Postpartum depression and child growth in Tanzania: a cohort study.

OBJECTIVE: To examine the association between postpartum depression and child growth in a Tanzanian birth cohort. DESIGN: Prospective cohort study. SETTING: Moshi, Tanzania. POPULATION: Pregnant women over the age of 18 who sought antenatal care at two health clinics in Moshi, and the children they were pregnant with, were assessed for inclusion in this study. METHODS: The women were interviewed twice during pregnancy and three times after birth, the final follow up taking place 2-3 years postpartum. Signs of postpartum depression were assessed approximately 40 days postpartum with the Edinburgh Postnatal Depression Scale. MAIN OUTCOME MEASURES: Child growth was assessed with anthropometric measurements at 2-3 years of age and expressed as mean z-scores. RESULTS: In all, 1128 mother-child pairs were followed throughout the duration of the study. In total, 12.2% of the mothers showed signs of postpartum depression. Adjusted mean height-for-age z-score (HAZ) was significantly lower at 2-3 years follow up for children of mothers with postpartum depression than for children of mothers without (difference in HAZ: -0.32, 95% CI-0.49 to -0.15). Adjusted mean weight-for-height z-score (WHZ) was significantly increased for the children exposed to postpartum depression (difference in WHZ: 0.21, 95% CI 0.02-0.40), whereas there was no significant difference in adjusted weight-for-age z-score (WAZ; difference in WAZ: -0.04, 95% CI -0.20 to 0.12). CONCLUSIONS: We found that postpartum depressive symptoms predicted decreased linear height in children at 2-3 years of age and slightly increased weight-for-height. TWEETABLE ABSTRACT: Postpartum depression in Tanzanian mothers is associated with impaired child growth at 2-3 years of age.

Intraoperative hyperventilation vs remifentanil during electrocorticography for epilepsy surgery - a case report.

BACKGROUND: Traditionally, intraoperative intracranial electroen-cephalography-recordings are limited to the detection of the irritative zone defined by interictal spikes. However, seizure patterns revealing the seizure onset zone are thought to give better localizing information, but are impractical due to the waiting time for spontaneous seizures. Therefore, provocation by seizure precipitants may be used with the precaution that spontaneous and provoked seizures may not be identical. OBJECTIVE: We present evidence that hyperventilation induced and drug induced focal seizures may arise from different brain regions in the same patient. METHODS: Hyperventilation and ultra short acting opioid remifentanil were used separately as intraoperative precipitatants of seizure patterns, while recording from subdural and intraventricular electrodes in a patient with temporal lobe epilepsy. Two different ictal onset zones appeared in response to hyperventilation and remifentanil. Both zones were resected and the patient has remained essentially seizure free for 1 year. Furthermore, this is the first description of hyperventilation used as an intraoperative seizure precipitant in human focal epilepsy.

Quality assurance ofallergen-specific immunotherapy during a national outbreak of anaphylaxis: results of a continuous sentinel event surveillance system.

BACKGROUND AND OBJECTIVE: Subcutaneous allergen-specific immunotherapy (SCIT) is an effective treatment for patients with allergic asthma and rhinitis. SCIT may be performed in many different ways and good safety profiles have been published. Other studies, however, have reported high frequencies of severe adverse events (SAEs) but without identifying the causes. After an increase in SCIT-related SAEs in Denmark between 2003 and 2004, strict performance regulations were imposed by the authorities. Because safety data from national databases were not available, we implemented a surveillance system aimed at identifying the causes of SAEs. METHODS: We prospectively registered the number of injections and SAEs during SCIT. A slow up-dosing regimen was used and adherence to international standards was optimized. RESULTS: No SAEs were observed with 28 992 injections. The maximal risk per injection was calculated at < 1.3 per 10 000 injections. DISCUSSION: Our results confirm the good safety profile of SCIT. We applied a sentinel SCIT surveillance system that may offer a means of guaranteeing safety by providing online feedback to all participating clinics when SAEs occur in order to explore their causes by root course analyses performed by all participants. Furthermore, such quality assurance documentation may facilitate wider acceptance of SCIT by health care administrators, clinicians, and patients.

Mismatch 'never events' in hip and knee arthroplasty: a cohort and intervention study.

