Oxidative and carbonyl stress in pregnant women with obstructive sleep apnea

PURPOSE

Pregnant women are particularly susceptible to sleep-disordered breathing. Obstructive sleep apnea (OSA) in pregnancy is associated with poor pregnancy and fetal outcomes. Oxidative stress caused by intermittent hypoxemia and reoxygenation may impact pregnancy health. We hypothesize that pregnant women with OSA have a pronounced oxidative stress profile.

METHODS

A case-control study was performed to study oxidative stress markers in the serum of pregnant women with or without OSA. Patients with OSA were identified between 2003 and 2009. Contemporaneous controls were pregnant subjects without apnea, gasping, or snoring around the time of delivery. Serum markers of oxidative and carbonyl stress were measured by spectrophotometric/fluorometric methods. Multiple linear regression analysis was used with a model including age, body mass index at delivery, history of diabetes, and gestational age.

RESULTS

Serum samples from 23 OSA cases and 41 controls were identified. Advanced oxidation protein products, a marker for oxidative stress, and advanced glycation end products (AGEs), a marker for carbonyl stress, were significantly lower in women with OSA than in controls (p value <0.0001). Total antioxidant capacity was higher in women with OSA in comparison to controls (p value <0.0001). The difference in AGEs remained significant even after adjusting for confounders.

CONCLUSION

Contrary to our hypothesis, the results of this study suggest that pregnant women with OSA have higher antioxidant capacity and lower oxidative and carbonyl stress markers compared to controls, suggesting a possible protective effect of intermittent hypoxia. Whether OSA in pregnancy impacts oxidative stress differently than OSA in the general population remains to be confirmed.

Serum Progesterone Levels in Pregnant Women with Obstructive Sleep Apnea: A Case Control Study

BACKGROUND

Pregnancy is a risk factor for sleep disordered breathing, including obstructive sleep apnea (OSA). Progesterone, one of the key hormones in pregnancy, a known respiratory drive stimulant, increases ventilation and may protect against OSA. We aimed to examine the relationship between circulating progesterone and OSA, after accounting for body weight and gestational age.

METHODS

A case control study was conducted of pregnant women with OSA and those at low risk for the disorder. Cases were identified by ICD-9 code and review of medical record. Controls were identified if they scored zero (never) for snoring, apnea, and gasping on the multivariable apnea prediction index questionnaire immediately following delivery. Subjects with available stored first and/or second trimester residual serum samples were then included in this study and serum analyzed for progesterone. Raw progesterone levels were adjusted for the effects of gestational age and maternal weight.

RESULTS

Twenty-seven cases and 64 controls with available serum were identified. Women with OSA had greater maternal weight and higher rates of related comorbidities, compared to controls. Progesterone levels correlated positively with gestational age and negatively with greater weight. Progesterone levels, adjusted for gestational age and maternal weight and expressed as multiples of median (MoM), were significantly lower in OSA cases compared to controls in both the first trimester (MoM = 0.71, confidence interval [95% CI] 0.60-0.83) relative to the MoM in controls of 1.00. In the second trimester levels were also lower in OSA cases (MoM = 0.84, 95% CI 0.73-0.96) compared to the MoM of 1.00 in controls.

CONCLUSIONS

Progesterone levels, after accounting for weight and gestational age, were lower in women with OSA than controls. Progesterone may play a protective role against OSA.

Effect of Fecal Microbiota Transplantation on Recurrence in Multiply Recurrent Clostridium difficile Infection: A Randomized Trial

BACKGROUND

To date, evidence for the efficacy of fecal microbiota transplantation (FMT) in recurrent Clostridium difficile infection (CDI) has been limited to case series and open-label clinical trials.

OBJECTIVE

To determine the efficacy and safety of FMT for treatment of recurrent CDI.

DESIGN

Randomized, controlled, double-blind clinical trial. (ClinicalTrials.gov: NCT01703494).

SETTING

Two academic medical centers.

PATIENTS

46 patients who had 3 or more recurrences of CDI and received a full course of vancomycin for their most recent acute episode.

INTERVENTION

Fecal microbiota transplantation with donor stool (heterologous) or patient's own stool (autologous) administered by colonoscopy.

MEASUREMENTS

The primary end point was resolution of diarrhea without the need for further anti-CDI therapy during the 8-week follow-up. Safety data were compared between treatment groups via review of adverse events (AEs), serious AEs (SAEs), and new medical conditions for 6 months after FMT. Fecal microbiota analyses were performed on patients' stool before and after FMT and also on donors' stool.

