Age-related patterns in high-risk alcohol and cannabis use and their associations with positive and negative affect in young adulthood.

OBJECTIVE: We examined age-varying associations between young adult simultaneous alcohol and marijuana/cannabis use (SAM) and heavy episodic drinking (HED) and positive and negative affect to inform harm reduction efforts. METHODS: Young adults reporting past-year alcohol use (n = 556; ages 19-25) were recruited in a state where alcohol and nonmedical cannabis use was legal for those 21 +. Participants provided 24 repeated monthly assessments. Among those reporting past-month cannabis use on at least one survey, logistic time-varying effect models estimated (1) the age-varying prevalence of and associations between past-month SAM and HED and (2) age-varying unique associations of affect with SAM and HED. RESULTS: There was a positive age-varying association between HED and SAM over time that was highest at age 19 (OR = 7.56), decreased until age 20.7 (OR = 3.39), increased until age 23.0 (OR = 4.85), and decreased until the association became non-significant by age 25. Negative affect was positively associated with SAM from ages 20.7 to 23.0, peaking at age 21.8 (OR = 1.36). Positive affect was positively associated with HED from ages 19.4 to 20.4 (peak OR = 1.25) and ages 22.5 to 24.5 (peak OR = 1.38). In contrast, positive affect was not uniquely associated with SAM nor negative affect with HED across ages 19-25. CONCLUSIONS: While HED and SAM were positively associated throughout young adulthood and interventions could target them in tandem, their associations with affect suggest differential etiologic processes. Preventive intervention and harm reduction efforts should attend to psychological context in which these behaviors occur.

Internet use habits and influenza vaccine uptake among US adults: results from seven years (2012-2018) of the National Health Interview Survey.

STUDY DESIGN: This is a Cross-sectional data analysis study. OBJECTIVES: Our goal was to examine the association between internet use habits and influenza vaccination uptake using a nationally representative sample of non-institutionalised US adults. STUDY DESIGN: This is a Cross-sectional data analysis study. METHODS: We pooled data from seven years (2012-2018) of the National Health Interview Survey for secondary data analysis (N = 220,570). We estimated influenza vaccination uptake among different population groups. We performed multivariable logistic regression models with influenza vaccination uptake as a dichotomous dependent variable. RESULTS: Influenza vaccination uptake was highest among those who used the internet for formal health information and communication with a provider (55.1%), and lowest among those internet users who did not use the internet for any type of formal or informal health information and communication (35.6%). About 45.2% of non-internet users received an influenza vaccination during the last 12 months. After controlling for covariates, compared with those who did not use the internet, adults who used the internet for formal health information and communication with providers were 1.52 times more likely to uptake an influenza vaccine (odds ratio [OR] = 1.52; 95% confidence interval [CI] = 1.45-1.59). Internet users who did not use the internet for any health information were significantly less likely to get vaccinated against influenza (OR = 0.92; 95% CI = 0.88-0.96). CONCLUSIONS: It appears that internet use habit impacts influenza vaccination uptake. Internet users who do not use the internet for any formal or informal health information tend to have lower rates of influenza vaccine uptake than other groups. Customised interventions for different populations based on their internet use habits can help increase the national influenza vaccination rate and other immunisation efforts for contagious diseases.

Cutaneous Adnexal Cylindroma of Breast: Epithelial Immunoreactivities for GATA-3, Mammaglobin, and E-Cadherin Do Not Equate to a Mammary Ductal Neoplasm.

Cylindromas are benign epithelial neoplasms derived from cutaneous eccrine adnexal structures. These tumors are most commonly encountered on the head, neck, and scalp of older women. In rare instances, solitary cylindromas may arise at other body sites. In the current case, a cylindroma of the skin of the breast was diagnosed by complete excision. Immunohistochemical studies confirmed the tumor cells to be immunoreactive with cytokeratin AE1/3, cytokeratin 5/6, cytokeratin 7, p63, and SOX10. The neoplastic cells were also noted to be immunoreactive with markers typically expected to be positive in ductal epithelium of the breast including GATA3, mammaglobin, and E-cadherin. The case emphasizes the importance of correlating clinical setting, imaging studies, patient history, and careful microscopic evaluation in arriving at an accurate diagnosis. This case also illustrates the point that not all "breast" tumors that are confirmed to be positive for GATA3, mammaglobin, and E-cadherin are derived from mammary ducts.

