Relationship of Incident Falls with Balance Deficits and Body Composition in Male and Female Community-Dwelling Elders.

OBJECTIVE: Sarcopenia and obesity are reported risk factors for falls, although the data are not consistent and most studies do not make sex comparisons. We investigated whether falls were associated with balance, gait, and body composition, and whether these relationships are sex-specific. DESIGN: Secondary analysis of 4-year follow-up data from of the New Mexico Aging Process Study. SETTING: Albuquerque, New Mexico. PARTICIPANTS: 307 participants (M, n=122, 75.8 yr. SD5.5; F, n=183, 74.6yr SD6.1). MEASUREMENTS: Gait and balance were assessed annually using the Tinetti test. Lean body mass (LBM), appendicular skeletal muscle mass (ASM), fat free mass (FFM), total fat mass (FM) were assessed annually by DXA. Falls were assessed using bimonthly falls calendars. Hazard ratios (HR) for 2-point worsening in gait and balance score and falls were calculated by Cox proportional hazard for men and women. RESULTS: Baseline balance deficits, and not body composition, represented the strongest predictor of falls. For the total balance score, the variables with significant sex interactions were ASM (Male-HR 1.02 95%CI 0.60-1.73; Female-HR 1.92 95%CI 1.05-3.52, p=0.03) and FFM (Male-HR 1.04 95%CI 0.64-1.70; Female-HR 1.91 95%CI 1.12-3.24, p=0.04), after adjustment for age, sarcopenia and physical activity. The body composition relationship with balance deficits was U-shaped with the strongest predictors being low LBM in males and high FM in females. CONCLUSIONS: Specific body composition components and balance deficits are risk factors for falls following sex-specific patterns. Sex differences need to be explored and considered in interventions for worsening balance and falls prevention.

The minimum important difference for the Pelvic Organ Prolapse-Urinary Incontinence Sexual Function Questionnaire.

INTRODUCTION AND HYPOTHESIS: Although the Pelvic Organ Prolapse-Urinary Incontinence Sexual Function Questionnaire (PISQ) is widely used to assess sexual function in women, the minimum important difference (MID) (defined as the smallest difference in scores of a patient-reported outcome measure that is perceived by patients as beneficial or harmful and which would lead the clinician to consider a change in treatment) is not known. The objective was to estimate the MID for the PISQ. METHODS: Two study populations, one of women with overactive bladder (OAB) and urgency UI (UUI) treated with tolterodine in a placebo-controlled trial (cohort I), and one of women treated surgically for prolapse and/or UI (cohort II) were used. Cohort I anchors were the Overactive Bladder Questionnaire (OAB-q), the Patient Perception of Bladder Condition (PPBC), the Patient Perception of Treatment Benefit Questionnaire (PPTBQ), and the change in number of UUI episodes in bladder diaries. Distribution MIDs were also calculated. RESULTS: In the anchor-based analysis, the MID values for changes in PISQ total scores at 3 months in cohort I were 5 points using the UUI anchor (diary-dry women), 5 points using the PPBC anchor, 5 points with the PPTBQ, and 9 points with the OAB-q. In cohort II, the MID at week 12 in PISQ total scores was 7 points in women with improved IIQ-7 scores. The distribution-based MID in PISQ total scores was 5.3 points in cohort I and 5.8 points in cohort II. CONCLUSION: A reasonable estimate of MID for the PISQ total score is 6 points. Improvements that meet these thresholds may be considered clinically important.

Premature aortic stiffness in systemic lupus erythematosus by transesophageal echocardiography.

To assess aortic stiffness by transesophageal echocardiography (TEE) and to determine its clinical predictors and relation to age, blood pressure, renal function, and atherosclerosis, 50 patients with systemic lupus erythematosus (SLE), 94% women, with a mean age of 38 ± 12 years, and 22 age and gender-matched healthy controls underwent clinical and laboratory evaluations and multiplane TEE to assess stiffness, intima-media thickness (IMT), and plaques of the proximal, mid, and distal descending thoracic aorta. Stiffness at each level and overall aortic stiffness by the pressure-strain elastic modulus was higher in patients than in controls after adjusting for age (overall, 8.25 ± 4.13 versus 6.1 ± 2.5 Pascal units, p = 0.01). Patients had higher aortic stiffness than controls after adjusting both groups to the same mean age, blood pressure, creatinine, and aortic IMT (p = 0.005). Neither IMT nor plaques were predictors of aortic stiffness. Moreover, normotensive patients, those without aortic plaques, and non-smokers had higher stiffness than controls (all p < 0.05). Age at SLE diagnosis and non-neurologic damage score were the only SLE-specific independent predictors of aortic stiffness (both p ≤ 0.01). Thus, increased aortic stiffness is an early manifestation of lupus vasculopathy that seems to precede the development of hypertension and atherosclerosis.

