Hypnotherapy or transcendental meditation versus progressive muscle relaxation exercises in the treatment of children with primary headaches: a multi-centre, pragmatic, randomised clinical study.

Many children suffer from headaches. Since stress may trigger headaches, effective techniques to cope with stress are needed. We investigated the effectiveness of two mind-body techniques, transcendental meditation (TM) or hypnotherapy (HT), and compared them with progressive muscle relaxation (PMR) exercises (active control group). Children (9-18 years) suffering from primary headaches more than two times per month received either TM (N = 42), HT (N = 45) or PMR (N = 44) for 3 months. Primary outcomes were frequency of headaches and ≥ 50% reduction in headaches at 3 and 9 months. Secondary outcomes were adequate relief, pain coping, anxiety and depressive symptoms, somatisation and safety of treatment. Groups were comparable at baseline. Headache frequency was significantly reduced in all groups from 18.9 days per month to 12.5 and 10.5 at respectively 3 and 9 months (p < 0.001), with no significant differences between the groups. Clinically relevant headache reduction (≥ 50%) was observed in 41% and 47% of children at 3 and 9 months respectively, with no significant differences between the groups. No differences were observed in secondary outcome measures between the intervention groups. No adverse events were reported.Conclusion: All three techniques reduced primary headache in children and appeared to be safe.Trial registration: NTR 2955, 28 June 2011 ( www.trialregister.nl ) What is Known: • Stress may be an important trigger for both tension type headache and migraine in children. • Good data are lacking on the effect of transcendental meditation, hypnotherapy or progressive muscle relaxation as possible stress-reducing therapies in children with primary headaches. What is New: • Three non-pharmacological techniques, i.e., transcendental meditation, hypnotherapy and progressive muscle relaxation exercises, all result in a clinically significant reduction of headaches and use of pain medication. • No large differences between the three techniques were found, suggesting that children can choose either one of the three techniques based on personal preferences.

Misoprostol for cervical priming prior to hysteroscopy in postmenopausal and premenopausal nulliparous women; a multicentre randomised placebo controlled trial.

OBJECTIVE: To evaluate the reduction of pain by misoprostol compared with placebo prior to hysteroscopy in postmenopausal and premenopausal nulliparous women. DESIGN: Randomised multicentre double-blind placebo controlled trial. SETTING: Two Dutch teaching hospitals and one Dutch university medical centre. POPULATION: Postmenopausal and premenopausal nulliparous women undergoing office hysteroscopy. METHODS: Patients were randomised to receive either 400 microgram misoprostol or placebo 12 and 24 hours before hysteroscopy. Pain was quantified by the use of real time pain measurement using the continuous pain score meter (CPSM) and VAS scores. MAIN OUTCOME MEASURES: Primary outcome was pain measured by the CPSM during passage of the hysteroscope through the cervical canal, quantified by the area under the curve (AUC). Secondary outcomes included VAS scores, other CPSM parameters, failures and side effects. RESULTS: In all, 149 patients were randomly assigned to either misoprostol (n = 74) or placebo (n = 75). The AUC during introduction did not significantly differ between the intervention and the placebo group. The VAS score during introduction, however, demonstrated a significant difference in premenopausal nulliparous women favouring misoprostol: 2.9 (95% CI 1.3-4.4) versus placebo 5.5 (95% CI 3.9-7.1), P = 0.02, as well as the AUC during the entire procedure: 618 (95% CI 410-827) versus 1126 (95% CI 671-1580), P = 0.04. Failures were equally distributed between the misoprostol (16%) and placebo group (13%). Intestinal side effects occurred significantly more frequently in the misoprostol group (67%) than in the placebo group (32%) [OR 4.2 (95% CI 2.1-8.3), P < 0.01]. CONCLUSION: Misoprostol prior to hysteroscopy reduces pain in premenopausal nulliparous women but not in postmenopausal women. It does cause side effects. TWEETABLE ABSTRACT: RCT: misoprostol versus placebo prior to hysteroscopy in 149 women significantly reduces some pain parameters.

Milk production after preterm, late preterm and term delivery; effects of different breast pump suction patterns.