AIMS: The aim of this study was to give estimates of the incidence of component incompatibility in hip and knee arthroplasty and to test the effect of an online, real-time compatibility check. MATERIALS AND METHODS: Intraoperative barcode registration of arthroplasty implants was introduced in Denmark in 2013. We developed a compatibility database and, from May 2017, real-time compatibility checking was implemented and became part of the registration. We defined four classes of component incompatibility: A-I, A-II, B-I, and B-II, depending on an assessment of the level of risk to the patient (A/B), and on whether incompatibility was knowingly accepted (I/II). RESULTS: A total of 26 524 arthroplasties were analyzed. From 12 307 procedures that were undertaken before implementation of the compatibility check, 21 class A incompatibilities were identified (real- or high-risk combinations; 0.17%; 95% confidence interval (CI) 0.11 to 0.26). From 5692 hip and 6615 knee procedures prior to implementation of the compatibility check, we found rates of class A-I incompatibility (real- or high-risk combinations unknowingly inserted) of 0.14% (95% CI 0.06 to 0.28) and 0.17% (95% CI 0.08 to 0.30), respectively. From 14 217 procedures after the introduction of compatibility checking (7187 hips and 7030 knees), eight class A incompatibilities (0.06%; 95% CI 0.02 to 0.11) were identified. This difference was statistically significant (p = 0.008). CONCLUSION: Our data presents validated estimates of the baseline incidence of incompatibility events for hip and knee arthroplasty procedures and shows that a significant reduction in class A incompatibility events is possible using a web-based recording system. Cite this article: Bone Joint J 2019;101-B:960-969.

Remifentanil-induced spike activity as a diagnostic tool in epilepsy surgery.

OBJECTIVES: To assess the value of remifentanil in intraoperative evaluation of spike activity in patients undergoing surgery for mesial temporal lobe epilepsy (MTLE). MATERIALS AND METHODS: Twenty-five patients undergoing temporal lobectomy for medically intractable MTLE were enrolled in the study. Electrocorticography (ECoG) recordings were performed on the intraventricular hippocampus and from the anterior inferior temporal and lateral neocortex before and after a 300 microg intravenous bolus of remifentanil. Spike activity was quantified as spike-count per minute. RESULTS: A significant increase (P < 0.005) in spike activity was observed after administration of remifentanil in 23 of 25 patients (92%). Furthermore, two patients who did not have any spike activity on the baseline ECoG developed spikes after administration of remifentanil. CONCLUSIONS: The results suggest that remifentanil can enhance spike activity in the epileptogenic zone and reveal otherwise concealed epileptogenic tissue in patients with MTLE. Thus, remifentanil may prove to be an important diagnostic tool during surgical treatment for intractable focal epilepsy.

Reproducibility of challenge tests at different times.

Bronchial challenge for determination of bronchial reactivity is widely used in the diagnosis of asthma, the grading of severity, and evaluation of effect of treatment with new antiasthmatic drugs. Allergen challenge is also used for diagnosis of specific IgE-mediated asthma and evaluation of the effect of immunotherapy. A number of factors influence the result of the challenge test including the selection of patients, criteria for carrying out the challenge test, a number of technical factors concerning the challenge, the dosing schedule, pulmonary function tests carried out and analysis of the data. All these factors have to be taken into consideration before reproducible challenge tests can be performed. Detailed description of the equipment and procedures used and inclusion criteria for the patients should be included in all publications concerning challenge tests in order to be able to compare results from different laboratories. Each clinic or laboratory needs to perform reproducibility studies on bronchial challenge testing procedures and equipment used in their clinic.

Complexation graft copolymer networks: swelling properties, calcium binding and proteolytic enzyme inhibition.

Graft copolymer networks of poly(methacrylic acid-g-ethylene glycol) were prepared by free radical solution UV-polymerization of methacrylic acid (MAA) and poly(ethylene glycol) monomethacrylate. Dynamic swelling studies indicated that complexation/decomplexation processes occurred due to hydrogen bonding between the carboxylic groups of the poly(methacrylic acid) (PMAA) and the ether groups of poly(ethylene glycol) (PEG). The effects of copolymer composition, graft chain molecular weight, environmental pH and ion content on network structure and gel behavior were studied. The largest change in swelling ratio and mesh size of the gel structure was observed in gels containing the highest content of PEG and the longest molecular weight PEG grafts. Complexation was greatest in hydrogels containing the longest PEG grafts and equimolar amounts of MAA and PEG. The swelling was much less pronounced in the presence of calcium chloride compared to sodium chloride which could be attributed to the complexation of calcium of the carboxylic groups in the polymer. The copolymers showed significant but less binding of calcium compared to poly(acrylates) like Carbopol 934P and polycarbophil. The P(MAA-g-EG) copolymers inhibited trypsin but to a lesser extent than the known protease inhibitors Carbopol 934P and polycarbophil. Results suggest that P(MAA-g-EG) copolymers are good drug delivery carrier candidates due to their pH-sensitive and controllable swelling behavior. Additionally, they possess some protease inhibition effect along with their bioadhesive properties which make them promising carriers for peptides or proteins.