Mitochondrial function in physically active elders with sarcopenia.

Physical activity is reported to protect against sarcopenia and preserve mitochondrial function. Healthy normal lean (NL: n=15) and sarcopenic (SS: n=9) participants were recruited based on body composition (DXA, Lunar DPX), age, and physical activity. Gastrocnemius mitochondrial function was assessed by (31)P MRS using steady-state exercise in a 4T Bruker Biospin. Total work (429.3+/-160.2J vs. 851.0+/-211.7J, p<0.001) and muscle volume (p=0.006) were lower in SS, although these variables were not correlated (NL r=-0.31, p=0.33, SS r=(0.03, p=0.93). In the SS resting ATP/ADP was lower (p=0.03) and ATP hydrolysis higher (p=0.02) at rest. Free energy ATP hydrolysis was greater at the end of exercise (p=0.02) and [ADP] relative to total work output was higher in SS (ANCOVA, p=0.005). [PCr] recovery kinetics were not different between the groups. Adjusting these parameters for differences in total work output and muscle volume did not explain these findings. These data suggest that aerobic metabolism in physically active older adults with sarcopenia is mildly impaired at rest and during modest levels of exercise where acidosis was avoided. Muscle energetics is coordinated at multiple cellular levels and further studies are needed to determine the loci/locus of energy instability in sarcopenia.

Intoxicated motor vehicle passengers: an overlooked at-risk population.

HYPOTHESES: Intoxicated motor vehicle passengers are similar to intoxicated drivers in recurrent health care encounters and risk of death for 5 years after injury. Intoxicated passengers have a greater risk of death than population controls. DESIGN: Historical cohort study. SETTING: University-based level I trauma center. PARTICIPANTS: Motor vehicle crash victims admitted to a level I trauma center in 1993. MAIN OUTCOME MEASURES: Recurrent hospitalization, emergency department visits, survival analysis, and standardized mortality ratios for 5 years following injury. RESULTS: More than one quarter of intoxicated passengers and drivers had recurrent hospitalizations and emergency department visits. Intoxicated occupants were more likely to return to the hospital and the emergency department than nonintoxicated controls (odds ratios, 2.0 and 2.7, respectively). Intoxicated passengers were at increased risk of dying compared with nonintoxicated occupants (P = .008) and with the general population (standardized mortality ratio = 5.8). Intoxicated occupants were more likely to die an alcohol-related death (P< .001). CONCLUSIONS: Intoxicated passengers injured in a motor vehicle crash are similar to intoxicated drivers in recurrent hospitalizations and emergency department visits. Intoxicated passengers have an increased mortality rate in the 5 years following injury.

Effect of short-term glucose control on glycemic thresholds for epinephrine and hypoglycemic symptoms.

Hypoglycemia is the principal barrier to achieving target glucose goals in type 2 diabetes. The effect of short-term improvement in glycemic control on plasma glucose thresholds for symptomatic and hormonal responses to hypoglycemia in type 2 diabetes is not known. We hypothesized that the thresholds for these events would be increased by 1 wk of improved glycemic control in elderly patients with type 2 diabetes. Ten elderly patients with type 2 diabetes were admitted for an 8-d inpatient protocol. All subjects underwent insulin-induced hypoglycemia on days 2 (preglucose control) and 8 (postglucose control). Between days 2 and 8, subjects received intensive diabetes management to improve their glycemic control. Timed blood glucose profiles were obtained daily during the week before and during admission. Plasma glucose, counterregulatory hormones, and hypoglycemic symptoms were assessed at baseline and every 10 min during the hypoglycemic studies. Mean blood glucose concentrations were significantly reduced by intensive diabetes management from 9.8 +/- 3.7 mmol/liter to 7.7 +/- 3.3 mmol/liter (P < 0.001). The plasma glucose threshold for epinephrine release during insulin-induced hypoglycemia was significantly increased by intensive management from a glucose concentration of 3.7 +/- 0.5 mmol/liter at baseline to 3.1 +/- 0.3 mmol/liter after intensive management (P < 0.05). The plasma glucose threshold for hypoglycemic symptoms was also increased by intensive therapy from a glucose concentration of 5.3 +/- 1.2 to 3.3 +/- 0.6 mmol/liter (P = 0.003). These rapid changes may increase the risk for severe hypoglycemia in type 2 diabetes and limit the ability of physicians to rapidly correct hyperglycemia in elderly type 2 diabetes patients.

