Online Resources for Robin Sequence; an Analysis of Readability

The objective was to evaluate the readability of easily accessible parent-directed information concerning Robin Sequence (RS) online, compared to the American Medical Association (AMA)-recommended sixth grade (age 11-12) readability level.

A Google search of the term "Pierre Robin Sequence information" was performed. The first ten websites were evaluated using six commonly used readability formulas. Sample texts from three websites were 'translated' by the authors, with the aim of achieving a sixth grade readability level.

The following outcomes were used: Automated Readability Index (ARI), Coleman Liau Index (CLI), Gunning Fog Score, Simple Measure of Gobbledygook (SMOG), Flesch Kincaid Grade Level (FKGL), and Flesch Reading Ease (FRE) score.

The mean pooled grade level of the top 10 included websites was 12.1 (age 17-18). The overall FRE Index was 45.8, which is equivalent to a College-grade reading level. The mean grade level by each test used was: Flesch-Kincaid Grade Level 11.6 (age 16-17), Gunning Fog Score 13.3 (age 18+), SMOG 10.0 (age 14-15), Coleman-Liau Index 13.8 (age 18+), and ARI 12.0 (age 17-18). The author-translated resources achieved pooled mean grade levels of 6.3-6.5.

Parent-directed online materials concerning RS have a readability in excess of the AMA-recommended sixth grade reading level. Even though the condition is complex, more readable resources are achievable. Coproduction of parent-directed resources in association with public an patient involvement (PPI) contributors is encouraged.

Admission patterns in a psychiatric intensive care unit in Ireland: a longitudinal follow-up

OBJECTIVE

This study aims to describe the course of admission and clinical characteristics of admissions to a psychiatric intensive care unit (PICU) in the Phoenix Care Centre (PCC), Dublin, Ireland.

METHODS

This retrospective chart study was conducted at the PCC, Dublin, Ireland. The cohort included all admission episodes (n = 91 complete data) over a three-year study period between January 2014 and January 2017.

RESULTS

The mean age of admitted cases was 37.1 (s.d. = 11.3; range 18-63). The mean length of stay (LOS) was 59.3 days (s.d. = 61.0; median 39.5 days). All patients were admitted under Mental Health Act legislation. Antipsychotic polypharmacy was used in 61% (n = 55) of the admissions. A diagnosis of acute psychotic disorder (B = -1.027, p = 0.003, 95% CI: -1.691, -0.363) was associated with reduced LOS in PICU.

CONCLUSION

Our study describes the cohort of patients admitted as being predominantly male, younger-aged, single, having a diagnosis of schizophrenia and being legally detained. The primary indication for referral is risk of assault, which highlights the need for the intensive and secure treatment model that a PICU can provide.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Kelp detritus: Unutilized productivity or an unacknowledged trophic resource?

Kelp beds are one of the most productive marine systems and, while little of this production is directly consumed, there is growing evidence that kelp detritus is an essential food source for many detrital and suspension feeders, and forms an important component of offshore sedimentary carbon pools. However, the extent of the contribution of kelp detritus to the nutrition of coastal fauna is not well resolved. In this study, we compare the contribution of phytoplankton, kelp detritus, and waste from fish cages to the diet of a sentinel suspension feeder, the blue mussel (Mytilus edulis) using stable isotopes. We found a significant depletion in both 13C and 15N in kelp tissue with age (distance from stipe to the deteriorating distal end of the kelp frond) which may have biased dietary estimates in previous studies which have applied isotopic source values derived from fresh kelp. Our mixing models indicate that macroalgal detritus formed 59% of the diet of the mussels in Berehaven, Bantry Bay, Ireland. We support the isotopic mixing model results by modelling the relative production of phytoplankton, kelp, and salmon farm waste, and found the supply of C and N from kelp and phytoplankton far exceeded the requirements of the mussels with much less coming from the nearby fish cages. Monthly chlorophyll measurements indicated there was only sufficient phytoplankton density to support mussel growth during the spring and autumn, explaining our observation of patterns in the relative importance of utilization of kelp detritus. Where there is pressure to harvest kelp beds, this study highlights the supporting ecosystem service they provide as an important dietary source in coastal food webs and emphasises the need for appropriate management measures for this resource.

401 Three Birds with One Stone: Ureteric Calculus Precipitates Diagnosis and Resection of Three Primary Neoplasms

A 67 year-old female presented to our centre with a 2 day history of right flank pain, clinically suggestive of ureteric colic. Computed tomography (CT) confirmed a 6mm right ureteric calculus. However, CT also revealed a large 13cm ipsilateral renal mass, concerning for renal cell carcinoma (RCC). At ureteroscopy for management of the obstructing calculus, a small papillary lesion was noted in the bladder, and excised. Histology confirmed pTa low-grade transitional cell carcinoma.