OBJECTIVE: This study aimed to compare the effectiveness of two different breast pump suction patterns (BPSP) during the initiation of lactation in mothers of term, late preterm and preterm infants. METHODS: Breast pump-dependent mothers (n=130) of term (n=19), late preterm (n=44) and preterm (n=67) infants were assigned to either a standard or irregular-BPSP after birth until the onset of secretory activation. Both groups used the same standard maintenance BPSP thereafter. Time to secretory activation, time to full milk production and daily milk output were compared between the standard and I-BPSP groups, and between the term, late preterm and preterm groups. RESULTS: Mothers using the irregular-BPSP demonstrated significantly greater daily milk output and established secretory activation significantly earlier. This effect was observed in mothers of term, late preterm and preterm infants. CONCLUSION: The irregular-BPSP mimicking sucking of healthy newborns is more effective at achieving secretory activation and an earlier adequate milk supply than the standard-BPSP. The irregular-BPSP can be used successfully for mothers of preterm up to term infants who are breast pump dependent during the establishment of lactation.

Trends in Serial Measurements of Ultrasound Markers in Second and Third Trimester Down Syndrome Fetuses.

OBJECTIVES: To evaluate trends of nasal bone length (NBL), prenasal thickness (PT), nuchal fold (NF), prenasal thickness to nasal bone length (PT-NBL) ratio, and prefrontal space ratio (PFSR), measured serially in second- and third-trimester Down syndrome (DS) fetuses. METHODS: Prenatal databases were searched for cases of continuing DS pregnancies with serial measurements, taken at least two weeks apart. Trends were plotted on previously reported normal ranges. RESULTS: Serial measurements were available in 25 Down syndrome fetuses. Median gestational age (GA) was 25 weeks; average number of visits per case was 2.44, with a median interval of 39 days between investigations. In DS fetuses, NBL and PT showed fairly stable trends with gestation. PFSR, but especially NF, had a more unpredictable trend. The PT-NBL ratio was the most stable marker, remaining unchanged in 95% of cases. NBL, PT, and NF showed more deviance from the normal range with advancing gestation, but MoM values remained stable. All but two fetuses had ultrasound markers or structural anomalies, especially heart defects. CONCLUSIONS: The PT-NBL ratio is the most constant DS marker throughout gestation, following a predictable trend.

Facial profile markers in second- and third-trimester fetuses with trisomy 18.

OBJECTIVES: To evaluate nasal bone length (NBL), maxilla-nasion-mandible (MNM) angle, fetal profile (FP) line, prenasal thickness (PT), prenasal thickness to nasal bone length (PT:NBL) ratio and prefrontal space ratio (PFSR) as markers of trisomy 18 in the second and third trimesters of pregnancy. METHODS: The NBL, MNM angle, FP line, PT, PT:NBL ratio and PFSR were measured retrospectively from stored two-dimensional images or three-dimensional volumes of trisomy-18 fetuses, and were compared with our previously reported normal ranges for euploid fetuses. Additional ultrasound findings were noted at initial routine second-trimester scan and at subsequent advanced ultrasound examination performed after referral for karyotyping. RESULTS: A total of 43 trisomy-18 fetuses were included in the analysis. At initial examination, median gestational age was 21 + 2 weeks. NBL and PT were correlated with gestational age (P < 0.001), but the other markers were not. Mean NBL, MNM angle, PT, PT:NBL ratio and PFSR were 3.76 mm, 16.67°, 4.25 mm, 1.39 and 0.87, respectively. The FP line was zero (normal) in 53.7% of cases and negative (abnormal) in 46.3%. All markers were significantly associated with trisomy 18, with the PT:NBL ratio yielding the highest detection rate (88.4%) followed by NBL (83.7%), MNM angle (56.4%), FP line (46.3%), PT (27.9%) and the PFSR (20.5%) (for a 5% false-positive rate for the continuous variables). Various combinations of the four best markers (NBL, FP line, MNM angle and PT:NBL ratio) yielded detection rates of between 72% and 95%. Structural anomalies were not detected in 22% of fetuses at the initial scan and in 2% at the advanced scan. CONCLUSIONS: The PT:NBL ratio and NBL are robust second- and third-trimester markers for trisomy 18. A negative FP line has a 0% false-positive rate and the potential to differentiate between trisomy 18 and Down syndrome, as in the latter the FP line is often positive. No major anomaly was observed at the initial scan in about a quarter of trisomy-18 fetuses, underlining the role of second-trimester facial marker evaluation.

