Coil embolization of a fistula from the right inferior phrenic artery to the right pulmonary artery with involvement of further arteries: A rare case report.

A 51-year-old female patient was presenting dyspnea for more than a year with no previous lung infections or surgery. Initially, a diagnostic computed tomography was made, showing a rare arterio-arterial malformation between the right inferior phrenic and right pulmonary artery leading into a vascular bundle in the middle lung lobe. Due to the patients' dyspnea and massive extent of malformation, the indication for transcatheter arterial embolization was made. The first transcatheter arterial embolization procedure involved the inferior phrenic and a selective branch of the internal thoracic artery. Interventional angiography as well as computed tomography revealed further extend of the malformation showing a connection of right lateral thoracic, hepatic, and inferior epigastric artery to the fistula. After one month, a second transcatheter arterial embolization of these arteries as well as a second approach of the proximal internal thoracic artery was performed. In the follow-up the patient described a substantial improvement of her dyspnea and showed no signs of infections. A phrenic artery to pulmonary artery fistula is an extremely rare case occurring congenital or acquired. Patients may be asymptomatic or present, among others, dyspnea, hemoptysis, pulmonary infections and congestive heart failure. Symptomatic patients require treatment using transcatheter arterial embolization or surgical resection. The patient had dyspnea and a substantial extent of malformation with possibly complicated clinical course. The recommended less invasive treatment using transcatheter arterial embolization was successfully performed. In conclusion, our patient represented a rare congenital case of systemic and pulmonary artery communication, which we were able to treat sufficiently with coil embolization.

Computed Tomography Radiomics to Differentiate Intrahepatic Cholangiocarcinoma and Hepatocellular Carcinoma.

AIMS: Intrahepatic cholangiocarcinoma (iCCA) and hepatocellular carcinoma (HCC) differ in prognosis and treatment. We aimed to non-invasively differentiate iCCA and HCC by means of radiomics extracted from contrast-enhanced standard-of-care computed tomography (CT). MATERIALS AND METHODS: In total, 94 patients (male, n = 68, mean age 63.3 ± 12.4 years) with histologically confirmed iCCA (n = 47) or HCC (n = 47) who underwent contrast-enhanced abdominal CT between August 2014 and November 2021 were retrospectively included. The enhancing tumour border was manually segmented in a clinically feasible way by defining three three-dimensional volumes of interest per tumour. Radiomics features were extracted. Intraclass correlation analysis and Pearson metrics were used to stratify robust and non-redundant features with further feature reduction by LASSO (least absolute shrinkage and selection operator). Independent training and testing datasets were used to build four different machine learning models. Performance metrics and feature importance values were computed to increase the models' interpretability. RESULTS: The patient population was split into 65 patients for training (iCCA, n = 32) and 29 patients for testing (iCCA, n = 15). A final combined feature set of three radiomics features and the clinical features age and sex revealed a top test model performance of receiver operating characteristic (ROC) area under the curve (AUC) = 0.82 (95% confidence interval =0.66-0.98; train ROC AUC = 0.82) using a logistic regression classifier. The model was well calibrated, and the Youden J Index suggested an optimal cut-off of 0.501 to discriminate between iCCA and HCC with a sensitivity of 0.733 and a specificity of 0.857. CONCLUSIONS: Radiomics-based imaging biomarkers can potentially help to non-invasively discriminate between iCCA and HCC.

2-methyltetrahydrofuran--lithium hexafluoroarsenate: a superior electrolyte for the secondary lithium electrode.

Rechargeable, high energy density lithium batteries require an efficient lithium electrode. Earlier work with electrolytes based on propylene carbonate, methyl acetate, and tetrahydrofuran yielded poor lithium electrode cycling efficiencies because of electrolyte reduction by lithium. Solutions of lithium hexafluoroarsenate in 2-methyltetrahydrofuran are found to be remarkably stable toward lithium, resulting in cycling efficiencies that approach 98 percent. The ability of 2-methyltetrahydrofuran to resist reduction by lithium is thought to be based on the position of its lowest unfilled molecular orbital relative to that of tetrahydrofuran.

The role of renal biomarkers to predict the need of surgery in congenital urinary tract obstruction in infants.