Following discussion at the Urology multidisciplinary tumour board, MRI venogram (MRV) was recommended to delineate the extension of tumour into the renal vein, and to characterise a pelvic mass seen on original CT. MRV showed enhancing material extending into the IVC, consistent with tumour thrombus. However, it also identified a concerning 6cm solid ovarian mass.

The patient proceeded to open right radical nephrectomy and IVC thrombectomy, hysterectomy, bilateral salpingo-oopherectomy, and omental biopsy, with combined input from Urological, Gynaecological and Vascular surgical teams. Post-operative course was uneventful. Histology showed an 11cm pT3a G2 clear cell RCC, and 7.5cm ovarian fibroma, both fully excised. This case demonstrated the serendipity of a simple ureteric calculus precipitating a cascade of investigations, that ultimately led to complete resection of three primary neoplasms.

Improving vaccine administration in patients with solid malignancies in the outpatient setting

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Background: Pneumococcal and influenza vaccinations are recommended for all patients with any malignancy in accordance with the Infectious Disease Society of America. Patients undergoing chemotherapy for solid tumors have a 40-50 fold higher risk for the development of invasive pneumococcal disease compared to healthy adults with a case fatality rate of 35% and should receive the sequential 13-valent pneumococcal conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23). In the outpatient setting, lack of provider knowledge, complexity of the pneumococcal vaccine regimen and disruption in work-flow of a busy clinic can lead to low rates of administration. Towards this end, we conducted a quality project to improve administration of both pneumococcal and influenza vaccines by at least 50% at one of our outpatient oncology clinics at Montefiore Medical Center in Bronx, NY during a 4 month period. Methods: We first provided provider and nursing education with regard to safety and efficacy of the vaccines in both the clinic as well as the infusion setting. Nurses were then prompted to screen patients and offer the vaccines during intake prior to all infusions and clinic visits. We created bulk orders which allowed nurses greater control of releasing vaccine orders previously entered by the director of the clinic. We also posted “cheat-sheets” on optimal timing, safety and sequence of administration of the vaccines in every patient room and nursing station. After our first cycle, we identified that there was a delay in work-flow in the outpatient clinic with delivery of the vaccines to the clinic from the pharmacy. We therefore obtained a secure vaccine fridge that was placed at the nursing station, which allowed nurses easy access to the vaccines. Results: When vaccine administration during the 2018-2019 influenza season was compared to the 2019-2020 influenza season, we found that these interventions improved the administration of the influenza vaccine by 70%. There was a dramatic increase in the number of PCV-13 vaccines administered by 350% (more than 5-fold) and increase in PPVS-23 by 12.5%. No immediate adverse reactions during this cycle were reported to our nurse manager. Conclusions: A simple intervention of improved work-flow of vaccine administration and increased education of providers and nurses translated to a dramatic improvement in the administration of influenza and PCV-13 vaccines in a busy outpatient oncology clinic.

Decreasing Time to Initiation of Chemotherapy for Patients Electively Admitted to a Hematologic Malignancy Service

PURPOSE

Delays in initiating elective inpatient chemotherapy can decrease patient satisfaction and increase length of stay. At our institution, we observed that 86% of patients who were admitted for elective chemotherapy experienced a delay-more than 6 hours-with a median time to chemotherapy of 18.9 hours. We developed a process improvement initiative to improve time to chemotherapy for elective chemotherapy admissions.

METHODS

Our outcome measure was the time from admission to chemotherapy administration in patients who were admitted for elective chemotherapy. Process measures were identified and monitored. We collected baseline data and used performance improvement tools to identify key drivers. We focused on these key drivers to develop multiple plan-do-study-act cycles to improve our outcome measure. Once we started an intervention, we collected data every 2 weeks to assess our intervention.

RESULTS

At the time of interim analysis, we observed a median decrease in time to chemotherapy administration from 18.9 hours to 8.85 hours (P = .005). Median time to laboratory results resulted decreased from 3.17 hours to 0.00 hours. There was no change in time from signing chemotherapy to nurse releasing the chemotherapy. We noted that more providers were signing the chemotherapy before patient admission.

CONCLUSION

By implementing new admission workflows, optimizing our use of the electronic medical record to communicate among providers, and improving preadmission planning we were able to reduce our median time to chemotherapy for elective admissions by 53.2%. Improvement is still needed to meet our goals and to ensure the sustainability of these ongoing efforts.

Prevalence and patterns of substance misuse in schizophrenia

Aims and Method

To identify the prevalence and patterns of substance misuse in patients with schizophrenia in a catchment population in Dublin, and to compare this with that of a control group from general practice. Ninety-nine patients and 75 controls were interviewed using a semi-structured technique. Urine samples were obtained from all patients and controls were analysed for illicit substances.

