have improved. We present the first report of SMA syndrome that occurred after segmental 'derotational' instrumentation. Computerized axial tomography was helpful in suggesting the diagnosis of this condition. The risk factors and pathophysiology of SMA syndrome are reviewed with respect to the biomechanical effects of casting and Harrington and segmental instrumentation systems on the spine. Attention to the three-dimensional nature of the scoliotic deformity, particularly in the sagittal plane, may help to predict those at risk for the development of this potentially fatal syndrome.

Does cesarean section decrease the incidence of major birth trauma?

OBJECTIVE

To determine whether the increase in frequency of cesarean section is associated with a decreased incidence of major birth trauma.

STUDY DESIGN

A retrospective cohort study was performed evaluating all neonatal cases of major birth trauma from January 1989 to December 1994. Major birth trauma was defined as peripheral plexus or nerve injuries, fractures, or lacerations. The data were grouped into two mutually exclusive periods (January 1989 to December 1990 vs January 1991 to December 1994) in which a significant difference in the cesarean section rate was known.

RESULTS

Of 17,957 deliveries during the period, 141 cases of birth trauma occurred. One hundred thirty-seven of the 141 medical records were available for review, and 116 were classified as having had major birth trauma and were included in the study. The overall incidence of major birth trauma was 6.5/1000 deliveries. During the two-year period (January 1989 to December 1990), 18.3% of deliveries were by cesarean section and the major birth trauma rate was 8.4/1000 deliveries. During the following 4 years, the cesarean section rate was 22.3% and the major birth trauma rate was 5.3/1000 deliveries. Significant differences in the birth trauma chi(2) = 6.12, p = 0.013) and cesarean section (chi(2) = 40.80, p < 0.001) rates were observed. Controlling for the mode of delivery lessened the association between time period and birth trauma incidence (chi(2)MH = 3.28, p = 0.07). A significant decrease in the occurrence of major birth trauma in neonates delivered by cesarean section in the later period was discovered (relative risk = 0.46, 95% confidence interval 0.22 to 0.97). This decrease appeared to be mediated by a decrease in total lacerations between the periods (chi(2) = 11.76, p < 0.001), because the rates of other types of major birth trauma did not differ in neonates delivered by cesarean section or the vaginal route.

CONCLUSIONS

With a 4% increase in rate of cesarean section at our institution, a significant decrease in the occurrence of major birth trauma was observed. This finding cannot be explained by a decreased risk of neonatal trauma in patients delivering vaginally, but rather by a decreased risk of neonatal trauma at cesarean section during the latter period.

Particulate matter less than 10 microns (PM10) and fine particles less than 2.5 microns (PM2.5): relationships between indoor, outdoor and personal concentrations

Among 17 homes in Switzerland, the relationship between indoor and outdoor levels for particulate matter less than 10 microns (PM10), particulate matter less than 2.5 microns (PM2.5) and NO2 was investigated. In 10 homes, the inhabitants also participated in conducting personal measurements. All homes were naturally ventilated. In homes without any indoor sources and where human activity was low, PM10 I/O ratios amounted to approximately 0.7. Of the indoor sources, smoking had the highest influence on I/O ratios (> 1.8). In homes not containing any apparent source, 'human activity' was an important factor accounting for high indoor levels. However, this factor is difficult to quantify. Personal exposure was in most cases higher than the indoor and the corresponding home outdoor levels. For NO2, gas-cooking was found to have the strongest influence on elevated I/O ratios (> 1.2) whilst for other homes, the I/O ratio was less than 1.