Transfusion support for a patient with McLeod phenotype without chronic granulomatous disease and with antibodies to Kx and Km.

BACKGROUND AND OBJECTIVES: Kell antigens are encoded by the KEL gene on the long arm of chromosome 7. Kx antigen is encoded by the XK gene on the short arm of the X chromosome. Kell and Kx proteins in the red cell membrane are covalently linked by a disulphide bond. The McLeod phenotype is characterized by weakened expression of antigens in the Kell blood group system, absence of Km and Kx antigens, and acanthocytosis. It has an X-linked mode of inheritance with transmission through carrier females. Some males with the McLeod syndrome also have chronic granulomatous disease (CGD). It is generally believed that patients with non-CGD McLeod may develop anti-Km but not anti-Kx, but that those with CGD McLeod can develop both anti-Km and anti-Kx. MATERIALS AND METHODS: We present serological data, DNA genotyping and gene sequencing, monocyte monolayer assay and neutrophil oxidative burst test from a patient with the McLeod phenotype without clinical evidence of CGD. RESULTS: We report here the second example of a patient with non-CGD McLeod who developed anti-Kx in addition to anti-Km. Sequencing of our patient's XK gene confirmed the presence of a mutation resulting in a premature stop codon and lack of Kx protein in the red cell membrane, which is consistent with the diagnosis of McLeod syndrome. Neutrophil oxidative burst test was normal, indicating that our patient did not have CGD. The challenge of providing 10 compatible blood units for multiple surgeries was met. CONCLUSION: The second case of a rare entity, a patient with non-CGD McLeod who developed anti-Kx and anti-Km, was managed successfully with a combination of autologous donations and procurement of compatible units from national and international sources.

Effects of lipodystrophy on quality of life and depression in HIV-infected men on HAART.

The aim of the study was a prospective assessment of the possible consequences of a diagnosis of lipodystrophy on health-related quality of life (HRQL) and depressive symptomatology in HIV-seropositive men who have sex with men. A standardized physical assessment for lipodystrophy was introduced within a prospective study in April 1999. Over a 2-year follow- up, 37 HIV-seropositive men who met the criteria for lipodystrophy were longitudinally compared to 92 HIV-seropositive men without lipodystrophy and 88 HIV-seronegative men on measures of HRQL and depression. A series of questionnaires, which included the Medical Outcomes Study Short-Form 36 (SF-36) and the Center for Epidemiological Studies-Depression (CES-D), were administered to assess HRQL and depression, respectively. SF-36 scores were summarized using the mental and physical components; CES-D results were reported as both dichotomous (with or with clinical depression) and continuous scores. Neither the mental nor physical components of the SF-36 showed any significant differences between patients with lipodystrophy versus HIV-seropositive patients without lipodystrophy. Similarly, lipodystrophy status was not significantly associated with either continuous depression scores or presence of clinical depression. However, consistent with previous results, HIV-seropositive men without lipodystrophy (compared to HIV-seronegative men) reported higher scores on both components of the SF-36 scales and both categorizations of the CES-D. The results of this study suggest that lipodystrophy does not negatively affect HRQL or depression, above and beyond, the diagnosis of HIV infection, although the impact of the severity of lipodystrophy on these conditions will require further study.

The natural history of pelvic organ support in pregnancy.

Little is known about the anatomic and physiologic changes in the pelvic floor that occur during pregnancy. The purpose of this study was to prospectively document pelvic organ support throughout pregnancy using the standardized system of the International Continence Society, also known as the Pelvic Organ Prolapse Quantification (POPQ) Staging System. Pelvic organ support evaluations were performed in nulliparous pregnant women presenting for routine obstetric care during each trimester. POPQ stage assignments and POPQ component measurements were compared for first-, second- and third-trimester examinations. Overall POPQ stage was significantly higher in the third trimester than in the first (P=0.001). Individual POPQ points which showed significant differences between the first and third trimesters include Aa, PB, Ap, Ba, Bp, TVL and GH. These findings probably represent normal physiologic changes of the pelvic floor during pregnancy, but suggest that significant changes may be objectively demonstrated prior to delivery.