INTRODUCTION: The diagnosis of renal function impairment and deterioration in congenital urinary tract obstruction (UTO) continues to be extremely challenging. The use of new renal biomarkers in this setting may favor early renal injury detection, allowing for a reliable choice of optimal therapeutic options and the prevention or minimization of definitive renal damage. OBJECTIVE: The aim of the study was to investigate a selection of promising biomarkers of renal injury with the intention of evaluating and comparing their profile with clinically based decisions for surgical intervention of infants with congenital obstructive uropathies. STUDY DESIGN: The first-year profile of renal biomarkers, serum creatinine (sCr), serum and urine cystatin C (CyC), neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), transforming growth factor beta-1 (TGF-ß1), retinol-binding protein (RBP), and microalbuminuria (µALB), was analyzed in a cohort of 37 infants with congenital UTO, divided into three subgroups, 14 cases with grade III unilateral hydro(uretero)nephrosis, 13 cases with grade III bilateral hydro(uretero)nephrosis, and 10 cases with low urinary tract obstruction (LUTO), compared with 24 healthy infants matched by gestational age and birth weight. Serum and urine samples were stored at -70 °C and thereafter analyzed by quantitative enzymatic immunoassay. RESULTS: Compared with the control group (Figure), all renal biomarker values were significantly increased in patients (P ≤ 0.02). In the unilateral hydronephrosis and LUTO group, RBP (P ≤ 0.043), NGAL (P ≤ 0.043), KIM-1 (P ≤ 0.03), and TGF-ß1 (P ≤ 0.034) values dropped significantly after surgery. Neutrophil gelatinase-associated lipocalin alone and in combination with urine and serum CyC demonstrated the best performance in determining the need for surgery (area under the curve, 0.801 and 0.881, respectively). Biomarker profile analysis was suggestive of surgical intervention in 55.4% (7/13) of non-operated cases, and most of the biomarker values were above the cutoff levels within at least 3 months before the clinically based surgical decision in 58% (14/24) of all operated patients. DISCUSSION: To the best of the authors' knowledge, this is the first study to present the clinical use of selected group of serum and urinary biomarkers in the setting of UTO to distinguish between patients who would benefit from surgery intervention. The most promising results were obtained using NGAL, RBP, TGF-ß1, and KIM-1, especially in the unilateral hydro(uretero)nephrosis and LUTO subgroups when compared with the control group. CONCLUSIONS: Urine biomarkers, alone and in combination, demonstrated high potential as a non-invasive diagnostic tool for identifying infants who may benefit from earlier surgical intervention.

Percutaneous ultrasound-guided renal biopsy in children - safety, efficacy, indications and renal pathology findings: 14-year Brazilian university hospital experience.

INTRODUCTION: Pediatric percutaneous renal biopsy (Bx) is a routine procedure in pediatric nephrology to obtain renal tissues for histological study. We evaluated the safety, efficacy, indications and renal findings of this procedure at a tertiary care pediatric university hospital and compared our findings with the literature. METHODS: Retrospective study based on medical records from January 1993 to June 2006. RESULTS: In the study period, 305 Bx were performed in 262 patients, 127 (48.5%) male, aged 9.8 A+/- 4.2 years. A 16-gauge needle was utilized in 56/305 Bx, an 18-gauge needle in 252/305 Bx (82.6%). 56.1% Bx were performed under sedation plus local anesthesia, 43.9% under general anesthesia. The number of punctures per Bx was 3.1 A+/- 1.3. Minor complications occurred in 8.6% procedures. The 16-gauge needle caused a higher frequency of renal hematomas (p = 0.05). The number of glomeruli per puncture was >or= 5 in 96.7% and >or= 7 in 92%. Glomeruli number per puncture and frequency of complications were not different according to the type of anesthesia used. A renal pathology diagnosis was achieved in 93.1% Bx. The main indications of Bx were nephrotic syndrome (NS), lupus nephritis (LN) and hematuria (HE). The diagnosis of minimal change disease (MCD) (61.3%), class V (35.6%) and IgA nephropathy (26.3%) predominated in NS, LN and HE patients, respectively. CONCLUSION: Pediatric real-time ultrasound-guided percutaneous renal biopsy was safe and effective. The main clinical indications for Bx were NS and LN, the predominant renal pathology diagnoses were MCD and class V LN.

Preventing Adverse Events at Research Facilities.