RESULTS

In the intention-to-treat analysis, 20 of 22 patients (90.9%) in the donor FMT group achieved clinical cure compared with 15 of 24 (62.5%) in the autologous FMT group (P = 0.042). Resolution after autologous FMT differed by site (9 of 10 vs. 6 of 14 [P = 0.033]). All 9 patients who developed recurrent CDI after autologous FMT were free of further CDI after subsequent donor FMT. There were no SAEs related to FMT. Donor FMT restored gut bacterial community diversity and composition to resemble that of healthy donors.

LIMITATION

The study included only patients who had 3 or more recurrences and excluded those who were immunocompromised and aged 75 years or older.

CONCLUSION

Donor stool administered via colonoscopy seemed safe and was more efficacious than autologous FMT in preventing further CDI episodes.

PRIMARY FUNDING SOURCE

National Institute of Diabetes and Digestive and Kidney Diseases.

Placenta-secreted circulating markers in pregnant women with obstructive sleep apnea

AIMS

Obstructive sleep apnea (OSA) is associated with placenta-mediated adverse clinical outcomes. We aimed at comparing placenta-secreted proteins, such as first and second trimester Down syndrome screening markers which have been linked to preeclampsia, and markers of angiogenesis in pregnant women with OSA, and pregnant controls at low risk for OSA.

METHODS

A case-control study of pregnant women with OSA and controls at low risk for OSA was performed. Levels of first and second trimester markers were reported as multiple of median (MoM), and adjusted for body mass index (BMI). Stored samples were tested for markers of angiogenesis and adjusted for gestational age, BMI, and chronic hypertension.

RESULTS

A total of 24 women with OSA and 166 controls had screening markers. BMI was higher in cases compared to controls, P=0.01. MoM levels of placenta associated plasma protein-A (PAPP-A) were significantly lower in cases versus controls, even after adjusting for BMI (0.52 IQR 0.48 vs. 1.01 IQR 0.63, P=0.009). The ratio of soluble vascular endothelial growth factor receptor 1 to placental growth factor was significantly higher in cases than controls, even after adjusting for confounders (4.42 IQR 2.52 vs. 2.93 IQR 2.01, P=0.009).

CONCLUSION

Circulating placenta-secreted glycoproteins and markers of angiogenesis are altered in pregnant women with OSA.

Orf: contagious pustular dermatitis

Orf is a common viral infection in sheep. It spreads to humans by direct contact. It is self-limiting, treatment having no beneficial effect. Misdiagnosis by those unfamiliar with its characteristic features is common, and may result in unnecessary treatment with antibiotics or surgery. We present a series of five cases of Orf in children of farmers in the west of Ireland, seen over a 10 year period.

Delayed presentation following accidental inhalation of a pushpin

A previously fit and well 18-year-old woman presented to the accident and emergency department following referral by her general practitioner with a provisional diagnosis of appendicitis. The history obtained from the patient revealed the presence of a bitemporal headache with associated neck stiffness, photophobia and vomiting for approximately 1.5 weeks. The patient complained of abdominal pain localised to her right iliac fossa and anorexia for approximately 1 week. She also noted the presence of a cough productive of green sputum for 3 weeks. A chest radiograph was obtained which showed a large area of consolidation in the right lower lobe consistent with infection and a linear density in keeping with a metallic foreign body. Following review of the chest radiograph, the patient was interviewed further and recalled having inhaled a pushpin approximately 1 year before her presentation. Aspiration of foreign bodies is relatively common in children and is often associated with delayed diagnosis and high morbidity. To prevent delayed diagnosis, characteristic symptoms and clinical and radiological signs of foreign body aspiration should be checked in all suspected cases and a low index of suspicion for ordering additional imaging or using bronchoscopy for diagnostic purposes should be employed.

Necessity breeds invention: a study of outpatient management of low velocity gunshot wounds

BACKGROUND

Since the late 1980s, the emergency department (ED) at the Mater Hospital, Belfast, has implemented a policy of treating conservatively patients who sustain low velocity gunshot wounds to the lower limbs. Wounds are cleaned and minimally debrided under local anaesthetic in the ED. Patients are given oral antibiotics, and reviewed 48 hours later at the ED review clinic.

OBJECTIVE

To investigate the outcome of outpatient ED management of low velocity gunshot wounds to the lower limbs.

METHOD

This was a retrospective, observational study from January 2000 to September 2004 inclusive. Notes were retrieved of those patients who had gunshot wound mentioned in the triage text. Patients were included if they presented with a low velocity gunshot wound to the lower limbs. Demographics and treatment regimen were recorded.