A rheological assessment of the nature of interactions between mucoadhesive polymers and a homogenised mucus gel.

The ability of mucoadhesive materials to produce a large increase in the resistance to deformation when incorporated into a mucus gel, relative to when the mucus gel and test materials are evaluated separately at the same concentration, has been reported in several previous studies. It has been proposed that this phenomenon, termed rheological synergism, can be used as a measure of the strength of the mucoadhesive interaction. This study investigated the interactions between four putative mucoadhesive polymers (Noveon, Pemulen TR-2, carageenan and sodium carboxymethylcellulose) and a homogenised mucus gel, using dynamic oscillatory rheology. It was shown that, with the exception of sodium carboxymethylcellulose, incorporating a mucoadhesive polymer into a mucus gel produces rheological behaviour indicative of a weakly cross-linked gel network, which suggested a structure containing physical chain entanglements and non-covalent (probably hydrogen) bonds. Optimum gel strengthening occurred in a weakly acidic environment, suggesting an optimum conformation and degree of ionisation of the polymer and mucus molecules. Subsequent work suggested that the macromolecular interactions between polymer and mucus are sensitive to temperature, with the dynamic moduli decreasing with increasing temperature, further indicating bonding of a non-covalent nature. This work provide further evidence that rheological methods can be used as a tool to evaluate the interactions between a mucoadhesive macromolecule and a mucus gel. It also adds to the perception that molecular interpenetration may be an important factor in mucoadhesion by strengthening the mucus in the mucoadhesive/mucosal interfacial layer.

Long-range correlations of serial FEV1 measurements in emphysematous patients and normal subjects.

In obstructive lung disease the annual change in lung function is usually estimated from serial measurements of forced expiratory volume in 1 s (FEV1). Frequent measurements in each patient may not improve this estimate because data are not statistically independent; i.e., the measurements are autocorrelated. The purpose of this study was to describe the correlation structure in time series of FEV1 measurements. Nineteen patients with severe alpha1-antitrypsin deficiency (phenotype PiZ) and moderate to severe emphysema and two subjects with normal lungs were followed for several years with daily self-administered spirometry. FEV1 measurements fulfilling standard criteria were detrended, and the autocorrelation profile and the power spectrum were calculated. On average the subjects were followed for >3 yr and performed >1,000 acceptable spirometries. The autocorrelation of FEV1 measurements in the emphysematous patients was approximately 0.35 for short intervals and decreased almost exponentially with a half time of 38 days. Between 3 and 4 mo, the autocorrelation function became negative. It reached a minimum of -0.1 at approximately 8 mo and then increased toward zero over the following 12 mo. The autocorrelation function in the two normal subjects showed a similar pattern, but with a faster decay toward zero. In the patients, the power spectrum had a peak at 1 cycle/wk and showed a 1/f pattern, where f is frequency, with a slope of -0.88 at lower frequencies. We conclude that serial spirometric measurements show long-range correlations. The practical implication is that FEV1 need not be measured more often than once every 3 mo in studies of the long-term trends in lung function.

Reproducibility of pressure-flow variables in patients with symptomatic benign prostatic hyperplasia.

OBJECTIVES: To study the reproducibility of pressure-flow studies in patients with symptomatic benign prostatic hyperplasia and to investigate if the reproducibility is influenced by the method of intravesical pressure measurement, that is, transurethral catheterization versus suprapubic puncture. METHODS: The within-patient variation of maximum urinary flow rates and detrusor pressure at maximum flow was investigated in 25 patients in whom 2 (transurethral group) or 3 (suprapubic group) sequential voidings during urodynamic investigation were analyzed. RESULTS: The within-patient variation of pressure-flow values was evaluated by the intraclass correlation coefficient, which was 0.71 for maximum urinary flow rate and 0.84 for detrusor pressure, suggesting a relatively high degree of reproducibility. However in 26% of the patients, the maximum flow rates changed by more than 3 mL/s or the detrusor pressure by more than 20 cm H2O during the repeated tests. There was no significant difference in the within-patient variation of pressure-flow values between the suprapubic group and the transurethral group. CONCLUSIONS: In larger clinical trials where the assessment of treatment effects between groups is desired, a single pressure-flow test is sufficient. In the individual patient, a single pressure-flow curve is of limited value due to a considerable within-patient variation of the test and, for these patients, multiple consecutive tests are recommended for diagnosis of intravesical obstruction and assessment of individual patient's response to treatment.