In this article, adverse events are defined as events that lead to significant injury or illness, unrelieved pain or distress, orthe death of an animal, excluding those caused by IACUC-approved research procedures. The ability to identify possible adverse events is an essential step in planning for risk prevention and mitigation. Using data from news sources and the Animal and Plant Health Inspection Service (APHIS) website, this article provides guidance to research facilities regarding various types of adverse events to consider in risk management plans because these events might occur or have occurred and, in some cases, have been documented as noncompliances at APHIS-regulated research facilities. APHIS classifies noncompliances as 'direct' when they currently (at the time of the inspection) have a serious or severe adverse effect on the health and wellbeing of animals. Not all direct noncompliances are associated with adverse events, and not all adverse events are documented as direct noncompliances (for example, a past adverse event that does not currently affect the wellbeing of animals is not a direct noncompliance). However, because APHIS does not require reporting of adverse events, the information regarding direct noncompliances was the only APHIS data available to study adverse events at research facilities. Direct noncompliances documented by APHIS were 4% of all documented noncompliances from 2010 through 2014. The greatestnumber of direct noncompliances was in the category of veterinary care issues (44%), followed by animal husbandry issues(34%), 'other issues' (15%), and physical plant issues (7%). The category of other issues included events due to human error,equipment failures, and accidents.

Celebrating a life by recognizing realities.

This special issue on nonhuman primate behavior and welfare, the proceedings of a special Animal Behavior Society session, celebrates the life of Dr. Sylvia Taylor (1963-2005). Sylvia's premature death reminded her friends to recognize the reality that life is short, but one can make the most of it. Many individuals and organizations have also recognized the reality that an educational venture such as this one requires adequate funding and support. Their generosity has made this undertaking a success. The idea behind the session was to recognize the reality that one cannot ensure nonhuman animal welfare without understanding animal behavior, and to explore the ways in which this principle applies to primates. One must also recognize the reality that nonhuman primate welfare depends on understanding the behavior of the human primate as well as the nonhuman primate. Ensuring the welfare of the nonhuman primate sometimes requires educating and motivating the human primate. This special issue will hopefully provide helpful information to increase the reader's knowledge of primate behavior and welfare and to help the reader educate others on these important topics.

Neonatal arterial hypertension in nephro-urological malformations in a tertiary care hospital.

An increase in the survival of neonates with antenatal diagnosis of malformations was achieved by the recent technical advances in neonatal intensive care units. The aim of this article is to describe the experience with neonatal arterial hypertension, in newborns with nephro-urological malformations, in a tertiary care referral Nursery, in a period of 4 years. Newborn medical records from the Nursery Annex to the Maternity of Hospital das Clinicas, School of Medicine, University of Sao Paulo, with the diagnosis of nephro-urological malformations and systemic arterial hypertension (SAH) at hospital discharge, in a period from January 1999 to January 2003, were retrospectively analysed. Among 10.278 live newborns in the studied period, 15 (0.15%) newborns were compatible with our inclusion criteria. Of these 15 newborns, 12 (80%) were male and three were premature (20%). In relation to aetiology, 13 (87%) showed urological malformations, 1 (6%) chronic renal insufficiency secondary to kidney dysplasia and one (6%) autosomal recessive polycystic kidney disease. SAH control was achieved with monotherapy in eight patients (53%), five patients (33%) needed an association of two drugs (calcium-channel blocker and angiotensin converting enzyme (ACE) inhibitor), one child used three types of antihypertensive drugs (calcium-channel blocker, ACE inhibitor and hydrochlorothiazide) for pressoric control and one child's blood pressure (BP) was controlled exclusively by peritoneal dialysis. The incidence of nephro-urological malformations in our service during the studied period was 0.89%. SAH incidence among these newborns was 19%. Our data reinforce previous studies pointing to the necessity to consider children with nephro-urological malformations as a risk group for SAH, who should have the BP evaluated since the neonatal period.

Pain and distress: what really matters?

Federal regulations mandate the minimization of both pain and distress in laboratory animals. That no clear definition exists for 'distress' complicates its recognition, quantification, and alleviation. The author argues that IACUCs and investigators should shift their focus from pain to distress, and that in doing so both problems will be better dealt with. She discusses criteria for defining 'significant' distress, and offers suggestions for the conduct of studies to determine levels of distress.