Results

Prevalence of illicit substance and alcohol misuse was similar among patients (illicit substances, 45%; alcohol, 33%) and controls (illicit substances, 43%; alcohol, 25%). Patterns of substance misuse were similar, apart from ecstasy, which was used more commonly by controls. Discrepancies were found between histories of drug use and urinalysis.

Clinical Implications

Illicit substance misuse in patients with schizophrenia may mirror usage in the general population, rates of misuse reflecting cultural factors rather than illness and patterns of misuse reflecting geographical variations in the availability of drugs. A combination of screening methods is more effective than the use of a single source of information.

Pharmacokinetics-directed Intravenous Busulfan Combined With High-dose Melphalan and Bortezomib as a Conditioning Regimen for Patients With Multiple Myeloma

BACKGROUND

High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) has a well-established role in the treatment of patients with multiple myeloma. Melphalan 200 mg/m² (Mel200) is the most commonly used preparative regimen. Several studies have provided evidence for potential synergism and safety when combining bortezomib (Btz) or busulfan (Bu) with melphalan (Mel).

PATIENTS AND METHODS

We conducted a prospective phase II study to investigate the safety and efficacy of conditioning with pharmacokinetics (PK)-directed intravenous (IV) Bu with Btz and Mel. Bu dosing was adjusted to target a total area under the curve (AUC) of 20,000 μM × min. Patients received Btz (1 mg/m² × 4 doses) and Mel (140 mg/m²).

RESULTS

A total of 19 subjects were enrolled. Their median age was 55 years, and the median follow-up period was 23.7 months. PK testing resulted in 86% of patients achieving an estimated total AUC of 20,000 ± 2500 μM × min. The overall response rate (ORR) at day +100 after ASCT was 100% in the evaluable patients, with 11% of patients achieving a complete response. The 2-year progression-free survival rate was 57.9% (95% confidence interval [CI], 38%-89%), and the 2-year overall survival rate was 88.5% (95% CI, 76%-100%). The most common grade 3 and 4 toxicities were febrile neutropenia, dysphagia/odynophagia, and oral mucositis. No case of hepatic sinusoidal obstruction syndrome developed. One treatment-related mortality occurred before day +100.

CONCLUSION

A preparative regimen of PK-directed IV Bu with Btz and Mel led to an ORR of 100% with acceptable toxicity and should be considered for direct comparison with the Mel200 regimen in future trials.

Mountain bikers priapism: a rare phenomenon

Soft tissue and bony injuries are well described risks of the increasingly popular sport of mountain biking. Priapism, a persisting unwanted penile erection, as a result of perineal straddle injury due to a fall astride bicycle handlebar, is rare. We present a case of a competitive mountain biker with high flow priapism after such an injury who presented late but was successfully treated by non-invasive selective arterial embolization.

Percutaneous renal artery angioplasty and stenting: indications, technique and results

BACKGROUND

Percutaneous interventions for renal arterial disease can be used to treat a variety of conditions including both atherosclerotic and non-atherosclerotic renal artery stenosis (RAS) as well as endovascular management of renal artery aneurysms (RAA).

AIM

We sought to examine the indications, techniques and results of percutaneous renal angioplasty and stenting in our institution over a 6-year period and review the current evidence for practice.

METHODS

Patient demographics, procedure indications, technical procedural details, complications, baseline and follow-up renal profile indices were analysed.

RESULTS

The most common indication for intervention was atherosclerotic RAS (69.2%) followed by RAS secondary to fibromuscular dysplasia (15.3%) and RAA (15.3%). There was a 100% technical success in our cohort of patients. The majority of patients (84.6%) had cross-sectional imaging in the form of computed tomography or magnetic resonance angiography prior to intervention.

CONCLUSION

When performed in appropriate settings following close liaison with referring physicians, percutaneous renal angioplasty and stenting remains an important treatment modality for renovascular disease.

The use of computerised tomography guided percutaneous fine needle aspiration in the evaluation of solitary pulmonary nodules

The evaluation of a solitary pulmonary nodule (SPN) has changed over the years with increased access to percutaneous computerised tomography (CT) guided fine needle aspiration (FNA), where bronchoscopy is unhelpful. The aim of our study was to evaluate the sample adequacy, diagnostic and complication rate of CT-FNA of a SPN at our academic teaching hospital over an 18 month period. CT-FNA was performed by a radiologist, with a cytopathologist in attendance to confirm the adequacy of the sample obtained. The size of the nodule, sample material and adequacy, diagnosis and complications were recorded. A total of 101 patients were included, 54 male and the mean age was 68 +/- 11 years. The mean size of the SPN was 2.3 cm (range 1-11 cm). 56 (56%) patients had a right SPN, 45 (45%) had a left SPN. CT-FNA was diagnostic in 80 (80%) patients and non-diagnostic in 21 (20%) patients. The sample was insufficient for immunocytochemistry, although the morphological appearance was diagnostic in 20 (25%) of the 80 patients. Pneumothorax occurred in 26/101 (26%) patients post CT-FNA, of these 7 (27%) required chest drain insertion, while 19 (73%) were managed conservatively. CT FNA is a useful tool for the diagnosis of a SPN, with our diagnostic accuracy comparable to that reported in the literature. However, CT-FNA may not provide adequate sample volume to perform ancillary testing and has a moderate complication rate.