Pelvic pain following radical retropubic prostatectomy: a prospective study.

OBJECTIVES: To evaluate subacute and chronic pelvic pain after radical retropubic prostatectomy (RRP) performed for clinically localized prostate cancer. METHODS: Twenty-four consecutive patients undergoing RRP completed pain, quality-of-life, and incontinence questionnaires. They also wore pads for 24 hours to measure urine loss objectively before and after surgery. RESULTS: Three patients had pelvic pain preoperatively. Thirteen, 7, and 5 patients had pelvic pain at 1, 3, and 6 months, respectively, after RRP. At 6 months, none of the 5 patients with pelvic pain required analgesic medication. There was a strong relationship between pain and cancer worry, as well as between pain and incontinence. CONCLUSIONS: Many patients have subacute pelvic pain after RRP but improve over time. Severe chronic pain is unlikely after RRP.

A prospective study of quantification of urinary incontinence and quality of life in patients undergoing radical retropubic prostatectomy.

OBJECTIVES: To prospectively evaluate the level of urinary incontinence and its impact on quality of life in patients undergoing radical retropubic prostatectomy. METHODS: Patients completed a 24-hour pad test together with an incontinence and quality-of-life questionnaire before and after surgery. RESULTS: Patients were followed up for an average of 7.6 months (range 4.7 to 12.5) after radical prostatectomy. The 24-hour pad test demonstrated that 87% of patients had some incontinence at 1 month and 63% at 6 months after surgery. The median volume of urine leakage was 34 mL at the last follow-up visit; 55% of patients indicated substantial bother from incontinence at the 1-month follow-up visit and 29% at the 6-month follow-up visit. For most patients, there was a substantial discrepancy between the reported and the measured level of incontinence. Patient-reported bother regarding incontinence correlated best to the actual amount of urine loss. CONCLUSIONS: Patients become incontinent after surgery but improve over time. Seventeen percent of patients still experienced leakage of more than 150 mL daily at the last follow-up visit. The questionnaire utilized in this study identifies the presence of incontinence but was not accurate in estimating the amount of urine loss. Initially, quality of life was reduced by surgery but improved over time and nearly returned to the preoperative level.

A rheological examination of the mucoadhesive/mucus interaction: the effect of mucoadhesive type and concentration.

The ability of mucoadhesive polymers to produce a large increase in the resistance to deformation when incorporated into a mucus gel, relative to when the mucus gel and test materials are evaluated separately at the same concentrations, has been reported in several previous studies. It has been proposed that this phenomenon, termed rheological synergism, can be used as a measure of the strength of the mucoadhesive interaction. In this investigation rheological synergism was investigated for a large range of putative mucoadhesive gels by dynamic oscillatory rheology. Changes in the storage modulus (G'), loss modulus (G"), and loss tangent (tan-delta) were found and the relative rheological synergism calculated. Rheological synergism was evident for a range of materials with known mucoadhesive properties giving behaviour between that of strongly cross-linked polymers gels and a physically entangled system. This effect was most marked with materials known to be of high mucoadhesive strength even when fully hydrated. Hence, polymers like sodium carboxymethylcellulose and high molecular weight poly(ethylene oxide) showed limited rheological synergism. When the effect of mucoadhesive concentration was investigated, relative rheological synergism occurred within a limited concentration range only, the values of which varied between materials. It was concluded that macromolecules possessing numerous hydrogen bond-forming groups and an open expanded network in the test environment gave pronounced rheological synergism, and the relevance of this to mucoadhesion studies will be investigated in further work. This study also confirmed the advantages of dynamic oscillatory rheology over simple viscosity measurement in the study of these systems.

Clinical manifestations of benign prostatic hyperplasia.

The clinical diagnosis of BPH is usually established after completing the initial evaluation of patients who present with symptoms of prostatism. The steps recommended in the initial evaluation include a medical history, symptom assessment using a Symptom Score Index, a digital rectal examination, a focused neurological examination, urinalysis, measurement of serum creatinine, and an optional PSA measurement. Further examinations such as uroflowmetry and cystoscopy are indicated only if the diagnosis is uncertain, or to determine the feasibility of specific invasive therapies.