Children with nocturnal enuresis have posture and balance disorders.

INTRODUCTION: Integration of the neuromuscular system is required for maintaining balance and adequate voiding function. Children with enuresis have delayed maturation of the motor cortex, with changes in the sensory and motor systems. Along with various alterations, including the genetic, hormonal, behavioral, and sleep disturbances, and neuromotor and sensory deficits associated with nocturnal enuresis (NE) in children and adults, a consistent alteration in the posture of children with NE has been observed in the current practice. Because posture and the balance control system are strongly connected, this study aimed to investigate posture and balance in children and teenagers with NE. MATERIAL AND METHODS: A total of 111 children with enuresis were recruited to the enuretic group (EG) and 60 asymptomatic children made up the control group (CG). The participants were divided into two age subgroups: (A) 7-11 years old, N = 77 for EG/A, N = 38 for CG/A; and (B) 12-16 years old, N = 34 for EG/B, N = 22 for CG/B. Balance was assessed using an electronic force plate (100 Hz) to calculate the area of the center of pressure (COP) displacement. The COP is the point that results from the action of vertical forces projected onto the force plate. Sensory integration was analyzed using a 60-s trial with the subject standing under four conditions: (1) eyes open, stable surface; (2) eyes closed, stable surface; (3) eyes open, unstable surface; (4) eyes closed, unstable surface. Posture was assessed by placing reflective anatomical landmarks on the anterior superior iliac spine, the posterior superior iliac spine, the greater trochanter, and lateral malleolus. A photograph was taken while the subject stood quietly. The angles were obtained from landmark connections using software to assess the following posture variables: pelvic ante/retroversion and pelvic ante/retropulsion. RESULTS: The EG showed a greater area of COP displacement compared with the CG under all four sensory conditions and both subgroups, except for EG/B in condition 3. Regarding posture, EG showed higher pelvic anteversion angles than CG. CONCLUSIONS: Enuretic children showed forward inclination of the pelvis and had worse balance compared with control children.

European union system for the evaluation of substances: the second version.

This publication presents major changes in the assessment of the risks of chemicals to human health and the environment as implemented in the second version of the European Union System for the Evaluation of Substances, EUSES 2.0. EUSES is a harmonised quantitative risk assessment tool for chemicals. It is the PC-implementation of the technical guidelines developed within the framework of EU chemical legislation for industrial chemicals and biocides. As such, it is designed to support decision making by risk managers in government and industry and to assist scientific institutions in the risk assessment for these substances. The development of EUSES 2.0 is a co-ordinated project of the European Chemicals Bureau, EU Member States and the European chemical industry. Several model concepts, the technical background and the user interface of EUSES have been improved considerably. Major changes in the environmental assessment such as the implementation of emission scenario documents for industrial chemicals and biocides, the addition of the marine risk assessment, the enhancement of the regional model to include global scales, and improvements in the secondary poisoning and environmental effects modelling will be discussed. The update of the human risk assessment module in EUSES focuses on the risk characterisation for both threshold and non-threshold substances with, among others, the introduction of assessment factors. The performance of EUSES is illustrated in an example showing the human and environmental risk assessment of a sanitation disinfectant for private use.

Constrictive Pericarditis in the Presence of Remaining Remnants of a Left Ventricular Assist Device in a Heart Transplanted Patient.

Constrictive pericarditis (CP) is a severe subform of pericarditis with various causes and clinical findings. Here, we present the unique case of CP in the presence of remaining remnants of a left ventricular assist device (LVAD) in a heart transplanted patient. A 63-year-old man presented at the Heidelberg Heart Center outpatient clinic with progressive dyspnea, fatigue, and loss of physical capacity. Heart transplantation (HTX) was performed at another heart center four years ago and postoperative clinical course was unremarkable so far. Pharmacological cardiac magnetic resonance imaging (MRI) stress test was performed to exclude coronary ischemia. The test was negative but, accidentally, a foreign body located in the epicardial adipose tissue was found. The foreign body was identified as the inflow pump connection of an LVAD which was left behind after HTX. Echocardiography and cardiac catheterization confirmed the diagnosis of CP. Surgical removal was performed and the epicardial tubular structure with a diameter of 30 mm was carefully removed accompanied by pericardiectomy. No postoperative complications occurred and the patient recovered uneventfully with a rapid improvement of symptoms. On follow-up 3 and 6 months later, the patient reported about a stable clinical course with improved physical capacity and absence of dyspnea.