The effects of hypoxia and hyperoxia on fetal-placental vascular tone and inflammatory cytokine production.

OBJECTIVE: To determine the effects of fetal hypoxia and hyperoxia on placental vascular tone and production of interleukin-6 and tumor necrosis factor-alpha. STUDY DESIGN: The maternal and fetal circulation of 2 cotyledons from 5 human placentas were perfused for 4 hours. The fetal circulation of 1 cotyledon was perfused with hypoxic Hanks' balanced salt solution; the other was perfused with hyperoxic Hanks' balanced salt solution. Fetal vascular pressures were recorded every 10 minutes, and fetal vein effluents were collected hourly. RESULTS: Fetal-placental vascular perfusion pressure was reduced from baseline during hypoxic conditions. Cytokine concentrations were elevated during hyperoxic conditions compared with hypoxic conditions, with significant differences achieved at 2, 3, and 4 hours for interleukin-6 and at 4 hours for tumor necrosis factor-alpha. CONCLUSION: Fetal-placental vasodilation may be a compensatory mechanism to improve hypoxic conditions. Supraphysiologic oxygenation may contribute to the fetal inflammatory response syndrome and to the development of cerebral palsy.

Neuroleptic malignant syndrome in pregnancy.

BACKGROUND: Neuroleptic malignant syndrome can be a serious neurologic complication of drug therapy during pregnancy. CASE: A young woman was admitted to the intensive care unit with worsening varicella pneumonia. After being given haldol for agitation, she developed fever, increasing agitation, rigidity, tachycardia, and tremors; she was diagnosed as having neuroleptic malignant syndrome. She was treated successfully with bromocriptine and dantrolene. CONCLUSION: Despite the common use of antipsychotic medications, neuroleptic malignant syndrome is seen infrequently during pregnancy. The diagnosis can be difficult to make, but if suspected, it can be treated successfully.

Perinatal hospice.

When the prenatal diagnosis of a lethal fetal anomaly has been established, some patients choose to continue their pregnancy. Currently, there is a paucity of medical literature addressing the specific management of families in this unique circumstance. We propose a model of care that incorporates the strengths of prenatal diagnosis, perinatal grief management, and hospice care to address the needs of these families. We discuss the identification of candidates for this form of care; the multidisciplinary team approach; and the aspects of antepartum, intrapartum, and postpartum care. Finally, we discuss some barriers that might need to be overcome when attempting to implement perinatal hospice care.

Ceftizoxime-induced hemolysis secondary to combined drug adsorption and immune-complex mechanisms.

BACKGROUND: Immune hemolytic anemia has been associated with the administration of various antibiotics, including cephalosporins. Presented here is a patient who developed severe acute hemolysis while receiving ceftizoxime (Ceftizox, Fujisawa USA), a third-generation cephalosporin. This is the fourth reported case of hemolysis in association with ceftizoxime. In the previous cases, ceftizoxime was shown to induce hemolysis by the immune-complex mechanism. However, in one of those reports, the concentration of drug used to treat the target RBCs in vitro may not have been optimal. CASE REPORT: The patient's antemortem blood samples were analyzed retrospectively for drug-dependent antibodies by the drug-adsorption and immune-complex methods. Antibody class and titer were evaluated. RESULTS: The patient's sample agglutinated RBCs coated with ceftizoxime as well as uncoated RBCs in the presence of ceftizoxime. The antibodies to ceftizoxime were IgM and IgG. CONCLUSION: This is the first report on both the immune-complex and drug-adsorption mechanisms of ceftizoxime-induced hemolysis. The differential diagnosis of a falling Hct in a patient receiving antibiotics should include drug-related hemolysis; once this diagnosis is considered, management includes the appropriate serologic workup, immediate cessation of the implicated drugs, and possible transfusion support.