Transurethral incision of the prostate.

Transurethral incision of the prostate (TUIP) is a safe and effective therapeutic modality for treating symptoms of bladder outlet obstruction in patients whose prostates have an estimated weight loss of less than 30 g. New minimal invasive techniques should be compared with TUIP instead of with transurethral resection of the prostate (TURP).

Neurosurgery for trigeminal neuralgia: comparison of alcohol block, neurectomy, and radiofrequency coagulation.

OBJECTIVES: We wished to assess the present condition of patients previously treated with a neurosurgical procedure or procedures for trigeminal neuralgia (TN) in 383 patients treated between 1976 and 1991, for TN at the Department of Neurosurgery, Hvidovre Hospital. Of these, 67 were lost to follow-up. The latest surgical intervention performed was radiofrequency coagulation (RFC) (64%), neurectomy (18%), alcohol block (16%), trigeminal tractotomy (1%), and microvascular decompression (1%); 72% of patients underwent only one neurosurgical procedure. METHODS: Questionnaires were sent to 316 patients treated neurosurgically for TN during the 16-year period; 288 (91%) patients responded. The follow-up period varied from 1 to 16 years (mean 8 years). Outcome measures were effect of RFC, neurectomy, and alcohol block; present pain conditions; and sequelae. RESULTS: After RFC, neurectomy, and alcohol block, 83, 51, and 42% of patients, respectively, experienced a pain-free postoperative period; 49, 78, and 84% of these patients had recurrence of pain. At present, 49, 17, and 18% are pain-free and 33, 21, and 36% now have less pain than they did preoperatively. Temporary or permanent analgesics for facial pain were required in 41, 72, and 69% of the patients. Sequelae were described by 65, 57, and 49% of the patients. The four most common sequelae were hypoesthesia, paresthesia, eye complaints, and dysesthesia. CONCLUSION: If relevant pharmacotherapy has been tried without benefit, RFC may still be considered as a treatment for TN.

Office spirometry: temperature conversion of volumes measured by the Vitalograph-R bellows spirometer is not necessary.

The aim of the present study was to investigate the relevance of BTPS (gas at body temperature, atmospheric pressure and saturated with water vapour) conversion of volumes measured with the Vitalograph bellows spirometer. The Vitalograph bellows were tested against a MicroMedical turbine spirometer in extreme temperatures (0-37 degrees C) using a biological control to deliver expired gas at BTPS. Before testing, it was shown that the accuracy of the DairyCard turbine was stable in the relevant temperature range. In a clinical trial six patients with emphysema performed home spirometry b.i.d for 1 month using both the Vitalograph and the turbine. Both the DairyCard and the Vitalograph showed stable accuracy at extreme temperatures when results were reported without any BTPS conversion. These findings were supported by the clinical trial but the conclusions from the clinical setting were weakened by the surprising fact that domiciliary temperatures showed almost no variation. We conclude that the Vitalograph bellows, during dynamic spirometry, measures expired volume at conditions closer to BTPS (than to ATPS) gas at ambient temperature, atmospheric pressure and saturated with water vapour). The use of the BTPS correction based on ambient temperature seems unjustified at office temperatures close to 23 degrees C and at extreme temperatures the conversion of volume will introduce significant over or underestimation.

Accuracy of recorded asthma deaths in Denmark in a 12-months period in 1994/95.

Many studies of asthma mortality rely on official registration. The aim of this study was to evaluate the accuracy of death certificates, where asthma was coded as cause of death. In a 12-month period, medical information on all subjects with asthma officially coded as the underlying cause of death in Denmark, was obtained by reviewing hospital records, contacting general practitioners and sometimes close relatives. A panel of four pulmonologists each examined the obtained information and independently assessed the cause of death. Of a total of 218 death certificates, 39 were excluded as the cause of death could not be validated. In 16 (9%) of the subjects death from asthma was judged to be the definite cause of death and in 12 (7%) death from asthma was possible. Of 151 non-asthma deaths coded as due to asthma, 109 were judged to have suffered or died from COPD and 14 from heart disease. The accuracy of Danish death certification in asthma deaths is poor, especially in the elderly, where COPD is often classified as asthma. We conclude that the true asthma mortality in Denmark is substantially lower than officially recorded.