RESULTS

In total, 90 patients sustained low energy injuries to the lower limb, with 70.5% of wounds involving the skin and soft tissue only. Most patients (n = 67) were treated as outpatients, which included 80% of unilateral injuries and 46.6% of bilateral injuries presented. There were 56 patients reviewed at clinic. Three patients developed minor complications

CONCLUSION

Irrigation and minimal debridement in the outpatient setting is an acceptable method of treatment for low energy gunshot wounds to the lower limbs, without orthopaedic or vascular involvement.

Defined contribution programs: how physicians and medical groups can prepare now for their impact

Facing continued premium increases and escalating employee dissatisfaction, employers and other purchasers are implementing defined contribution programs for health care benefits. These programs depart from traditional health benefits by offering employees more flexibility and using Internet services to streamline administrative processes. This article gives an overview of these defined contribution programs and suggests steps medical practices can take to prepare for them. While these programs remain largely untested, they could present physicians with opportunities to improve financial performance and enhance patient satisfaction.

Where do we go after the three standard cervical spine views in the conscious trauma patient? A survey

The objective of this study was to assess, by questionnaire survey, national practice in respect of radiological assessment of the cervical spine in the conscious adult patient with suspected neck injury. The physicians in charge of accident and emergency departments with more than 25000 new patients per year were sent a questionnaire. One hundred and ninety-one replies were received from 243 physicians (79%). Sixty-five per cent of departments have written protocols for imaging the cervical spine. Seven per cent of departments use fewer than the three standard views for clearing the cervical spine. If adequate views do not visualize the cervicothoracic junction, 89% use swimmer's views and 12% use supine oblique views, prior to computerized tomography scanning. It is concluded that the majority of departments use three standard views in the first instance. Swimmer's views are the most common additional X-rays taken if the C7-T1 junction is not visualized, even though supine oblique views give better information about spinal alignment. Imaging of the cervical spine following trauma is difficult and guidelines should be drawn up to address these problems.

The pattern of alcohol consumption of a general hospital population in north Belfast

This study aimed to examine the pattern of alcohol use among those attending a General Hospital and to explore the perception of safe drinking. The Alcohol Use Disorders Identification Test (AUDIT) questionnaire was given for self-completion to all inpatients and outpatients on separate days and to all adults attending the Accident and Emergency Department (A&E) on both a midweek and a weekend period. Additional questions to determine attitudes to, and intake of, alcohol were also given. Of the 464 people approached, 82% completed the questionnaire. Twenty-nine per cent of outpatients, 37.5% of inpatients and 20% of those attending A&E were leetotal. Fifteen per cent of outpatients, 16% of inpatients and 38.5% of those attending A&E scored as misusers of alcohol according to the AUDIT questionnaire. Males were three times more likely to misuse alcohol than females. Younger women were much more likely to misuse alcohol than older women. An unexpectedly large number of those attending the gynaecological clinic reported alcohol misuse. Of the inpatient alcohol misusers identified by AUDIT, only 50% were independently detected by either nursing or medical staff, the lower misuse scores being more frequently missed. We conclude that there continues to be a significant identifiable proportion of alcohol misuse that goes undetected. These individuals attend throughout the hospital and a simple self-completion questionnaire would considerably aid their detection.

Psychological consequences of the Kegworth air disaster

BACKGROUND

The study sought to quantify psychiatric morbidity among survivors of a major air crash and to identify aetiological factors linked with post-traumatic stress disorder (PTSD).

METHOD

Sixty-eight of the 79 survivors (86%) were assessed at a clinical interview within one year of the disaster. The majority also completed the General Health Questionnaire, the Impact of Events Scale (IES) and the Zung Anxiety and Depression Scales.

RESULTS

Fifty-four of the study group (79%) met DSM-III-R criteria for a psychiatric disorder within one year of the disaster, of whom 27 (50%) had PTSD. Those who saw injured or dead people at the scene, or had sustained less severe injuries as measured by their Injury Severity Scores, or were under 35 years old, were significantly more likely to develop PTSD.

CONCLUSIONS

High rates of psychiatric morbidity are found in survivors of transportation disasters. Further studies are needed to identify those at most risk and to evaluate the benefits of psychological intervention.