Fetal facial profile markers of Down syndrome in the second and third trimesters of pregnancy.

OBJECTIVES: To investigate the use of the maxilla-nasion-mandible (MNM) angle and fetal profile (FP) line to assess the degree of midfacial hypoplasia in Down-syndrome fetuses in the second and third trimesters of pregnancy. METHODS: The MNM angle and FP line were measured retrospectively in stored two-dimensional images or three-dimensional volumes of fetuses with Down syndrome. Data collected from January 2006 to July 2013 were retrieved from the digital databases of participating units. The MNM angle was expressed as a continuous variable (degrees) and the FP line as positive, negative or zero. Measurements were obtained from stored images in the midsagittal plane by two experienced examiners and compared with our previously reported normal ranges for euploid fetuses. A MNM angle below the 5(th) centile of the reference range and a positive or negative FP line were considered as abnormal. RESULTS: A total of 133 fetuses with Down syndrome were available for analysis, eight of which were subsequently excluded because of inadequate images. The MNM angle was not influenced by gestational age (P = 0.48) and was significantly smaller in Down-syndrome fetuses than in euploid fetuses (mean, 12.90° vs 13.53°, respectively; P = 0.015). The MNM angle was below the 5th centile for euploid fetuses in 16.8% of fetuses with Down syndrome (P < 0.01). In the cohort of Down-syndrome fetuses, a positive FP line was present in 41.6% of cases (with a false-positive rate (FPR) of 6.3%) and was positively correlated with Down syndrome and gestational age (P < 0.01). There was no case with a negative FP line. In cases of Down syndrome, a positive FP line was correlated with a small MNM angle (P < 0.01). CONCLUSIONS: A small MNM angle and a positive FP line can be regarded as novel markers for Down syndrome. The FP line is an easy marker to measure, has a low FPR, does not require knowledge of normal reference values and has the potential to differentiate between Down syndrome and trisomy 18, as, in the latter, the FP line is often negative.

Is 3D technique superior to 2D in Down syndrome screening? Evaluation of six second and third trimester fetal profile markers.

OBJECTIVE: The objective of this article is to investigate whether in the clinical setting of second trimester ultrasound (US) investigations, 3D multiplanar correction prior to the measurement of Down syndrome (DS) facial markers (nasal bone length, prenasal thickness, fetal profile line, maxilla-nasion-mandible angle, prenasal thickness to nasal bone length ratio, and prefrontal space ratio) is superior to subjective judgment of a correct midsagittal plane by 2D technique. METHODS: Measurements were performed on 2D images and 3D volumes (corrected to the midsagittal plane), acquired during the same scanning session. RESULTS: All six markers were measured in 105 datasets (75 of euploid fetuses and 30 of DS fetuses). The maxilla-nasion-mandible angle measured on 2D images was significantly larger than on 3D volumes (p < 0.01). In all other markers, there was no significant difference between measurements performed on 2D images or 3D volumes. No statistical difference was found for any marker between measurements performed on images acquired by either 2D or 3D US in their ability to discriminate between normal and DS fetuses. CONCLUSIONS: Nasal bone length, prenasal thickness, fetal profile line, prenasal thickness to nasal bone length ratio, and prefrontal space ratio can be confidently used as DS markers in second trimester US examinations performed by 2D US. © 2014 John Wiley & Sons, Ltd.

Nasal bone length, prenasal thickness, prenasal thickness-to-nasal bone length ratio and prefrontal space ratio in second- and third-trimester fetuses with Down syndrome.