Auditory event-related potentials in post- and prelingually deaf cochlear implant recipients

The development of central auditory functions in cochlear implant (CI) patients was studied over six months of rehabilitation. Examinations were performed beginning with the first week after processor calibration, and in monthly follow-up sessions thereafter. The subjects were given a simple auditory perception task (detection of a 400 Hz and a 1450 Hz tone), as well as an oddball-paradigm (detection of one of the tones as a rare deviant). Auditory evoked potentials, reaction time and errors were recorded. Results from five patients, two postlingually deaf and three prelingually deaf CI recipients are shown. Generally, in the auditory evoked potentials of patients a shortening of N100 latency towards those of subjects with normal hearing was seen from month to month. However, in the prelingually deaf patients this effect was weaker and more variable over time. Three CI recipients showed a P300 component in the oddball-paradigm in correlation with their performance. Two prelingually deaf patients failed to show a P300 in the oddball-paradigm. For both components, the N100 and the P300 we found a larger spreading over the skull in the patients compared to a normal hearing person. The results show that from the very first days after initial processor fitting prelingually and postlingually deaf CI recipients may show cortical correlates of stimulus processing and discrimination. For some components of the auditory evoked potentials an initial temporal change but a maintained larger spreading over the skull was seen.

Biochemical markers in synovial fluid identify early osteoarthritis of the glenohumeral joint

The objective of this study on the glenohumeral joint was to assess the (1) accuracy of clinical diagnosis of osteoarthritis compared with arthroscopic diagnosis, and (2) the ability of biochemical markers in synovial fluid to detect osteoarthritis. Patients (96) were examined clinically and the preoperative diagnosis of osteoarthritis was recorded. At surgery (arthroscopy or arthroplasty), the glenohumeral joint was inspected for signs of osteoarthritis, and the joint osteoarthritis grade (I-IV) was recorded. At surgery, synovial fluid lavage was obtained from the joint, and later analyzed to determine levels of aggrecan components: total sulfated glycosaminoglycan and keratan sulfate epitope, link protein and the chondroitin sulfate epitope recognized by antibody 3B3 (3B3(-)). Compared with arthroscopic diagnosis of osteoarthritis, the results showed that the clinical diagnosis did not wrongly identify joints without osteoarthritis, and was always able to identify joints with advanced (Grade IV) osteoarthritis. Grade II osteoarthritis was rarely identified (10% of the time), and Grade III osteoarthritis was identified 50% of the time. Biochemical assessment of the synovial fluid showed that the catabolic markers (sulfated glycosaminoglycan, keratan sulfate and link protein) were elevated in fluids from joints with moderate (Grade III) and advanced osteoarthritis (Grade IV), and the 3B3(-) epitope was elevated in Grades II, III, and IV. These results show that arthroscopic diagnosis for osteoarthritis, of the glenohumeral joint is particularly useful for early and moderate osteoarthritis, where clinical (nonarthroscopic) diagnosis is poor, and that biochemical analysis of the synovial fluids corresponds well to arthroscopic diagnosis of shoulder osteoarthritis.

[The effect of valproic acid monotherapy on behavior and cognitive performance of children with idiopathic generalized epilepsy]

Valproic acid (VPA) currently plays an important role in the treatment of several different types of epilepsy. Especially in children and adolescents, VPA is used because of a minimum of adverse effects and generally little impact on cognitive and psychomotor functions. However, reports in the literature regarding the influence of VPA on behavior and cognitive performance and on EEG parameters vary widely. We investigated the effect of VPA monotherapy on behavioral components (attention, concentration, inhibitory control), cognitive efficiency (motor reaction time, learning, retention) and evoked potentials in 19 children aged 6 to 14 years with idiopathic generalized epilepsy and compared the results with those of healthy controls matched for age. In addition, we analyzed the serum levels of VPA and some of the VPA metabolites in all of the children with epilepsy immediately before the psychophysiological assessments. Our results show marked differences between the children with epilepsy and the healthy controls in all types of behavior and cognitive performance assessed. Abnormal behavior (disturbances of attention and concentration, impulsive behavior patterns) and significant changes in evoked potentials appear to be correlated with serum levels of VPA and certain VPA metabolites.