Hypertension in chronic kidney disease: navigating the evidence

Hypertension is both an important cause and consequence of chronic kidney disease. Evidence from numerous clinical trials has demonstrated the benefit of blood pressure control. However, it remains unclear whether available results could be extrapolated to patients with chronic kidney diseases because most studies on hypertension have excluded patients with kidney failure. In addition, chronic kidney disease encompasses a large group of clinical disorders with heterogeneous natural history and pathogenesis. In this paper, we review current evidence supporting treatment of hypertension in various forms of chronic kidney disease and highlight some of the gaps in the extant literature.

Management of patients seen post-sexual assault at a north London inner city genitourinary medicine clinic 2005–2008

An audit of all patients presenting to an inner city sexual health clinic post-sexual assault over a four-year period was undertaken to evaluate the overall management of these patients. Sixty-five cases were identified; 22.6% had a pre-existing vulnerability factor and 21.0% a sexually transmitted infection (STI). Recommendations from the audit included: to offer non-invasive methods of testing for STIs to patients presenting at less than one week, improve documentation by completing the specific clinic template and ensure all patients are offered emotional support when they first attend.

Selective salpingography and recanalisation of blocked fallopian tubes

Fallopian tubal disease is a common cause of subfertility. Reproductive surgery or assisted reproduction techniques such as in vitro fertilization (IVF) have been the main treatment options for patients with tubal disease in Ireland, although access to these treatments remains limited. We describe a case of pregnancy following selective salpingography and fallopian tube recanalisation.

Comprehensive ultrasound assessment of complications post-liver transplantation

Human liver transplantation for end-stage liver disease was first performed in 1963. Refinements in surgical technique and new immunosuppressive regimens have improved outcomes. Today, transplant patients have a 5-year survival rate of approximately 75%. Nevertheless, significant complications still occur. Ultrasonography (US), is the initial imaging modality of choice allowing bedside assessment for detection and follow-up of early and delayed graft complications, and facilitating interventional procedures. This review outlines the role of ultrasound in post-transplantation assessment.

Syphilitic periostitis in a newly diagnosed HIV-positive man

A 36-year-old man presented for an HIV test, which answered positive. He gave a six-week history of headache and fever. His syphilis serology was also positive with a Venereal Disease Research Laboratory (VDRL) titre of 1:32, and positive Treponema pallidum particle agglutination (TPPA) assay and fluorescent treponemal antibody (FTA). When he attended for treatment of the syphilis, he had developed severe pain in both lower limbs. Plain radiographs were normal. An isotope bone scan showed multiple areas of increased uptake, consistent with syphilitic periostitis. Some of these lesions were asymptomatic. He was treated with benzathine penicillin and his pain resolved. The bone scan had normalized after six months. We review the previous literature regarding syphilitic bone pain and periostitis. We discuss the importance of considering syphilis in the differential diagnosis of any sexually active adult presenting with bone pain, and highlight the usefulness of isotope bone scans in clarifying the clinical picture.

Treatment of “High-Flow” Priapism with Superselective Transcatheter Embolization: A Useful Alternative to Surgery

PURPOSE

To review the efficacy of treatment of high-flow priapism with superselective transcatheter embolization.

METHODS

Over a 2-year period, we reviewed five patients who were treated for traumatic high-flow priapism with superselective embolization. All patients underwent diagnostic angiography that demonstrated a communication between the cavernosal artery and the corpora cavernosa. Each identified fistula was embolized using gel-foam, blood clot, microcoils, or a combination of these.

RESULTS

All five patients had successful detumesence of priapism postprocedure. There was normal recurrence of early morning erection with successful detumescence for each patient within a 2- to 4-week period. Two of five patients (40%) presented with recurrence of priapism at 6 months and required a repeat embolization procedure. At 1 year, four of the five patients (80%) had normal erectile function.

CONCLUSION

Superselective transcatheter embolization is a useful therapeutic modality in the treatment of high-flow priapism. It provides equivalent rates of detumesence when compared to surgical techniques, and appears to have a greater success in preserving erectile function.

Oxidative stress and endometriosis

BACKGROUND

Little is known about the aetiology of endometriosis; however, in the presence of oxidative stress, reactive oxygen species might increase growth and adhesion of endometrial cells in the peritoneal cavity, leading to endometriosis and infertility. Within a study investigating persistent organic compounds and endometriosis, the authors evaluated the association between oxidative stress and endometriosis.