Perinatal outcome following fetal single umbilical artery diagnosis.

OBJECTIVE: We report the frequency of associated congenital abnormalities in fetuses with a single umbilical artery as well as the sensitivity, specificity, positive predictive value and negative predictive value of ultrasound for detecting these abnormalities. We also report the pregnancy outcome of fetuses complicated by single umbilical artery, both isolated and with other congenital anomalies. METHODS: All pregnancies complicated by fetal single umbilical artery from 1995 to 1999 were identified. A retrospective chart review was performed on both the prenatal records and the ultrasound records of these pregnancies, determining the nature and incidence of other congenital abnormalities. Delivery data were collected to include gestational age at delivery, Apgar score, birth weight, mode of delivery, fetal gender and any complications. RESULTS: Ninety-two pregnancies were identified with a fetal single umbilical artery, of which outcome data were available for 65. Forty-eight (74%) cases were identified as isolated single umbilical artery. Seventeen (26%) cases had other congenital abnormalities. High-resolution ultrasound had 100% sensitivity and specificity for identifying single umbilical artery and an 85% sensitivity and 98% specificity for detecting other congenital abnormalities. Compared to isolated single umbilical artery, pregnancies complicated by single umbilical artery with other abnormalities had a statistically significantly increased rate of fetal aneuploidy, lower birth weight, preterm delivery and Cesarean delivery. CONCLUSION: Pregnancies complicated by fetal single umbilical artery, especially when associated with other congenital abnormalities, are at increased risk for adverse pregnancy outcome.

Influence of gestational age and maternal height on fetal femur length calculations.

OBJECTIVE: To determine whether current methods of detecting Down syndrome based on fetal femur length calculations are influenced by gestational age or maternal height. METHODS: Four formulas were used to calculate expected femur length (FL) based on the fetal biparietal diameter (BPD) between 15 0/7 weeks' gestation and 19 6/7 weeks' gestation. For each gestational age, the BPD:FL ratio for women shorter than one standard deviation (SD) below the mean height was compared with the ratio for women taller than one SD above the mean height. A measured:expected FL ratio of 0.91 or less and a BPD:FL ratio greater than 1.5 SD above the mean was considered abnormal. RESULTS: The four formulas used to calculate measured:expected FL ratios were significantly more likely to be abnormal at 15--16 weeks' gestation, compared with 18-19 weeks' gestation (P <.05). Maternal height correlated with femur lengths at 18 and 19 weeks' gestation (P <.05) but not at earlier gestational ages. At 18 and 19 weeks' gestation, women shorter than one SD below the mean were twice as likely to have an abnormal BPD:FL ratio compared with women taller than one SD above the mean (relative risk 2.38; 95% confidence interval 1.21, 4.69). CONCLUSION: Early gestational age increases a woman's risk of having an abnormal measured:expected FL ratio, whereas short stature increases a woman's risk of having an abnormal BPD:FL ratio at later gestational ages. These findings indicate that risk assessment for fetal Down syndrome for such patients might be inaccurate. (Obstet Gynecol 2001;97:742-6.

Extreme elevation of maternal serum alpha-fetoprotein associated with mosaic trisomy 8 in a liveborn.

Constitutional mosaic trisomy 8 has been associated with syndromic dysmorphology, corneal opacities, leukemias, and trophoblastic disease. However, abnormal maternal serum alpha-fetoprotein (MSAFP) has not been reported in association with mosaic trisomy 8. Our case first presented for evaluation of an extremely elevated MSAFP with mild elevation of MShCG in an otherwise normal pregnancy: MSAFP 13.89 MoM, MShCG 3.57 MoM, and MSuE3 1.04 MoM. Fetal dysmorphism was limited to bilateral pyelectasis and a prominent third ventricle. Spontaneous labor at 38 weeks resulted in the birth of a 3,570-gram AGA male with APGARs 7(1)/8(5). The neonate had facial asymmetry, 5th finger clinodactyly, 2-3 toe syndactyly, undescended testicle, abnormal prepuce, and mild pyelectasis. CT scan revealed hypoplasia of the corpus callosum, while echocardiography demonstrated bicuspid aortic valve, and the neonatal karyotype (blood) returned 46,XY/47,XY+8. Evaluation at 3 months revealed more prominent facial asymmetry, plagiocephaly, plantar creases, descent of the testis, and mild developmental delay. Review of the literature does not include any previously reported maternal serum alpha-fetoprotein aberrations in mosaic trisomy 8.