OBJECTIVES: To evaluate nasal bone length (NBL), prenasal thickness (PT), prenasal thickness-to-nasal bone length (PT-NBL) ratio and prefrontal space ratio (PFSR) as markers for Down syndrome in the second and third trimesters. METHODS: NBL, PT, PT-NBL ratio and PFSR were measured retrospectively in stored two-dimensional images or three-dimensional volumes (corrected to the mid-sagittal plane) of fetuses with Down syndrome, which were retrieved from the digital databases of participating units. Measurements were performed on the stored images and volumes by two experienced operators, and the values obtained were compared to our previously reported normal ranges for euploid fetuses in order to assess the detection rates for Down syndrome. RESULTS: A total of 159 fetuses with Down syndrome were included in the analysis, six of which were excluded because of inadequate available images. Median maternal age was 36.0 years and median gestational age was 23 + 1 weeks. NBL and PT were correlated with gestational age (P < 0.001), but the PT-NBL ratio and PFSR were not. Mean NBL, PT, PT-NBL ratio and PFSR were 4.42 mm, 5.56 mm, 1.26 and 0.34, respectively. The nasal bone was absent in 23 (15.4%) cases. As a marker for Down syndrome, the PT-NBL ratio yielded the highest detection rate (86.2%), followed by PFSR (79.7%), PT (63.4%) and NBL (61.9%). All markers were abnormal in 33.6% of cases, whilst all were normal in 4.7%. At least one of the four markers was abnormal in 95.3%, and either the PT-NBL ratio or PFSR was abnormal in 93.8%. Detection rates were not related to gestational age. CONCLUSIONS: The PT-NBL ratio and PFSR are robust second- and third-trimester markers for Down syndrome. Both provide high detection rates and are easy to use, as the cut-off for normality is constant throughout gestation. Ltd.

Premaxillary protrusion assessment by the maxilla-nasion-mandible angle in fetuses with facial clefts.

OBJECTIVE: The aim of the study was to measure the degree of premaxillary protrusion in fetuses with orofacial clefts of various severities. METHODS: The maxilla-nasion-mandible (MNM) angle was measured retrospectively on by multiplanar corrected volumes. Sixty-two fetuses with orofacial clefts and known outcome volumes of the fetal head were available. RESULTS: In 48 of the 62 cases, the MNM angle could be measured [mean gestational age 23 (range, 18-30) weeks]. The mean MNM angle was normal in all nine cases with cleft lip and intact alveolar ridge (15.2°; range, 12.5°- 16.9°). In 24 cases with unilateral cleft lip with or without cleft palate (UCL/P), the mean MNM angle was 20.0° (range, 13.3-26.2°), being above the 95th percentile in 79% (n = 19) and normal in 21% (n = 5). In 14 bilateral cleft lip and palate (BCL/P) cases, the mean MNM angle was 26.5° (range, 19.2°-33.7°) and above the 95th percentile in all cases. There was no difference in MNM angle between isolated clefts and clefts associated with other anomalies. In one case with a Tessier 4 cleft, the MNM angle was above the 95th percentile (25.2°). CONCLUSION: The premaxilla tends to protrude in both BCL/P as UCL/P cases. The degree of protrusion varies greatly, especially in the BCL/P group.

Three-dimensional ultrasound and maternal bonding, a third trimester study and a review.

OBJECTIVE: To compare the effect of third trimester three-dimensional and four-dimensional (3D/4D) versus two-dimensional (2D) ultrasound (US) of the fetal face on maternal bonding. Studies quantifying the psychological effect of 3D/4D US on mothers, pregnant of a fetus with no detectable abnormalities, were reviewed. METHODS: One hundred sixty Caucasian women attended a third trimester 3D/4D or 2D US examination. Women filled out the Maternal Antenatal Attachment Scale (MAAS) 1 to 2 weeks before (MAAS1) and 1 to 2 weeks after (MAAS2) the US examination. Visibility, recognition and attractiveness were assessed. RESULTS: Within both US groups, the MAAS2 scores were significantly higher than the MAAS1 scores (p < 0.0001). No differences in MAAS scores between the US groups emerged. Visibility and recognition were significantly positively related with the increase in MAAS scores (p = 0.003 and p = 0.042) in the 3D/4D group. Of 13 psychological studies, eight studies evaluated bonding and found no difference between 3D/4D and 2D US. The effect of 3D/4D US on satisfaction or perception showed conflicting results, and on anxiety/stress, reduction was the same as after 2D US. CONCLUSIONS: Bonding increases after either a 3D/4D or 2D US. The effect of 3D/4D US on bonding is stronger at better degrees of visibility and recognition.