METHODS

Women aged 18-40 years who were undergoing laparoscopy were contacted to participate in the study (n = 100); 84 were eligible and agreed to be interviewed; 78 provided blood specimens. Four markers of oxidative stress and antioxidant status were measured in serum for 61 women. Multiple imputation of missing data was used to generate values for the missing oxidative stress data.

RESULTS

Thirty-two women had visually confirmed endometriosis at laparoscopy while 52 did not, including 22 undergoing tubal ligation and 30 with idiopathic infertility. There was a weak association between thiobarbituric acid-reactive substances (nmol/ml) and endometriosis, after adjusting for age, body mass index, current smoking, hormone use in the past 12 months, gravidity, serum vitamin E, serum estradiol, and total serum lipids (beta = 1.18; 95% CI-0.04, 2.39).

CONCLUSIONS

These results suggest that oxidative stress might play a role in the development and progression of endometriosis, which should be evaluated in larger studies.

Oxidative stress and glucose levels in a population-based sample

OBJECTIVES

To examine the relationship between markers of oxidative status and glucose on a population basis.

STUDY DESIGN AND SETTING

We report here on a population-based sample of 1315 women and 981 men, aged 35-79 years, randomly selected from residents of Erie and Niagara Counties in western New York between 1996 and 1999. Thiobarbituric reactive substances (TBARS), erythrocyte glutathione (GSH) and plasma glutathione peroxidase (GSH-Px) were measured as markers of oxidative status. Study sample was categorized by quartiles of glucose, degree of abnormality of fasting glucose, and level of metabolic control in patients with diabetes.

RESULTS

Men and women in the uppermost quartiles of glucose had higher levels of TBARS (men: Quartile 4 = 1.55 +/- 0.03, Quartile 1 = 1.36 +/- 0.03, women: 1.49 +/- 0.02, 1.30 +/- 0.02 nmol/ml) and lower levels of GSH (men: Quartile 4 = 1.57 +/- 0.03, Quartile 1 = 1.69 +/- 0.03, women: 1.71 +/- 0.03, 1.97 +/- 0.0 mmol/l packed RBCs). In women, compared with normal fasting glucose, impaired fasting glucose was associated with higher levels of TBARS (1.29 +/- 0.01 vs. 1.84 +/- 0.04 nmol/ml), lower levels of GSH (1.85 +/- 0.02 vs. 1.76 +/- 0.05 mmol/l packed RBCs), and higher GSH-Px activity (618.94 +/- 2.64 vs. 644.77 +/- 8.90 IU/l). In women, abnormal fasting glucose was associated with higher levels of TBARS (1.84 +/- 0.04 nmol/ml), lower levels of GSH (1.68 +/- 0.06 mmol/l packed RBCs), and higher levels of GSH-Px (647.72 +/- 9.87 IU/l) than normal or impaired fasting glucose. In men, abnormal fasting glucose was associated with higher TBARS (1.76 +/- 0.04 vs. 1.37 +/- 0.07 nmol/ml), and lower GSH (1.62 +/- 0.05 vs. 2.78 +/- 0.02 mmol/l packed RBCs), than normal fasting glucose. Poor metabolic control was associated with higher TBARS (men: 2.07 +/- 0.08 vs. 1.33 +/- 0.14 nmol/l, women: 2.02 +/- 0.09 vs. 1.35 +/- 0.18 nmol/l) and GSH-Px activity (men: 654.34 +/- 13.45 vs. 599.86 +/- 24.76, women: 660.61 +/- 13.25 vs. 579.42 +/- 27.42 IU/l).

CONCLUSIONS

Glucose levels play a role in determining oxidative status in a population sample. The balance between oxidative and antioxidant processes appears to be sensitive to glucose levels with moderate elevations of glucose affecting the oxidative status.

Obstetric adversity and age at first presentation with schizophrenia: evidence of a dose-response relationship

OBJECTIVE

The purpose of the study was to determine if a dose-response relationship exists between obstetric adversity and age at first presentation with schizophrenia.

METHOD

The Dublin Psychiatric Case Register was used to identify subjects with schizophrenia. Data on obstetric complications, social class of origin, and family history of psychiatric illness were obtained for those subjects.

RESULTS

A total of 409 patients with ICD-9 schizophrenia were identified. Patients with a history of obstetric complications presented earlier to psychiatric services. As the number of complications increased, the mean age at first presentation decreased. This effect was independent of social class of origin and family history of psychiatric illness.

CONCLUSIONS

Obstetric adversity exerts an independent influence on the age at first presentation with schizophrenia, in a dose-response manner. This finding supports the existence of a causal relationship between obstetric adversity and age at first presentation with schizophrenia.

