Maternal anaemia and folate intake in early pregnancy.

Background: The World Health Organization recommends that women take 400 µg of folate supplementation daily throughout pregnancy. We examined the relationship between total folate intake from the diet and supplements at the first prenatal visit and haematological indices at this visit and subsequently. Methods: Women were recruited at their convenience and in addition to clinical and sociodemographic details, detailed questionnaires on dietary intakes and supplementation consumption were completed under supervision. A full blood count and serum and red blood cell (RBC) folate levels were taken. Results: Of the 502 women studied, 97.5% had inadequate total dietary folate intake at the first visit, but, 98.2% were taking folic acid (FA) supplementation. Only 1.8% (n = 9) had anaemia at their first visit (with no case of macrocytosis). Subsequently, 212 women had a further Hb sample in the third trimester and 8.5% (n = 18) were anaemic and 43.4% (89/205) were anaemic postnatally. There was a relationship between the development of anaemia postnatally and lower RBC folate levels at the first visit (P = 0.02). Conclusions: In a country where FA food fortification remains voluntary, these findings support the recommendation that women should start FA supplementation before pregnancy and continue FA after the first trimester.

Greater yogurt consumption is associated with increased bone mineral density and physical function in older adults.

In this cohort of community dwelling older adults (>60 years), we observed significant positive associations between the frequencies of yogurt intake with measures of bone density, bone biomarkers, and indicators of physical function. Improving yogurt intakes could be a valuable health strategy for maintaining bone health in older adults. INTRODUCTION: The associations of yogurt intakes with bone health and frailty in older adults are not well documented. The aim was to investigate the association of yogurt intakes with bone mineral density (BMD), bone biomarkers, and physical function in 4310 Irish adults from the Trinity, Ulster, Department of Agriculture aging cohort study (TUDA). METHODS: Bone measures included total hip, femoral neck, and vertebral BMD with bone biochemical markers. Physical function measures included Timed Up and Go (TUG), Instrumental Activities of Daily Living Scale, and Physical Self-Maintenance Scale. RESULTS: Total hip and femoral neck BMD in females were 3.1-3.9% higher among those with the highest yogurt intakes (n = 970) compared to the lowest (n = 1109; P < 0.05) as were the TUG scores (-6.7%; P = 0.013). In males, tartrate-resistant acid phosphatase (TRAP 5b) concentrations were significantly lower in those with the highest yogurt intakes (-9.5%; P < 0.0001). In females, yogurt intake was a significant positive predictor of BMD at all regions. Each unit increase in yogurt intake in females was associated with a 31% lower risk of osteopenia (OR 0.69; 95% CI 0.49-0.96; P = 0.032) and a 39% lower risk of osteoporosis (OR 0.61; 95% CI 0.42-0.89; P = 0.012) and in males, a 52% lower risk of osteoporosis (OR 0.48; 95% CI 0.24-0.96; P = 0.038). CONCLUSION: In this cohort, higher yogurt intake was associated with increased BMD and physical function scores. These results suggest that improving yogurt intakes could be a valuable public health strategy for maintaining bone health in older adults.

Epidemiological, clinical and genetic aspects of adult onset isolated focal dystonia in Ireland.

BACKGROUND: Adult onset idiopathic isolated focal dystonia presents with a number of phenotypes. Reported prevalence rates vary considerably; well-characterized cohorts are important to our understanding of this disorder. AIM: To perform a nationwide epidemiological study of adult onset idiopathic isolated focal dystonia in the Republic of Ireland. METHODS: Patients with adult onset idiopathic isolated focal dystonia were recruited from multiple sources. Diagnosis was based on assessment by a neurologist with an expertise in movement disorders. When consent was obtained, a number of clinical features including family history were assessed. RESULTS: On the prevalence date there were 592 individuals in Ireland with adult onset idiopathic isolated focal dystonia, a point prevalence of 17.8 per 100 000 (95% confidence interval 16.4-19.2). Phenotype numbers were cervical dystonia 410 (69.2%), blepharospasm 102 (17.2%), focal hand dystonia 39 (6.6%), spasmodic dysphonia 18 (3.0%), musician's dystonia 17 (2.9%) and oromandibular dystonia six (1.0%). Sixty-two (16.5%) of 375 consenting index cases had a relative with clinically confirmed adult onset idiopathic isolated focal dystonia (18 multiplex and 24 duplex families). Marked variations in the proportions of patients with tremor, segmental spread, sensory tricks, pain and psychiatric symptoms by phenotype were documented. CONCLUSIONS: The prevalence of adult onset idiopathic isolated focal dystonia in Ireland is higher than that recorded in many similar service-based epidemiological studies but is still likely to be an underestimate. The low proportion of individuals with blepharospasm may reflect reduced environmental exposure to sunlight in Ireland. This study will serve as a resource for international comparative studies of environmental and genetic factors in the pathogenesis of the disorder.