Aneuploidy and isolated mild ventriculomegaly. Attributable risk for isolated fetal marker.

BACKGROUND: Does the prenatal ascertainment of isolated mild ventriculomegaly increase the a priori risk for aneuploidy when isolated or not associated with advanced maternal age? Does isolated mild ventriculomegaly increase the risk for pediatric developmental delay? METHODS: The Wayne State University (WSU) Reproductive Genetics abnormal case data base and the Madigan Army Medical Center (MAMC) experience were reviewed to compare the rates of aneuploidy for cases with fetal ventriculomegaly. Cases were classified by maternal age and associated sonographic markers of aneuploidy. Aneuploidy rates were compared between the isolated ventriculomegaly, ventriculomegaly with advanced maternal age (AMA), and ventriculomegaly associated with multiple anomalies. Rates of aneuploidy were compared to identify association. RESULTS: A total of 118 cases with ventriculomegaly were identified for comparison. Ninety-four cases were identified in the WSU cohort; 46 demonstrated isolated ventriculomegaly alone, and aneuploidy was present in 3/25 (12%) with invasive fetal testing, 0/24 (0%) cases in the MAMC cohort demonstrated aneuploidy. Isolated mild ventriculomegaly cases at MAMC were identified for further tests. DISCUSSION: Although the two study populations vary in age and risk distributions, the attributable risk for isolated mild ventriculomegaly poses a counseling conundrum due to the neurodevelopmental implication of this minor dysmorphism more so than its association with aneuploidy.

Parental decision-making differences between patients in two healthcare systems for choroid plexus cysts.

OBJECTIVE: We evaluated the medical-sociological implications of parental perception of risk and decision-making choices for prenatally ascertained choroid plexus cysts (CPCs) between two obstetric populations with similar clinical situations. METHODS: The Wayne State University (WSU) Reproductive Genetics database and the Madigan Army Medical Center (MAMC) experience were reviewed to compare the rates of aneuploidy and invasive testing for cases with CPC. Aneuploidy rates were compared between those with isolated CPC, CPC with advanced maternal age (AMA), and CPC associated with multiple anomalies. RESULTS: 186 cases were identified in the WSU cohort, of whom 27 (15%) declined invasive fetal testing. In the remaining 159 cases, aneuploidy was present in 2/132 (1.5%) isolated CPCs, 3/11 (27%) CPCs with AMA, and 15/16 (93%) CPCs with multiple anomalies. 107 cases were identified in the MAMC cohort, of whom 99 (92%) declined invasive fetal testing. No cases of aneuploidy were found in the 3/12 AMA cases or 5/95 non-AMA cases who underwent amniocentesis. CONCLUSIONS: The 2 cases of aneuploidy with isolated CPC cannot be ignored, and provide an estimated attributable risk of at least 0.8%, a higher risk than 38 years of age. However, the parental sociologic context may be as important as the genetic-prognostic risk for decision-making.

Vasodilatory response of fetoplacental vasculature to adrenomedullin after constriction with the thromboxane sympathomimetic U46619.