Temporal aspects of feeding events in tammar (Macropus eugenii) and parma (Macropus parma) wallabies. I. Food acquisition and oral processing

We studied parameters that influence the efficiency of food acquisition and oral processing in the tammar wallaby (a grazer) and the parma wallaby (a grazer/browser), both in captivity and under free range on Kawau Island, New Zealand.In captivity, both species spent less time feeding per gram of dry matter intake when browsing than when grazing, and there were no significant differences between the species with respect to the rates of feeding per gram of dry matter intake of a given food. However, under free-ranging conditions, tammar wallabies spent longer feeding than did parma wallabies, so it was likely that tammar wallabies spent more time grazing than browsing. Differences in the relationships between feeding event and inter-feed interval duration in captive and free-ranging wallabies indicated that feeding behaviour was influenced by different factors in the two situations.Microtemporal analysis of the chewing sounds of free-ranging tammar and parma wallabies showed that the interval between the first and second sounds in a 'run' of chewing sounds was longer than that between subsequent intervals, indicating that there was a time cost associated with food aquisition. However, as there were no significant differences between the two wallaby species, either in the mean duration of 'runs' of chewing sounds within feeding events or in the mean duration of whole feeding events, this cost was similar for grazing and browsing. Chewing characteristics differed from those of larger (eutherian) herbivores in that the numbers of chews in a run were not randomly distributed, both species having a preponderance of runs with seven chews. Whilst, the intervals between the second and subsequent chewing sounds in a run did not vary in a periodic manner, such as would occur in batch processing of food, they were more prolonged in runs with more chewing sounds and were significantly longer in tammar wallabies than in parma wallabies. Thus, the slower rate of oral processing of grass was likely due to a generally slower rate of chewing when grazing than when browsing.

Lipid hydroperoxide stimulates retinal neovascularization in rabbit retina through expression of tumor necrosis factor-alpha, vascular endothelial growth factor and platelet-derived growth factor

To test the hypothesis that oxidative damage associated with tissue hypoxia plays a role in neovascularization, a lipid hydroperoxide (LHP) was injected into the vitreous of rabbits. Single injections of LHP (50-600 microg) caused a sustained retinal neovascularization visualized clinically by ophthalmoscopy and confirmed by microscopy. Vasodilators, i.e. histamine and nitric oxide, peaked at 6h and 7 days, respectively. The levels of both tumor necrosis factor-alpha and interleukin-1alpha peaked at 12h and dropped to basal levels by 24h. Expression of vascular endothelial growth factor (VEGF) and transforming growth factor-beta peaked at 24h and were sustained throughout the following 3 weeks, and platelet-derived growth factor was also elevated throughout the same period. Upregulation of these five angiogenic cytokines, but not basic fibroblast growth factor, occurred prior to the appearance of neovascularization. Leakage of fluorescein at the tips of new vessels was demonstrated by fluorescein angiography. Linoleic hydroperoxide induced neovascularization, but saturated or unsaturated native C-18 fatty acids had no effect. The cascade of multiple, angiogenic cytokines induced by LHP may interact to promote sustained neovascularization.

Minimal and best linear combination of oxidative stress and antioxidant biomarkers to discriminate cardiovascular disease

BACKGROUND AND AIM

Free radicals have been implicated in the atherosclerotic process of coronary heart disease (CHD). Well-developed laboratory methods may make available a large number of biomarkers of individual oxidative stress and antioxidant status. Such markers are able to quantify different phases of the oxidative stress and antioxidant status of an individual. However, limited knowledge is available on how to combine these biomarkers to best discriminate between individuals with and without CHD.

METHODS AND RESULTS

We evaluated combined discrimination properties of six biomarkers of oxidative stress and antioxidant status, as indicators of CHD, in a cross-sectional random sample of 968 white men and women from Buffalo, New York. Individuals with CHD had significantly higher levels of thiobarbuturic acid reacting substances (TBARS) and uric acid, and significantly lower levels of high-density lipoproteins (HDL) after adjusting for age and gender, when compared to healthy subjects. There were no significant differences in erythrocyte glutathione (GSH), trolox equivalent antioxidant capacity (TEAC), and glutathione peroxidase (GSHPx) levels. TBARS were found to be the best discriminating of the biomarkers when it was individually evaluated. TBARS discriminate 76.2% (95% C.I. 0.66-0.82) of the CHD cases from healthy controls. When combining TBARS, GSH, TEAC, HDL, uric acid and GSHPx, they discriminate 81.5% (95% C.I.: 0.67-0.90) of the area under the curve.

CONCLUSIONS

These preliminary findings suggest that the combination of multiple markers of oxidative stress does not greatly improve ability to differentiate between individuals with and without CHD compared to the use of TBARS alone.