Prenasal thickness-to-nasal bone length ratio: a strong and simple second- and third-trimester marker for trisomy 21.

OBJECTIVES: To study the ratio of prenasal thickness (PT) to nasal bone length (NBL) in normal and trisomy-21 fetuses in the second and third trimesters of pregnancy. METHODS: The PT and NBL were measured retrospectively in 106 normal fetuses (in three-dimensional (3D) volumes) and in 30 fetuses with trisomy 21 (10 on two-dimensional (2D) images and 20 in 3D volumes). RESULTS: In normal fetuses the mean PT and NBL increased between 15 and 33 weeks' gestation from 2.3 to 6.1 mm (r = 0.85, P < 0.001) and from 3.3 to 9.6 mm (r = 0.87, P < 0.001), respectively. The PT : NBL ratio was stable throughout gestation, with a mean of 0.61 (95% CI, 0.59-0.63; r = - 0.04, P = 0.7). The 5(th) and 95(th) percentiles were 0.48 and 0.80, respectively. In trisomy-21 fetuses the mean PT and NBL increased between 14 and 34 weeks from 3.0 to 9.2 mm (r = 0.86, P < 0.001) and from 1.9 to 7.8 mm (r = 0.85, P < 0.001), respectively. The PT : NBL ratio was significantly higher than in normal fetuses (P < 0.001) but also stable throughout gestation, with a mean of 1.50 (95% CI, 1.20-1.80; r = - 0.35, P = 0.07). Twenty-three (77%) of the 30 fetuses with trisomy 21 had a PT above the 95(th) percentile and 20 (67%) had an NBL below the 5(th) percentile. All the trisomy-21 fetuses had a PT : NBL ratio above the 95(th) percentile. When the 95(th) percentile of the PT : NBL ratio was used as a cut-off value the detection and false positive rates for trisomy 21 were 100 (95% CI, 89-100)% and 5 (95% CI, 2-11)%, respectively. The positive likelihood ratio was 21.2. CONCLUSIONS: The PT : NBL ratio is stable in the second and third trimesters of pregnancy in both normal and trisomy-21 fetuses, but all trisomy-21 fetuses in this series had a PT : NBL ratio above the 95(th) percentile. The ratio is therefore a strong marker for trisomy 21.

Three-dimensional ultrasound imaging and measurement of nasal bone length, prenasal thickness and frontomaxillary facial angle in normal second- and third-trimester fetuses.

OBJECTIVES: To assess the feasibility of nasal bone length (NBL), prenasal thickness (PT) and frontomaxillary facial (FMF) angle measurements performed on the same three-dimensional (3D) multiplanar-corrected profile view in healthy second- and third-trimester fetuses, to create reference ranges and to review published measurement techniques. METHODS: 3D volumes of 219 healthy second- and third-trimester fetuses were retrospectively analyzed. The quality of images and measurability of the markers were assessed with 5-point and 3-point scoring systems, respectively. Measurements of NBL (with care to exclude the frontal bone), PT and FMF were obtained in the exact mid-sagittal plane. Reference ranges were constructed based on measurements from images with high-quality (4 or 5 points) and high measurability (2 or 3 points) scores and compared with those in the most relevant published literature. RESULTS: A high-quality score was assigned to 111 images. Among these, a high measurability score was significantly more often achieved for NBL (98.2%) and PT (97.3%) than for the FMF angle (26.1%) (P < 0.001). Both NBL (NBL = - 6.927 + (0.83 × GA) - (0.01 × GA(2))) and PT (PT = (0.212 × GA) - 0.873) (where GA = gestational age) showed growth with gestation, with less pronounced growth for NBL after 28 weeks. Our reference range for the NBL showed a systematically smaller length than those in other two-dimensional (2D) ultrasound-based publications. The FMF angle measurements that we obtained did not show a significant change with GA. CONCLUSIONS: NBL and PT are easily measured using 3D ultrasound whereas FMF angle measurement is more challenging. When it is measured in the exact mid-sagittal plane and care is taken to exclude the frontal bone, measurements of the NBL are systematically smaller than those in previous 2D ultrasound-based publications.