Routine monitoring and assessment of adults living with HIV: results of the British HIV Association (BHIVA) national audit 2015.

BACKGROUND: The clinical care of people living with HIV changed fundamentally as a result of the development of effective antiretroviral therapy (ART). HIV infection is now a long-term treatable condition. We report a national audit to assess adherence to British HIV Association guidelines for the routine investigation and monitoring of adult HIV-1-infected individuals. METHODS: All UK sites known as providers of adult HIV outpatient services were invited to complete a case-note review and a brief survey of local clinic practices. Participating sites were asked to randomly select 50-100 adults, who attended for specialist HIV care during 2014 and/or 2015. Each site collected data electronically using a self-audit spreadsheet tool. This included demographic details (gender, ethnicity, HIV exposure, and age) and whether 22 standardised and pre-defined clinical audited outcomes had been recorded. RESULTS: Data were collected on 8258 adults from 123 sites, representing approximately 10% of people living with HIV reported in public health surveillance as attending UK HIV services. Sexual health screening was provided within 96.4% of HIV services, cervical cytology and influenza vaccination within 71.4% of HIV services. There was wide variation in resistance testing across sites. Only 44.9% of patients on ART had a documented 10-year CVD risk within the past three years and fracture risk had been assessed within the past three years for only 16.7% patients aged over 50 years. CONCLUSIONS: There was high participation in the national audit and good practice was identified in some areas. However improvements can be made in monitoring of cardiovascular risk, bone and sexual health.

Flexor digitorum accessorius causing tarsal tunnel syndrome in a paediatric patient: A case report and review of the literature.

The flexor digitorium accessorius muscle is an unusual anatomical variant found in the posteromedial aspect of the hindfoot and ankle. As previously described, its location predisposes patients to developing tarsal tunnel syndrome. This case illustrates the diagnosis, treatment and resolution of tarsal tunnel syndrome in a paediatric patient, secondary to the presence of flexor digitorium accessorius muscle.

Lateral ankle and hindfoot instability: a new clinical based classification.

Ankle sprains are one of the most common soft tissue injuries accounting for nearly 40% of sports injuries. There are large number of procedures for its treatment reported in the literature with largely good results. The ankle forms a functional unit with the subtalar joint. We present a new classification for peritalar lateral instability. There are two intents of this classification. Firstly, the classification demonstrates an assessment and treatment guideline for the many causes of peritalar lateral instability. The second use of the classification is for research purposes so that cohorts of patients can be accurately described and the efficacy of different operations in different groups can be properly assessed.

Loneliness and vascular biomarkers: the Dublin Healthy Ageing Study.

BACKGROUND: Loneliness has been associated with poor physical health and a link has been suggested between the presence of loneliness, cardiovascular health and inflammatory markers. OBJECTIVE: To investigate the association between vascular disease biomarkers and loneliness in a community-dwelling non-demented elderly population. DESIGN: cross-sectional community based assessment. PARTICIPANTS: 466 subjects with mean age 75.45 (SD, 6.06) years. 208 (44.6%) were male. RESULTS: Higher levels of HbA1c, but not other vascular biomarkers were independently associated with being lonely. CONCLUSION: Loneliness was associated with raised levels of HbA1c in a community dwelling elderly population. The mechanism for this association has yet to be elucidated but may reflect an abnormal stress response in people who are lonely.

A patient with a rare leukodystrophy related to lamin B1 duplication.

The hereditary leukodystrophies are rare disorders caused by molecular abnormalities leading to destruction of or failure of development of central white matter. For almost 30 years there has been increasing recognition of later onset Autosomal Dominant Leukodystrophy (ADLD). We report the first genetically confirmed case of lamin B1 duplication causing ADLD from Ireland.

Extra-abdominal desmoid tumours: a review of the literature.

Extra-abdominal desmoid lesions, otherwise known as aggressive fibromatosis, are slow-growing benign lesions which may be encountered in clinical practice. Recent controversies exist regarding their optimal treatment. Given their benign nature, is major debulking surgery justified, or is it worth administering chemotherapy for a disease process which unusually defies common teaching and responds to such medications? We present a literature review of this particular pathology discussing the aetiology, clinical presentation, and various current controversies in the treatment options.

Associations between holotranscobalamin, vitamin B12, homocysteine and depressive symptoms in community-dwelling elders.