Correlates of markers of oxidative status in the general population

Oxidative stress has been implicated in the etiology of many chronic diseases, including cardiovascular disease. However, limited information exists on the factors that may influence oxidative status in the general population. In a random sample of the population of two counties in western New York, levels of several markers of oxidative status (i.e., thiobarbituric acid-reactive substances, erythrocyte glutathione, and glutathione peroxidase) were determined. A total of 894 men and 903 women aged 35-79 years were included in the study (1996-1999). In addition, a number of sociodemographic and lifestyle characteristics and cardiovascular disease risk factors were measured. Age, markers of glucose metabolism (e.g., plasma glucose level) and insulin resistance (e.g., serum triglycerides, high density lipoprotein cholesterol, body mass index), and postmenopausal status in women were associated with increased oxidative stress and reduced antioxidant potentials. Oxidative status and antioxidant potentials appear to be significantly associated with a number of major cardiovascular disease risk factors; most of them are linked to abnormalities in glucose and insulin metabolism.

TBARS and cardiovascular disease in a population-based sample

BACKGROUND

Oxygen radicals might play a crucial role in the pathogenesis of various diseases, including atherosclerosis. Thiobarbituric acid reaction substances (TBARS), a biomarker of oxidative stress, have been proposed as a summary measure of total circulating oxidation. However, there is no strong indication that circulating levels of TBARS are increased in patients with atherosclerosis.

DESIGN

We evaluated the relation between TBARS and cardiovascular disease (CVD) in a cross-sectional random sample of white men and women from Buffalo, New York.

METHODS

Logistic regression was used to estimate the risk associated with high levels of TBARS. The area under the ROC curve was used to evaluate the discriminating power of TBARS.

RESULTS

After adjusting for age and gender, TBARS levels were significantly higher in those with prevalent CVD (OR= 1.73, 95% CI=1.32-2.38), compared to those without a CVD diagnosis. These OR were almost 50% higher after correcting for measurement error (ME) (OR=1.93, 95% CI=1.07-3.40). The area under the ROC curve was 0.69 (95% CI=0.62-0.77) and when corrected for ME reached 0.80 (95% CI=0.65-0.89).

CONCLUSIONS

Our results indicate that elevated levels of TBARS were associated with increase risk of the prevalence of CVD, but this effect was no longer significant after adjusting for glucose.

The suppressive effect of dietary restriction and weight loss in the obese on the generation of reactive oxygen species by leukocytes, lipid peroxidation, and protein carbonylation

Increased reactive oxygen species generation by the leukocytes of the obese may be responsible for increased oxidative injury to lipids and proteins and, hence, atherosclerosis. We have investigated whether reactive oxygen species generation by leukocytes and other indexes of oxidative damage in the body fall with short-term dietary restriction and weight loss. Nine nondiabetic obese subjects (body mass index, 32.5-64.4 kg/m(2)), not taking any antioxidants, were put on a 1000-Cal diet. Fasting blood samples were taken at 0, 1, 2, 3, and 4 weeks and at 12 weeks after the cessation of dietary restriction. Blood samples were also obtained at 1 and 2 h after administration of 75 g oral glucose at 0 and 4 weeks. Mononuclear cells (MNC) and polymorphonuclear leukocytes (PMN) were isolated, and reactive oxygen species generation was measured. Plasma concentrations of thiobarbituric acid-reactive species (TBARS), 13-hydroxyoctadecadienoic acid (13-HODE), 9-hydroxyoctadecadienoic acid (9-HODE), carbonylated proteins, o-tyrosine, and m-tyrosine as indexes of oxidative damage to lipids, proteins and amino acids, respectively, were measured. Antioxidant vitamins were measured as indexes of antioxidant reserves. Plasma tumor necrosis factor-alpha concentrations were also measured. Mean weight loss was 2.4 +/- 0.6 kg at week 1, 2.5 +/- 1.7 kg at week 2, 3.9 +/- 0.8 kg at week 3, and 4.5 +/- 2.8 kg at week 4 (P < 0.05). Reactive oxygen species generation by PMN fell from 236.4 +/- 95.8 to 150.9 +/- 69.0, 125.9 +/- 24.3, 96.0 +/- 39.9, and 103.1 +/- 35.7 mV at weeks 1, 2, 3, and 4, respectively (P < 0.001). It increased 3 months after the cessation of dietary restriction to 270.0 +/- 274.3 mV. Reactive oxygen species generation by MNC fell from 187.8 +/- 75.0 to 101.7 +/- 64.5, 86.9 +/- 42.8, 63.8 +/- 14.3, and 75.1 +/- 32.2 mV and increased thereafter to 302.0 +/- 175.5 mV at 1, 2, 3, 4, and 16 weeks, respectively (P < 0.005). Reactive oxygen species generation by PMN and MNC increased in response to glucose; the relative increase was greater at 4 weeks than that at week 0 due to a fall in the basal levels of reactive oxygen species generation. Consistent with the fall in reactive oxygen species generation, there was a reduction in plasma TBARS from 1.68 +/- 0.17 micromol/L at week 0 to 1.47 micromol/L at 4 weeks (P < 0.05). The 13-HODE to linoleic acid ratio fell from a baseline of 100% to 56.4 +/- 36.1% at 4 weeks (P < 0.05), and the 9-HODE to linoleic acid ratio fell from a baseline of 100% to 60.5 +/- 37.7% at 4 weeks (P < 0.05). Carbonylated proteins fell from 1.39 +/- 0.27 microgram/mg protein at week 0 to 1.17 +/- 0.12 microgram/mg protein at week 4 (P < 0.05); o-tyrosine fell from 0.42 +/- 0.03 mmol/mol phenylalanine at week 0 to 0.36 +/- 0.02 mmol/mol phenylalanine at 4 weeks (P < 0.005), and m-tyrosine fell from 0.45 +/- 0.04 mmol/mol phenylalanine at week 0 to 0.40 +/- 0.03 mmol/mol phenylalanine at 4 weeks (P < 0.05). The basal concentrations of TBARS, 9-HODE, 13-HODE, carbonylated proteins, o-tyrosine, and m-tyrosine in the obese were significantly greater than those in normal subjects. On the other hand, tumor necrosis factor-alpha concentrations did not change during this 4-week period, nor was there any change in antioxidant vitamins. This is the first demonstration of 1) an increase in reactive oxygen species-induced damage in lipids, proteins, and amino acids in the obese compared with normal subjects; and 2) a decrease in reactive oxygen species generation by leukocytes and oxidative damage to lipids, proteins, and amino acids after dietary restriction and weight loss in the obese over a short period.