No firm association between N-terminal pro-brain natriuretic peptide and percentage of pulmonary vascular obstruction in patients with acute pulmonary embolism.

INTRODUCTION: High concentrations of N-terminal-pro-brain natriuretic peptide (NT-proBNP) are found in patients with right ventricular overload. Right ventricular overload may be the result of large perfusion defects in patients with pulmonary embolism (PE). NT-proBNP levels are associated with poorer outcome in patients with acute PE. Likewise, the percentage of pulmonary vascular obstruction (PVO) has shown to be a prognostic parameter for outcome in PE-patients. We postulated that NT-proBNP is associated with the amount of perfusion defects, expressed as the PVO, on perfusion scintigraphy. METHODS: We included 85 consecutive patients in whom the diagnosis PE was confirmed by ventilation-perfusion scintigraphy. PVO was calculated in all patients. NT-proBNP concentrations were measured at presentation. We plotted the logarithm of NT-proBNP versus the PVO. The strength of the estimated association between NT-proBNP and the PVO was expressed by R2. RESULTS: Eighteen percent of the variation in PVO could be explained by NT-proBNP. A positive association becomes apparent for NT-proBNP values above 200 pg/mL, with an increase in PVO of 6.3% (95% Confidence Interval 2.0 to 10.6), with every doubling of NT-proBNP. CONCLUSION: There is an association between NT-proBNP concentrations and PVO, although this relation is quite weak. Some patients with low NT-proBNP values can have a high PVO, which might be relevant for outcome. Therefore, we advise caution in risk stratification and not to focus on NT-proBNP, without involving the clinical condition.

Maxilla-nasion-mandible angle: a new method to assess profile anomalies in pregnancy.

OBJECTIVES: To collect normative data and test the feasibility and reproducibility of measurement of the maxilla-nasion-mandible (MNM) angle between 16 and 36 weeks' gestation and its diagnostic ability in a group of pathological cases. METHODS: The MNM angle is defined as the angle between the intersection of the maxilla-nasion and mandible-nasion lines in the exact mid-sagittal plane. After assessing reproducibility, the MNM angle was measured in 3D volumes in 241 fetuses cross-sectionally and in 11 fetuses longitudinally. The MNM angle was then tested in 18 pathological cases with facial malformations or syndromes with specific facial features. RESULTS: The MNM angle could be measured in 92.3% of normal fetuses. Intra- and interobserver intraclass correlation coefficient (ICC) variability was 0.92 and 0.81, respectively. The difference between paired measurements performed by one or two observers was less than 2.5° and 3.6°, respectively in 95% of the cases. The mean MNM angle was 13.5° and did not change significantly during pregnancy (r = - 0.08, P = 0.25). The MNM angle was above the 95(th) centile in all cases of retrognathia and maxillary alveolar ridge interruption. The MNM angle was below the 5(th) centile in Apert syndrome, thanatophoric dysplasia and in two of the three Down syndrome cases. CONCLUSIONS: The feasibility and reproducibility of measurement of the MNM angle is good. The MNM angle can be used to evaluate the convexity of the fetal profile by enabling an objective assessment of the anteroposterior relationship of the jaws and it may therefore be of help in the diagnosis of retrognathia, maxillary alveolar ridge interruption and flat profile.

Three-dimensional multiplanar ultrasound is a valuable tool in the study of the fetal profile in the second trimester of pregnancy.