Charged particle ratio fluctuation as a signal for quark-gluon plasma

In this Letter we argue that the event-by-event fluctuations of the ratio of the positively charged and the negatively charged pions provide a signal for a quark-gluon plasma. The fact that quarks carry fractional charges is ultimately responsible for this distinct signal.

Histological and immunohistochemical findings of prostatic carcinoma after external or interstitial radiotherapy.

In a retrospective study, the extent of reactions of different types of prostatic carcinomas to external or interstitial radiotherapy was compared with reactions to hormonal therapy. It is shown that prostatic carcinomas of different grades of differentiation can be divided into two main subgroups with distinctly different survival rates; i.e., prostatic carcinomas grades of malignancy Ib/IIa and grades IIb/III. Within an observation time of 10 years, the prostatic carcinoma grade of malignancy Ib/IIa shows a good response to external and interstitial radiotherapy. None of the patients died of the prostatic carcinoma. In the more poorly differentiated prostatic carcinomas, 2 out of 11 patients with external radiotherapy died of the carcinoma. The death rates from disease after hormonal therapy were higher, and the survival times were very short without therapy. Regressive changes are much more distinctly expressed in the better-differentiated carcinoma group. Differential diagnostic difficulties between regressive changes in carcinomatous glands and normal glands could be resolved by immunohistochemical proof of high-molecular-mass cytokeratin in basal cells.

Molecular mimicry in halothane hepatitis: biochemical and structural characterization of lipoylated autoantigens.

Exposure of human individuals to halothane causes, in about 20% of all cases, a mild transient form of hepatotoxicity. A small subset of exposed individuals, however, develops a potentially severe and life-threatening form of hepatic damage, coined halothane hepatitis. Halothane hepatitis is thought to have an immunological basis. Sera of afflicted individuals contain a wide variety of autoantibodies against hepatic proteins, in both trifluoroacetylated form (CF3CO-proteins) and, at least in part, in native form. CF3CO-proteins are elicited in the course of oxidative biotransformation of halothane, and include the trifluoroacetylated forms of protein disulfide isomerase, microsomal carboxylesterase, calreticulin, ERp72, GRP 78, and ERp99. Current evidence suggests that CF3CO-proteins arise in all halothane-exposed individuals; however, the vast majority of individuals appear to immunochemically tolerate CF3CO-proteins. The lack of immunological responsiveness of these individuals towards CF3CO-proteins might be due to tolerance, induced through the occurrence of structures in the repertoire of self-determinants, which immunochemically and structurally mimic CF3CO-proteins very closely. In fact, lipoic acid, the prosthetic group of the constitutively expressed E2 subunits of the family of mammalian 2-oxoacid dehydrogenase complexes and of protein X, was shown by immunochemical and molecular modelling analysis to be a perfect structural mimic of N6-trifluoroacetyl-L-lysine (CF3 CO-Lys), the major haptenic group of CF3CO-proteins. As a consequence of molecular mimicry, autoantibodies in patients' sera not only recognize CF3CO-proteins, but also the E2 subunit proteins of the 2-oxoacid dehydrogenase complexes and protein X, as autoantigens associated with halothane hepatitis. Furthermore, a fraction of patients with halothane hepatitis exhibit irregularities in the hepatic expression levels of these native, not trifluoroacetylated autoantigens. Collectively, these data suggest that molecular mimicry of CF3CO-Lys by lipoic acid, or the impairment thereof, might play a role in the susceptibility of individuals for the development of halothane hepatitis.

Expression of mucin-associated carbohydrate core antigens in esophageal squamous cell carcinomas.

In contrast to gastrointestinal cancer, where a correlation between the expression of different mucin-associated core antigens with clinico-pathological parameters and survival probability, has been established, little is known about their importance in esophageal cancer. Therefore, we characterized esophageal squamous cell carcinomas from 84 patients immunohistochemically by applying monoclonal antibodies (mabs) directed against the Thomsen-Friedenreich (TF) antigen MUC1-bound TF antigen and sialyl-Tn. TF was observed in about 40% of the cases and MUC1-TF epitope in about 75%. Sialyl-Tn was detectable in about half of the carcinomas under study. None of these mabs showed any correlation between binding pattern and clinico-pathological variables, such as TNM stage, lymph node metastasis or grading. However, a strong expression of MUC1-TF epitope as well as sialyl-Tn antigen predicted a poor survival probability. In conclusion, it is suggested that mucin-associated carbohydrate core antigens are involved in the biology and clinical course of esophageal squamous carcinomas.