BACKGROUND: Vitamin B12 and homocysteine have been shown to be associated with depression or depressive symptoms, but the relationship has not been universal. Both vitamin B12 and homocysteine may exert an effect via vascular mechanisms; it is possible that other mechanisms apply. Holotranscobalamin is a novel, more accurate measure of tissue vitamin B12. OBJECTIVES: To examine associations between vitamin B12, serum folate, holotranscobalamin, homocysteine and depressive symptoms in a sample of healthy elderly. METHODS: Cross-sectional, observational community based study. RESULTS: Lower levels of holotranscobalamin and vitamin B12 were associated with higher levels of depressive symptoms when controlled for Mini-mental state examination scores and psychosocial and cardiovascular risk factors. Homocysteine was not associated with depressive symptoms when biological and psychosocial covariates were included. CONCLUSIONS: It is possible that low levels of vitamin B12 or holotranscobalamin are associated with depressive symptoms via mechanisms other than vascular pathology.

Transcobalamin II receptor polymorphisms are associated with increased risk for neural tube defects.

OBJECTIVE: Women who have low cobalamin (vitamin B(12)) levels are at increased risk for having children with neural tube defects (NTDs). The transcobalamin II receptor (TCblR) mediates uptake of cobalamin into cells. Inherited variants in the TCblR gene as NTD risk factors were evaluated. METHODS: Case-control and family-based tests of association were used to screen common variation in TCblR as genetic risk factors for NTDs in a large Irish group. A confirmatory group of NTD triads was used to test positive findings. RESULTS: 2 tightly linked variants associated with NTDs in a recessive model were found: TCblR rs2336573 (G220R; p(corr)=0.0080, corrected for multiple hypothesis testing) and TCblR rs9426 (p(corr)=0.0279). These variants were also associated with NTDs in a family-based test before multiple test correction (log-linear analysis of a recessive model: rs2336573 (G220R; RR=6.59, p=0.0037) and rs9426 (RR=6.71, p=0.0035)). A copy number variant distal to TCblR and two previously unreported exonic insertion-deletion polymorphisms were described. CONCLUSIONS: TCblR rs2336573 (G220R) and TCblR rs9426 represent a significant risk factor in NTD cases in the Irish population. The homozygous risk genotype was not detected in nearly 1000 controls, indicating that this NTD risk factor may be of low frequency and high penetrance. 9 other variants are in perfect linkage disequilibrium with the associated single nucleotide polymorphisms. Additional work is required to identify the disease-causing variant. Our data suggest that variation in TCblR plays a role in NTD risk and that these variants may modulate cobalamin metabolism.

Apoptosis, but not necrosis, of infected monocytes is coupled with killing of intracellular bacillus Calmette-Guérin.

We have examined the effect of killing of host monocytes infected with bacillus Calmette-Guérin (BCG) on the viability of the intracellular mycobacteria. Peripheral blood monocytes were infected in vitro with a single bacillus per cell and maintained in culture for 6-8 d to allow the bacilli to replicate. Replicating viable BCG were found singly in perinuclear vacuoles bounded by tightly apposed lipid bilayers. Monocytes were then exposed to toxic mediators that induced killing of cells as evaluated by 51Cr release into the culture medium. Both hydrogen peroxide (H2O2) (an inducer of cell necrosis) and adenosine triphosphate (ATP4-) (an inducer of cell apoptosis) treatment killed infected monocytes. H2O2-induced killing had no effect on BCG viability. ATP-induced cell death was accompanied by DNA fragmentation and nuclear condensation. Apoptosis was associated with a swelling of the phagocytic vacuoles which became multibacillary and with a reduction of BCG viability as enumerated by colony-forming units.

Recognition and destruction of Bacillus Calmette-Guerin-infected human monocytes.

We have established a long-term culture system to study macrophages chronically infected with mycobacteria. Monocytes are infected with Bacillus Calmette-Guerin (BCG) and support exponential intracellular replication without profound perturbation of normal host cell function. We have used this system to investigate lymphokine-activated killer (LAK)-mediated cytolysis. We have found that interleukin 2 stimulation of peripheral blood lymphocytes generates a cytotoxic activity against human monocytes. A CD56- subpopulation of LAK cells specifically recognizes and lyses BCG-infected cells. Lysis of the host cell has no effect on parasite viability and results in the liberation of bacteria capable of infecting more cells.

The systemic influence of recombinant interleukin 2 on the manifestations of lepromatous leprosy.