OBJECTIVES: To evaluate the additional value of three-dimensional (3D) multiplanar ultrasound in the examination of the fetal profile. METHODS: Two 3D volumes of the fetal head were obtained from 84 fetuses at 22 to 29 weeks' gestation. The volumes were taken starting at the midsagittal plane with the fetus facing the transducer. The success rate and acquisition time to obtain each volume and display the exact midsagittal plane by 3D multiplanar ultrasound were analyzed. The correction angles from the original two-dimensional (2D) profile view to the exact midsagittal plane were noted. Of six measurements, related to the fetal nose and jaws, the success rate and the intraobserver reproducibility between the 2D and the 3D multiplanar ultrasound were compared. RESULTS: In 81 (96.4%) cases we succeeded in obtaining a profile volume, 70% of the volumes being obtained within 10 min. It was possible to define by multiplanar mode the exact midsagittal plane in less than 1 min. The mean rotation necessary to obtain the exact midsagittal plane with 3D multiplanar mode was significantly larger around the y-axis (11.9 degrees ) than around the z-axis (4.3 degrees ) of the fetus. For between 5 and 12% of the six measurements under investigation it was not possible to obtain values with 2D ultrasound. However, 3D ultrasound made these measurements possible in at least one volume. The intraobserver reproducibility was higher with 3D multiplanar ultrasound than with 2D ultrasound, this difference being statistically significant for five of the six measurements. CONCLUSIONS: 3D multiplanar ultrasound improves the topographic depiction of the midsagittal profile view, enables correct measurement of anatomical details and improves intraobserver reproducibility. 3D multiplanar ultrasound is a powerful instrument for investigating the fetal profile.

No change in rectal sensitivity after gut-directed hypnotherapy in children with functional abdominal pain or irritable bowel syndrome.

OBJECTIVES: Gut-directed hypnotherapy (HT) has recently been shown to be highly effective in treating children with functional abdominal pain (FAP) and irritable bowel syndrome (IBS). This study was conducted to determine the extent to which this treatment success is because of an improvement in rectal sensitivity. METHODS: A total of 46 patients (aged 8-18 years) with FAP (n=28) or IBS (n=18) were randomized to either 12 weeks of standard medical therapy (SMT) or HT. To assess rectal sensitivity, a pressure-controlled intermittent distension protocol (barostat) was performed before and after the therapy. RESULTS: Rectal sensitivity scores changed in SMT patients from 15.1+/-7.3 mm Hg at baseline to 18.6+/-8.5 mm Hg after 12 weeks of treatment (P=0.09) and in HT patients from 17.0+/-9.2 mm Hg to 22.5+/-10.1 mm Hg (P=0.09). The number of patients with rectal hypersensitivity decreased from 6 of 18 to 0 of 18 in the HT group (P=0.04) vs. 6 of 20 to 4 of 20 in the SMT group (P=0.67). No relationship was established between treatment success and rectal pain thresholds. Rectal sensitivity scores at baseline were not correlated with intensity, frequency, or duration of abdominal pain. CONCLUSIONS: Clinical success achieved with HT cannot be explained by improvement in rectal sensitivity. Furthermore, no association could be found between rectal barostat findings and clinical symptoms in children with FAP or IBS. Further studies are necessary to shed more light on both the role of rectal sensitivity in pediatric FAP and IBS and the mechanisms by which hypnotherapy results in improvement of clinical symptoms.

A risk profile for identifying community-dwelling elderly with a high risk of recurrent falling: results of a 3-year prospective study.

INTRODUCTION: The aim of the prospective study reported here was to develop a risk profile that can be used to identify community-dwelling elderly at a high risk of recurrent falling. MATERIALS AND METHODS: The study was designed as a 3-year prospective cohort study. A total of 1365 community-dwelling persons, aged 65 years and older, of the population-based Longitudinal Aging Study Amsterdam participated in the study. During an interview in 1995/1996, physical, cognitive, emotional and social aspects of functioning were assessed. A follow-up on the number of falls and fractures was conducted during a 3-year period using fall calendars that participants filled out weekly. Recurrent fallers were identified as those who fell at least twice within a 6-month period during the 3-year follow-up. RESULTS: The incidence of recurrent falls at the 3-year follow-up point was 24.9% in women and 24.4% in men. Of the respondents, 5.5% reported a total of 87 fractures that resulted from a fall, including 20 hip fractures, 21 wrist fractures and seven humerus fractures. Recurrent fallers were more prone to have a fall-related fracture than those who were not defined as recurrent fallers (11.9% vs. 3.4%; OR: 3.8; 95% CI: 2.3-6.1). Backward logistic regression analysis identified the following predictors in the risk profile for recurrent falling: two or more previous falls, dizziness, functional limitations, weak grip strength, low body weight, fear of falling, the presence of dogs/cats in the household, a high educational level, drinking 18 or more alcoholic consumptions per week and two interaction terms (high education x 18 or more alcohol consumptions per week and two or more previous falls x fear of falling) (AUC=0.71). DISCUSSION: At a cut-off point of 5 on the total risk score (range 0-30), the model predicted recurrent falling with a sensitivity of 59% and a specificity of 71%. At a cut-off point of 10, the sensitivity and specificity were 31% and 92%, respectively. A risk profile including nine predictors that can easily be assessed seems to be a useful tool for the identification of community-dwelling elderly with a high risk of recurrent falling.