Modulation of adenylylcyclase by protein kinase C in human neurotumor SK-N-MC cells: evidence that the alpha isozyme mediates both potentiation and desensitization

Exposure of human SK-N-MC neurotumor cells to 4 beta-phorbol 12-myristate 13-acetate (PMA) increased isoproterenol stimulation of cyclic AMP levels by severalfold. This potentiation was blocked by inhibitors of protein kinase C (PKC) and did not occur in cells in which PKC had been down-regulated. PMA treatment also enhanced the stimulation by dopamine, cholera toxin, and forskolin. Thus, the effect of PMA on the adenylylcyclase system was postreceptor and involved either the guanine nucleotide binding regulatory (G) proteins or the cyclase itself. As PMA treatment did not impair the inhibition of isoproterenol stimulation by neuropeptide Y, an involvement of the inhibitory G protein Gi was unlikely. Cholate extracts of membranes from control and PMA-treated cells were equally effective in the reconstitution of adenylylcyclase activity in S49 cyc- membranes, which lack the stimulatory G protein subunit Gs alpha; thus, Gs did not appear to be the target of PMA action. Membranes from PMA-treated cells exhibited increased adenylylcyclase activity to all stimulators including Mn2+ and Mn2+ plus forskolin. In addition, activity was increased when control membranes were incubated with ATP and purified PKC from rat brain. This is consistent with a direct effect of PKC on the adenylylcyclase catalyst in SK-N-MC cells. PMA treatment also resulted in a shift to less sensitivity in the K(act) for isoproterenol but not for dopamine or CGP-12177 (a beta 3-adrenergic agonist) stimulation. Thus, the beta 1 but not the D1 or beta 3 receptors were being desensitized by PKC activation. Analysis of SK-N-MC cells by western blotting with antibodies against different PKC isozymes revealed that both the alpha and zeta isozymes were present in these cells. Whereas PKC-alpha was activated and translocated from cytosol to membrane by phorbol esters, the zeta isozyme was not. Thus, PKC-alpha, which has been implicated in desensitization in other cell lines, also appears to potentiate adenylylcyclase activity.

Non-Hodgkin's lymphomas of the nose and paranasal sinuses in the pediatric population

Paranasal and nasal neoplasms often elude early diagnosis in the pediatric population. This report examines 3 cases of nasal and paranasal sinus lymphomas out of 29 lymphomas and lymphoproliferative disorders seen from 1983 to 1990. Diagnostic delays are common. The development of orbital signs and symptoms often leads to diagnosis. Computed tomography and magnetic resonance imaging are important in delineating the extent of disease and allow appropriate staging. Transnasal biopsy yields the definitive diagnosis, with low associated morbidity. Aggressive chemotherapy and irradiation prolongs survival; with this regimen all of our patients have remained alive, although 1 has residual disease. B-cell lymphomas are more common than T-cell varieties in children. One patient demonstrated B-cell immunodeficiency and preleukemia prior to developing primary paranasal sinus non-Hodgkin's lymphoma; this case reiterates the systemic nature of lymphoma, Key differences between children and adults in the manifestations of nasal and sinus lymphomas are emphasized.

Communication of discharge information for elderly patients in hospital

The delivery of the discharge note to the general practitioners following discharge of elderly patients from a geriatric medical unit was studied over a two-month period. Handwritten discharge notes were received by the general practitioners in 75% of cases, and the delay was reduced to a median of two days by the use of a pre-printed envelope. Postal communications were also received by 89% of general practitioners after a median delay in two days. A dual system of hand-delivery and postal delivery would ensure faster and more complete receipt of information.

Regulation of neutrophil superoxide by antichymotrypsin-chymotrypsin complexes

The ability of neutrophils to generate free radicals is a crucial component of host defense (Babior, B. M. (1978) N. Engl. J. Med. 298, 659-668, 721-725. Neutrophil oxidants, however, can cause significant host tissue destruction (Weiss, S. J. (1989) N. Engl. J. Med. 320, 365-376), and the regulation of free radical production is not well understood. We have previously shown that recombinant antichymotrypsin (rACT), a serine protease inhibitor, inhibits superoxide production in intact neutrophils (Kilpatrick, L., Johnson, J. L., Nickbarg, E. B., Wang, Z., Clifford, T. F., Banach, M., Cooperman, B. S., Douglas, S. D., and Rubin, H. (1991) J. Immunol. 146, 2388-2393). Using a cell-free NADPH oxidase preparation, we now demonstrate that rACT alone has no effect on superoxide production and that antichymotrypsin-chymotrypsin (rACT.CT) complexes are required to inhibit superoxide, suggesting that neutrophil chymotrypsin-like proteases produce conformational changes in ACT, allowing it to become active in regulating superoxide production. Additionally, we have identified NADPH oxidase itself as the target for rACT.CT and have demonstrated that rACT.CT interferes specifically with activation of the NADPH oxidase without changing the Km for NADPH or the rate constant describing the rate-limiting step in activation. These observations suggest an important role for antichymotrypsin in the regulation of NADPH-oxidase activation, which is a prerequisite for neutrophil superoxide production, and predict possible therapeutic uses for rACT in conditions where unregulated neutrophil-free radical production has been implicated in the mechanism of tissue destruction.