14 patients with lepromatous leprosy received twice daily injections of 10 micrograms recombinant interleukin 2 (rIL-2), by the intradermal route, in the skin of the back for 8 d (total dose, 160 micrograms). Lymphokine administration was accomplished without drug toxicity, or the development of acute nerve damage. The majority of patients developed nontender axillary lymphadenopathy during the course of treatment. Local injection sites showed progressively larger zones of induration, peaking at 24 h and persisting for many days. Early 12-h reactions were of a macular, erythematous nature and exhibited an increasingly striking diurnal variation. The morning injection sites were three- to fourfold larger in diameter than those placed in the evening (9 am to 9 pm). Systemic manifestations of intradermal rIL-2 administration were noted. Peripheral blood T cells, including CD4+ and CD8+ phenotypes, increased 2-2.5-fold and NK cells increased sixfold. Elevations in [3H]TdR incorporation into peripheral blood mononuclear cells occurred to a variety of mycobacterial antigens, but not to those of Mycobacterium leprae. Within 2 wk, biopsies at sites far removed from the back showed increased infiltration of mononuclear cells in 12 of 14 patients. Immunocytochemistry revealed the presence of newly emigrated CD4+ T cells, monocytes, and dermal CD1+ Langerhans cells. Endothelial cells of small dermal vessels expressed major histocompatibility complex class II determinants on their surface. Transmission electron microscopy of these specimens revealed markedly enlarged endothelial cells with many surface projections extending into the lumen as well as extravasating lymphoid cells. The numbers of acid-fast M. leprae in the peripheral sites were examined by slit smear and in biopsies of matched leprosy lesions taken before and after IL-2 administration. Within 2 mo, slit smears showed a 0.5 log or greater reduction in 12 of 14 patients, with a mean for all patients tested of 0.5 log units. Biopsy specimens showed a 1 log unit or greater reduction in the bacterial index (B.I.) in 6 of 14 patients. Historical controls in this Nepalese population showed a 0.5 log unit reduction after multidrug therapy over a period of 12 mo. Thus, after 8 d of IL-2 injections, a fivefold reduction in B.I. was observed during the first 2 mo of the study. Antibody levels against M. leprae phenolic glycolipid 1 (PGL-1) and lipoarabinomanan B were markedly elevated after IL-2 injections, while PGL-1 antigen levels were reduced. We conclude that the administration of rIL-2 has had a significant effect in decreasing the total body burden of M. leprae.(ABSTRACT TRUNCATED AT 400 WORDS)

Listening styles of undergraduate health students.

BACKGROUND: Concerns about poor communication in the medical and other healthcare professions are common in the empirical literature, with studies showing direct relationships between practitioners' effective listening and patients' satisfaction and less risk of litigation. Furthermore, people do not simply listen or not listen, rather they adopt particular listening styles, making the understanding and investigation of practitioner communication a complex topic. The objective of this study was to identify the listening styles of undergraduate health science students enrolled at one Australian university. METHODS: A cross-sectional study using a paper-based version of the Listening Styles Profile (LSP-16) was administered to a cohort of students enrolled in undergraduate education programs in eight different health disciplines: emergency health (paramedics), nursing, midwifery, occupational therapy, physiotherapy, nursing/emergency health dual degree, health science and nutrition and dietetics. The LSP-16 is a validated and reliable scale that assesses participants' preferences for each of four distinct listening style constructs. There were 1459 health students eligible for inclusion in the study. Ethics approval was granted. RESULTS: A total of 860 students participated in the study (response rate of 58%), of whom 87.2% (n=750) were female. Across the group, a strong preference was shown for the People Listening Style (LS), which is a listening style characterised by a concern for people's feelings and emotions. Otherwise, an unexpected amount of homogeneity in preferred listening style was found within the group of health science students. Female students reported a slightly stronger preference for the People LS, whereas males reported slightly stronger preferences for the Action LS and Content LS. There were no statistical differences in preference for LS by students' age or year level of undergraduate enrolment. CONCLUSION: The health professional student participants of this study reported a preference for a range of listening styles, which is appropriate for many healthcare settings. However, a strong preference for the People LS and a moderate preference for the Content LS were evident. This study should be replicated with practicing professionals to establish if the demands of the workplace affect practitioners' listening style(s).

Neisseria meningitidis as a Cause of Septic Arthritis: An Unusual Case of Periprosthetic Joint Infection.

One of the most feared complications after arthroplasty is infection due to its significant impact on patient morbidity. Infection may transfer to the joint at the time of surgery or be seeded, haematologically, to the prosthetic joint from another infection source. In this case, a 72-year-old female presented with symptoms of septic arthritis seven years after her original arthroplasty surgery. At presentation, she denied trauma and any comorbidity which would predispose her to infection. Culturing of samples taken revealed the patient was infected with Neisseria meningitidis, and the patient underwent a DAIR procedure. She continued postoperative long-term antimicrobial therapy with resolution of her infection. Follow-up at one year showed complete resolution of the patient's illness with a return to premorbid baseline. To our knowledge, this is the third reported case of septic arthritis caused by Neisseria meningitidis in a prosthetic joint in the literature.