Angst om te vallen: psychometrische aspecten van Tinetti's Falls Efficacy Scale.

In this article we report on the psychometric characteristics of Tinetti's Falls Efficacy Scale. It appears that the scale is homogeneous and has good internal consistency. Expected associations with age, gender, physical activity, chronic diseases and history of falls were confirmed. It is concluded that the scale is a reliable and valid instrument to measure fear of falling in performing everyday activities inside the house.

Ischemic preconditioning and the beta-adrenergic signal transduction pathway.

BACKGROUND: Previous studies from our laboratory showed cyclic increases in tissue cAMP during a multiple-cycle preconditioning (PC) protocol, followed by attenuated cAMP accumulation during sustained ischemia. The aim of this study was to determine whether ischemia-induced activation of the beta-adrenergic signaling pathway could act as a trigger in eliciting protection. METHODS AND RESULTS: Isolated perfused rat hearts were preconditioned by 3x5 minutes of global ischemia, interspersed by 5 minutes of reperfusion. beta-Adrenergic responsivity was assessed by measurement of tissue cAMP generation after beta-adrenergic agonist administration at the end of the PC protocol. Tissue cAMP, adenylyl cyclase, and protein kinase A (PKA) activities and beta-adrenergic receptor characteristics were assessed at different times. The role of cAMP generation in eliciting PC was studied by investigation of functional recovery during reperfusion after 25 minutes of global ischemia after (1) cAMP increases in the trigger period were prevented with the beta-adrenergic blocker alprenolol 7.5x10(-5) mol/L and (2) increases in cAMP were elicited by administration of forskolin 10(-7) and 10(-6) mol/L or isoproterenol 10(-8), 10(-7), and 10(-6) mol/L. Intermittent ischemia resulted in reduced beta-adrenergic responsivity at the end of the protocol, although B(max) and K(d) values of the beta-adrenergic receptor population and adenylyl cyclase and PKA activities were increased. Abolishment of cyclic increases in cAMP before sustained ischemia attenuated myocardial protection against ischemia, whereas agonists elicited protection. No clear correlation between protection and beta-adrenergic desensitization was observed. CONCLUSIONS: Ischemia-induced activation of the beta-adrenergic signaling pathway during preconditioning should also be considered a trigger in eliciting preconditioning.

Long-term effect of hyperbaric oxygenation treatment on chronic distressing tinnitus.

Tinnitus is still a phenomenon with an unknown pathophysiology with few therapeutic measures. During the last two decades, hyperbaric oxygenation therapy (HBO) has been used in the treatment of sudden deafness and chronic distressing tinnitus. In this study, we prescribed HBO to 20 patients who had had severe tinnitus for more than one year and who had already had other forms of tinnitus therapy with unsatisfactory results. Four patients could not cope with the pressure gradient. The effect of HBO was assessed using subjective evaluation and VAS scores before and after HBO. Follow-up continued until one year after treatment. Six patients had a reduction of tinnitus and accompanying symptoms, eight patients did not notice any change and two patients experienced an adverse effect. Any outcome persisted with minor changes until one year after treatment. HBO may contribute to the treatment of severe tinnitus, but the negative effect on tinnitus should be weighed carefully.