Backslabs and plaster casts: which will best accommodate increasing intracompartmental pressures?

Plaster-of-Paris backslabs are presently used after closed or operative reduction of fractures as they are thought to accommodate any swelling which may occur. This study was designed to examine the ability of different types of cast to expand with increasing internal pressure. The results of the study show clearly that a split and spread cast is the only safe cast to use after fracture as it allows for swelling. Backslabs are no better than a complete plaster at accommodating increased internal pressure. It is therefore recommended that backslabs are no longer used to maintain reductions when swelling is anticipated.

Effects of counselling on knowledge about HIV-1 among transfusion recipients and their partners. Transfusion Safety Study Group

The present study determined how much HIV-1-positive persons knew about AIDS, and HIV-1 transmission and prevention, in comparison with HIV-1-negative controls in a predominantly heterosexual cohort. The subjects were blood donors, blood recipients, hemophiliacs, and their sexual partners. A 16-item questionnaire about AIDS, HIV-1 transmission, and knowledge of safe sexual practices was administered to 228 subjects to determine background information. The HIV-1-positive cohort answered more questions correctly (mean = 8.5) than did the HIV-1-negative cohort (mean = 6.5), largely as a result of general information about AIDS among those with steady sexual partners. All persons, however, were poorly informed about HIV-1 transmission and safe sexual practices. Thus, there is a great need for effective counselling.

Epidemiologists in the United States: an assessment of the current supply and the anticipated need

We provide 1985 estimates of the work force of epidemiologists in the United States, the number of graduates from training programs in epidemiology, and a projection of the future need for these health professionals. Our methods included a search of mailing lists from professional organizations, mail contact with graduate training programs, telephone interviews with experts, and a review of job announcements in professional journals. The study indicates that the current work force of epidemiologists in the United States is estimated to include 4,600 persons, more than half of whom are physicians; most epidemiologists are located in either a state with a major federal public health agency or one with a large population; and programs in epidemiology graduate an average of 475 persons with one or two years of master's level education and approximately 80 with doctoral-level education each year. After considering the factors that influence the supply of epidemiologists, we project a substantial need for more epidemiologists in the future than current sources will provide.

Health beliefs and physician identified "worried well"

Health belief variables of the frequent and inappropriate user of medical services, or "worried well," were examined in two studies. Study 1 showed the physician identified "worried well" to be concerned about both general and mental health issues and to perceive typically minor symptoms as more serious than other frequent appropriate users, infrequent users, and mental health comparison groups. Study 2, a prospective study, measured beliefs and subsequent use for one year. Ratings of inappropriateness of use and psychosomatic involvement made by medical providers were predicted by high degrees of self reported somatic symptomatology, mental health concern, belief in self responsibility for health care, belief that one should handle one's own problems, and a limited belief in the responsibility of powerful others for health care.

Tardive akathisia and agitated depression during metoclopramide therapy

The authors describe two cases of tardive akathisia following metoclopramide therapy, in which there were concomitant symptoms of agitated depression.

An independent labor-support nursing service

The development of a monitrice service as an independent nursing practice is described including design, legality, implementation into several hospitals, and response by the consumer, provider, and hospital staff. Specific information also includes orientation to hospitals, scheduling, pricing, and a description of the service.

Health beliefs and physician identified "worried well"

Health belief variables of the frequent and inappropriate user of medical services, or "worried well," were examined in two studies. Study 1 showed the physician identified "worried well" to be concerned about both general and mental health issues and to perceive typically minor symptoms as more serious than other frequent appropriate users, infrequent users, and mental health comparison groups. Study 2, a prospective study, measured beliefs and subsequent use for one year. Ratings of inappropriateness of use and psychosomatic involvement made by medical providers were predicted by high degrees of self reported somatic symptomatology, mental health concern, belief in self responsibility for health care, belief that one should handle one's own problems, and a limited belief in the responsibility of powerful others for health care.