Labour and delivery complications and schizophrenia. Case-control study using contemporaneous labour ward records

BACKGROUND

Controversy continues regarding an association between obstetric complications and risk of schizophrenia in early adult life.

AIMS

To compare the rate of labour and delivery complications among persons who developed schizophrenia with controls; to establish whether any complication is associated with later schizophrenia.

METHOD

We located the labour ward records of 431 individuals with schizophrenia and of same-gender controls from the same hospital birth series. Mothers were matched by age, socio-economic group and parity. Individual complications were evaluated blindly using two obstetric complication scales.

RESULTS

Overall, the rate of labour and delivery complications for those who developed schizophrenia did not differ from that of controls. Males who had presented to psychiatric services before the age of 30 had a greater frequency of and more severe labour/delivery complications than their matched controls.

CONCLUSIONS

Other than among young-onset males we found no increase in labour and delivery complications among cases.

Effect of triiodothyronine on reactive oxygen species generation by leukocytes, indices of oxidative damage, and antioxidant reserve

We have examined the effect of short-term triiodothyronine (T3) administration on reactive oxygen species (ROS) generation by leukocytes in 9 euthyroid subjects. At a dose of 60 microg/d orally for 7 days, T3 induced a significant increase in ROS generation by mononuclear cells (MNCs) from 183 +/- 102 mV at baseline to 313 +/- 111 mV on the seventh day (P < .02), and by polymorphonuclear leukocytes (PMNLs) from 195 +/- 94 mV at baseline to 302 +/- 104 mV on the seventh day (P < .02). There was also a significant increase in meta-tyrosine (P < .001) and ortho-tyrosine (P < .001), known indices of oxidative damage to proteins and amino acids. However, there was no increase in plasma thiobarbituric acid-reactive substances (TBARS), an index of oxidative damage to lipids, and in the level of carbonylated proteins, a less sensitive index to assess protein oxidation. There was no decrease in the level of antioxidants such as alpha-tocopherol, vitamin A, beta-carotene, lycopene, and lutein/zeaxanthin. The stimulatory effect on ROS generation may reflect a generalized increase in metabolic activity or may be a specific effect on NADPH oxidase in leukocyte membranes. The absence of a significant change in TBARS, carbonylated proteins, alpha-tocopherol, vitamin A, beta-carotene, lycopene, and lutein/zeaxanthin may reflect the short duration of the increased ROS load.

Labour and delivery complications at birth and later mania. An Irish case register study

BACKGROUND

Several reports postulate that manic depression and schizophrenia share environmental risk factors. Although obstetric adversity has been suggested as a risk factor for schizophrenia, few studies have examined its relationship to bipolar affective disorder.

AIMS

To assess the rate of obstetric complications incurred by patients with mania compared with controls.

METHOD

From the Dublin Psychiatric Case Register we identified individuals with a discharge diagnosis of mania and traced their birth records. Each case was matched with a control of the same gender, born in the same hospital, in the same year, matched for maternal age, parity and social class. Two obstetric complications scales were used to make blind evaluations of labour and delivery data.

RESULTS

Patients with mania did not experience a greater frequency or severity of labour and delivery complications than their matched controls. Rates of obstetric adversity were unrelated to the presence or absence of family history of psychiatric disorder. Obstetric adversity was unrelated to the age at first diagnosis.

CONCLUSIONS

These findings suggest that obstetric adversity is not a risk factor for later mania.