A pernicious leucoencephalopathy.

Pernicious anaemia may manifest various neurological symptoms and signs ranging from the subtle to the dramatic. We describe a young man with cobalamin deficiency presenting with sensorimotor deficits, ataxia, dysarthria, mild cognitive deterioration and altered mood of insidious onset. The MRI brain findings were in keeping with a leucoencephalopathy without evidence of MRI changes in the spinal cord. This constellation of features has been reported rarely. His response to treatment as well as the marked improvement of the leucoencephalopathy on imaging suggests at least partial reversibility of the neurological deficits.

Fixation of ankle fractures - a major trauma centre's experience in improving quality.

BACKGROUND: Ankle fracture malreduction has been shown to result in poor long-term functional outcomes. Varying methods can be used to change practice and thereby outcomes. We present over four years' worth of results with the effects of different techniques for change. METHODS: Two audit cycles were performed incorporating three audit data collections; an initial standard setting audit in 2013, with re-audits in 2015 and 2017. Between the first and second audit was a period of education and reflection. Between the second and third audit there was a change in process in ankle fracture management supported by education. Image intensifier films were reviewed on the hospital picture archiving and communication system, by at least two blinded observers in each cycle. These were scored based on the criteria published by Pettrone et al. RESULTS: In the initial audit in 2013, there were 94 patients, with a malreduction rate of 33%. In the second audit in 2015, there were 68 patients, with an increase in malreduction rate to 43.8%. In the third audit in 2017, there were 205 patients, with a significant decrease in malreduction rate to 2.4%. The final major complication rate was 0.98%. The rate of deep infection was 0.5%. CONCLUSIONS: By recognising and addressing the need to improve the quality of ankle fracture fixation, we have made significant improvements in radiological outcomes. Education alone, without system change, was not successful in our department in achieving improved outcomes.

A practical 'safe zone' technique for lag screw fixation of the fibula.

Introduction During ankle fracture fixation, iatrogenic trauma to retro fibula structures can result in morbidity and reoperation. We describe a safe zone for lag screw insertion. Materials and methods This study was completed in three sections. We identified the average entry and exit points for the lag screw using 45 Weber B ankle fractures identified from our trauma database. We then analysed 26 sequentially presented ankle magnetic resonance images, concentrating on axial sections at 4, 8, 12 and 16 mm above the ankle joint. Finally, we used 63 sequentially performed magnetic resonance scans to confirm the safe zone from these consistent structures. Results The typical lag screw exit point was 14.2 mm above the ankle joint (95% confidence Interval 11.3-17.1 mm). A safe zone trajectory occurred between 31 and 45 degrees taken from the anterior aspect of the flat fibular surface at this level. The obvious palpable landmark to direct screw trajectory and avoid 'at risk' structures was found to be the medial edge of the Achilles tendon. Our final dataset confirmed in 63 scans, the medial aspect of the Achilles tendon to be a consistent safe zone with a minimum distance of at risk structures of 4 mm. Conclusion This simple method of directing the fibula lag screw towards the palpable medial edge of the Achilles tendon is practical, easy to teach and directs the screw on a safe trajectory away from the most commonly injured structures around the back of the fibula.

Symptomatic nonunion after fracture of the calcaneum. Demographics and treatment.

We have treated 14 patients (15 fractures) with nonunion of an intra-articular fracture of the body of the calcaneum. The mean follow-up was six years (2 to 8.5). A total of 14 fractures (93%) had initially been treated operatively with 12 (86%) having non-anatomical reductions. Four feet (27%) had concomitant osteomyelitis. Of the nonunions, 14 (93%) went on to eventual union after an average of two reconstructive procedures. All underwent bone grafting of the nonunion. The eventual outcome was a subtalar arthrodesis in ten (67%) cases, a triple arthrodesis in four (27%) and a nonunion in one (6%). Three patients had a wound dehiscence; all required a local rotation flap. The mean American Orthopaedic Foot and Ankle Society score at latest follow-up was 69, and the mean Visual analogue scale was 3. Of those who were initially employed, 82% (9 of 11) eventually returned to work. We present an algorithm for the treatment of calcaneal nonunion, and conclude that despite a relatively high rate of complication, this complex surgery has a high union rate and a good functional outcome.