White coat hypertension in adolescents.

BACKGROUND: Although white coat hypertension (WCH) seems to occur in 20% or more of the adult hypertensive population, this clinical condition has rarely been described in adolescents. DESIGN: Routine use of ambulatory blood pressure monitoring (ABPM) procedure as part of the investigation of arterial hypertension in adolescents. METHODS: Office blood pressure was checked after 5 minutes of rest in the seated position by the auscultation method and ABPM was performed with oscillometrical equipment (SpaceLabs 90207, Redmond, Washington, USA). RESULTS: In the present study 6 adolescents (5 females, 3 white), suspected to suffer from arterial hypertension as judged by office blood pressure measurements, mean age 15.1 years (12.2 - 17.7), mean height 164.5 cm, mean weight 77.2 kg, mean body mass index 28.8 kg/m2 (25 - 35.2), were diagnosed with WCH using ambulatory blood pressure monitoring (ABPM). CONCLUSION: White coat hypertension should also be considered in the evaluation of arterial hypertension in adolescents.

Correlation of drug-related aluminum intake and dialysis treatment with deposition of argyrophilic aluminum-containing inclusions in CNS and in organ systems of patients with dialysis-associated encephalopathy.

CNS tissue and peripheral organs of 50 autopsy cases with chronic renal failure (CRF) and dialysis treatment were evaluated for aluminum- (Al) containing argyrophilic inclusions using the Howell and Black method modified by Reusche. Morphological alterations were correlated with the duration of hemodialysis (HD) and to the amount of prescribed Al-containing drugs for better control of hyperphosphatemia. Significant correlations were found between the degree of morphological alterations and Al intake up to 2.5 kg (p = 0.0003), as well as for morphology and duration of longterm HD up to 178 months (p = 0.001). Most sensitive structure for CNS deposits were choroid epithelia, followed by glial cells and neurons. Autonomic ganglia, heart, ovary/testis, parathyroid, adrenal, and pituitary demonstrated reliably peripheral deposits. Al-containing drugs, administered preferentially during HD, explain the additional significance of Al uptake and duration of dialysis (R-Qu. = 0.6697). The deposition of Al-containing proteinaceous inclusions is apparently irreversible. After renal transplantation, with termination of drug-related Al intake and normalized renal Al excretion, the Al-induced argyrophilic degradation products remained in the cellular cytoplasm in unchanged fashion up to 10 years.

Neonatal neurobehavioral examination. A new instrument for quantitative analysis of neonatal neurological status.

A new neonatal neurobehavioral examination (NNE) was designed in response to the need for a more quantitative assessment of neonatal neurological status. The NNE consists of 27 items divided into three sections: 1) tone and motor patterns, 2) primitive reflexes, and 3) behavioral responses. Each section consists of 9 items scored on a three-point scale. Fifty-four healthy full-term infants were examined at 2 days of age and demonstrated total NNE scores ranging from 70 to a maximum possible score of 81 (X = 76, s = 1.03). Mean section scores for these infants ranged from 25.3 to 26.6 (s = .59-1.79). Intertester agreement was 88% by item and 95% by total score in each section. Two hundred ninety-eight high-risk infants were then examined at 37 to 40 weeks conceptional age (gestational age plus chronological age) or at discharge from the neonatal intensive care unit, whichever occurred first. Total NNE mean scores for high-risk infants fell into discrete clusters by conceptional age at the time of examination (37-42 weeks, mean score = 66.5; 34-36 weeks, mean score = 60.7; less than 34 weeks, mean score = 51.1). Similar clustering occurred for the three section scores. Highly significant differences existed between the three conceptional age groups for total scores and section scores. No clinically significant score differences were associated with severity of illness or gestational age at birth. The results of this study suggest that the NNE easily and reliably assesses infants' neonatal neurobehavioral status at a given conceptional age. Additional studies are in progress to determine the value of the NNE in predicting subsequent developmental disabilities.