[Idiopathic varus gonarthrosis: diminished nociceptive vs. unchanged somatosensory sensitivity]

Neuromuscular control deficits are supposed to contribute to the development of osteoarthritis (OA). Pain measurements were performed to clarify whether nociceptive afferents differ between OA patients and healthy subjects. Thermal pain thresholds were significantly higher in OA subjects as compared to controls, but there was no difference in perceptual thresholds after electrical stimulation. Lateralization, gender, site of OA changes, previous operations, or medication did not affect these findings.

[Extra-articular pathogenetic factors in arthritis and deformities in old age as exemplified by varus gonarthrosis]

Extraarticular, predominantly neuromuscular, factors are thought to contribute to the development of osteoarthritis. With increasing age, changed temporal dynamics of motor reflexes and reduced muscular force may affect the efficacy of neuromuscular protection of the knee joint. In three experimental studies conducted with osteoarthritis patients and healthy controls, no difference was found in monosynaptic reflex times and latencies of somatosensory evoked brain potentials. Muscular force was generally diminished in the patients, with the most prominent reduction during coxal abduction. Osteoarthritis patients had marked nociceptive hyposensitivity, but no difference was seen in fast conduction afferent systems. In an animal study with high locomotion load, interruption of articular afferent nerve fibers led to a precipitation of cartilage degeneration. It is concluded that minor extraarticular functional deficits acting over time, probably support and aggravate the development of osteoarthritic changes.

The effect of fluorescent whitening agent on hunter camouflage clothing

Fluorescent whitening agents (FWAs) are chemicals added to most fabrics and papers during manufacture to increase color temperature, "whiteness," and "brightness." FWAs accomplish this by absorbing energy in the ultraviolet (UV) part of the spectrum and emitting it as visible blue light. Recently, hunters have become concerned that FWA could be reducing the effectiveness of their camouflage clothing. As a result, some manufacturers have begun making their camouflage clothing (camo) without FWA, and a spray-on product has been introduced to block the action of FWA. Radiometric spectra from camo and foliage samples suggest, however, that these concerns might not be fully justified. Under full sun and in the shade, spectra from 300 to 500 nanometers (nm) (i.e., UV and visible blue light) showed that camo samples containing FWA matched the foliage reasonably well. No evidence of a major problem caused by the FWA was detected, and no significant need for the use of UV absorbing dyes to block the action of FWA was found.

Smoking deprivation in "early" and "late" smokers and memory functions

Reports on smoking and nicotine effects upon memory are contradictory: improvement, no change, and impairment have been observed. These inconsistencies may be due at least in part to different types of learning tasks and to experimental designs: in most studies, acute nicotine effects were analysed after previous smoking deprivation. This study compared learning, retention, and retrieval between nonsmoking after previous deprivation and "usual" smoking without previous deprivation. Twenty female smokers (S) participated in two sessions, between 8.00 and 11.00 a.m. The Austin maze and a Word Recognition Task (WRT) were applied. During the WRT, ERP were recorded from Fz and Cz scalp locations. Heart rate, CO, and subjective ratings (dizziness and smoking need) but neither WRT nor maze performance discriminated between deprivation and smoking. However, significant differences were obtained between those Ss who usually start smoking within 1 h after getting up (ES) and those who start later (LS). In maze learning and WRT, LS performed better when deprived than smoking, and ES performed better when smoking than deprived, i.e. when the time of the tests met their usual smoking habits. Results are discussed in terms of a modulation of smoking effects on memory functions by the Ss' internal state.

Refractive-index measurements for the correction of particle sizing methods

For many optical methods in liquid particle sizing the refractive index of the liquid must be known. There is no problem if the data are available in the literature. If the liquid is unknown or if the refractive index changes because of a heating process or chemical reactions, the refractive index must be measured to achieve accurate sizing. A method is presented to determine the real part of the refractive index of droplets using the shift in the position of the first rainbow. Results from the application of this method to burning droplet streams are presented.