OBJECTIVE: This study was undertaken to determine whether adrenomedullin, a hypotensive peptide, decreases vasomotor tone in fetoplacental vasculature that has been constricted with the thromboxane sympathomimetic U46619. STUDY DESIGN: The fetoplacental vascular beds of 20 perfused human placental cotyledons were vasoconstricted with a continuous infusion of U46619 (10(-8) mol/L). The vasculature was then sequentially injected with deionized water, 30 ng adrenomedullin, 300 ng adrenomedullin, and 3000 ng adrenomedullin. Any change in perfusion pressure was noted after each dose. In a separate experiment the fetoplacental vasculature in 2 perfused cotyledons from each of 10 placentas was vasoconstricted with U46619 (10(-8) mol/L). Adrenomedullin was infused continuously at either 200 ng/min (n = 5) or 2000 ng/min (n = 5) for 40 minutes. A corresponding control cotyledon from each placenta had isotonic sodium chloride solution added to its perfusion. Perfusion pressures were recorded every minute during the infusion and for 40 minutes afterward. Analysis of variance was used to compare pressure changes in the cotyledons that received bolus doses of adrenomedullin. Paired t tests of mean percentage pressure changes were used to compare the study and control groups that received the continuous infusions. RESULTS: In the cotyledons that received bolus doses of adrenomedullin, the mean (+/-SEM) percentage perfusion pressure changes from the baseline were -6.7 +/- 0.5 for 30 ng adrenomedullin (P =.0039), -8.5+/- 0.7 for 300 ng adrenomedullin (P <.0001), and -13.1 +/- 1.0 for 3000 ng adrenomedullin (P <.0001). With the continuous adrenomedullin infusion of 200 ng/min, there was no significant difference in the mean percentage pressure change from baseline between the study and control groups (-0.57%). At 2000 ng/min there was a significant difference (-15.34%; P <.0001). CONCLUSION: Adrenomedullin caused vasodilatation of fetoplacental vasculature previously constricted with the thromboxane sympathomimetic U46619 in the isolated perfused placental cotyledon. This vasodilatation occurred in a dose-dependent manner.

Localization of messenger ribonucleic acid for adrenomedullin and adrenomedullin receptor in the human placenta in normal pregnancies and pregnancies complicated by oligohydramnios.

OBJECTIVE: The purpose of this study was to identify the placental expression of adrenomedullin and adrenomedullin receptor messenger ribonucleic acid and compare them between placentas from pregnancies associated with oligohydramnios as a result of uteroplacental insufficiency and placentas from normal pregnancies. STUDY DESIGN: Total ribonucleic acid was extracted from the amnion, chorion, cotyledon, umbilical vein, and umbilical artery in 5 normal placentas and 3 placentas from pregnancies complicated by oligohydramnios. A cell line known to express messenger ribonucleic acid of adrenomedullin and its receptor was used to optimize the polymerase chain reaction and served as a positive control preparation in all experiments. Semiquantitative reverse transcriptase-polymerase chain reaction results for adrenomedullin and adrenomedullin receptor were compared between tissues as densitometric ratios of adrenomedullin or adrenomedullin receptor messenger ribonucleic acid to beta(2)-microglobulin messenger ribonucleic acid. Results were analyzed with a Kruskal-Wallis 1-way analysis of variance. Immunohistochemical staining with an antibody to human adrenomedullin was used to localize adrenomedullin in all tissue types. RESULTS: Messenger ribonucleic acid sequences for adrenomedullin and adrenomedullin receptor genes were identified in all tested placental tissue components. Within the normal placentas the expressions of adrenomedullin and adrenomedullin receptor messenger ribonucleic acid sequences did not differ statistically between the tissue components. Within placentas from patients with oligohydramnios the expressions of adrenomedullin and adrenomedullin receptor messenger ribonucleic acid did not differ statistically between the tissue components. When normal placentas were compared with placentas from pregnancies complicated by oligohydramnios, however, a 5-fold increase in adrenomedullin messenger ribonucleic acid and a 3-fold increase in adrenomedullin receptor messenger ribonucleic acid were seen in placentas from patients with oligohydramnios. Adrenomedullin immunoreactivity was present in all tissues studied. CONCLUSION: The expression of messenger ribonucleic acid for both adrenomedullin and its receptor in these tissue components implies that placental tissues function in both synthesis and action of adrenomedullin. The increased adrenomedullin messenger ribonucleic acid expression in the umbilical artery and the elevated adrenomedullin receptor messenger ribonucleic acid expression in the cotyledons of placentas from patients with oligohydramnios may represent a local fetoplacental physiologic adaptive response to vascular compromise.