Cigarette smoking, alcohol consumption, and the risk of systemic lupus erythematosus: a case-control study.

OBJECTIVE: To investigate the effects of cigarette smoking and alcohol consumption on the development of systemic lupus erythematosus (SLE). METHODS: We interviewed 125 patients with SLE and 125 controls in a case-control study. Demographically similar controls randomly selected from outpatient clinics were matched to SLE cases for sex and age. Clinical data, including cigarette smoking, drinking habits, and other demographic variables, were collected by an interview-administered questionnaire. RESULTS: To minimize bias associated with reactive habits induced by disease, cigarette smoking before the diagnosis of SLE was the primary variable for subsequent analysis. Analysis of the data by multivariate conditional logistic regression revealed that both cigarette smoking before SLE diagnosis and ex-smoking before SLE diagnosis significantly increased the risk of development of SLE (OR 6.69, 95% CI 2.59, 17.28, p < 0.001; and OR 3.62, 95% CI 1.22, 10.70, p = 0.02, respectively). This association remained even when statistically controlling for the effects of family history and education, indicating an independent effect. Alcohol did not place an individual at increased risk nor did it have a protective role. CONCLUSION: The results of this study provide further evidence that cigarette smoking may be an associated risk factor for the development of SLE.

Population-based study of microinvasive adenocarcinoma of the uterine cervix.

OBJECTIVE: To analyze lymph node status and survival rates of women with microinvasive cervical adenocarcinoma (International Federation of Gynecology and Obstetrics stages IA(1) and IA(2)). METHODS: The Surveillance, Epidemiology, and End Results (SEER) Public-Use Database was used to identify cases of microinvasive cervical adenocarcinoma diagnosed between 1988 and 1997. Variables analyzed included stage, extent of surgery, lymph node status, radiation therapy, and age. Statistics included analysis of trends, analysis of variance, log-rank test, one-sided binomial confidence interval estimation, and power analysis. RESULTS: Among 301 reported cases, 131 had stage IA(1) and 170 IA(2) disease. Simple hysterectomies were done in 54 women with IA(1) and 64 with IA(2) disease and radical hysterectomies were done in 50 and 83 women, respectively. Only one of 140 women who had lymphadenectomy had a single positive lymph node. There were four tumor-related deaths (one with IA(1), and three with IA(2) disease). There were no deaths among 96 women (47, IA(1); 49, IA(2)) treated by simple hysterectomy alone. The mean follow-up was 46.5 months (range 1--119). The censored survival rate was 98.7% overall (99.2% IA(1), 98.2% IA(2)). Power analysis estimated that 720 patients would be required in each group to detect a 2% difference in survival. Using one-sided 95% confidence interval estimations, the risk-adverse events rate for IA(1) was no more than 3.57%, and 4.50% for IA(2) disease. CONCLUSION: Prognosis is excellent for microinvasive adenocarcinoma of the uterine cervix. In 96 cases (31.9%), simple hysterectomy alone proved adequate.

Differential effects of fasting and dehydration in the pathogenesis of diabetic ketoacidosis.

Glycemia varies widely in patients with diabetic ketoacidosis (DKA), with plasma glucose concentrations between 10 to 50 mmol/L commonly encountered. The mechanism of this glycemic variability is uncertain. Our study examined the differential effects of fasting and dehydration on hyperglycemia induced by withdrawal of insulin in type 1 diabetes. To evaluate the respective roles of dehydration and fasting in the pathogenesis of DKA, 25 subjects with type 1 diabetes were studied during 5 hours of insulin withdrawal before (control) and after either 32 hours of fasting (n = 10) or dehydration of 4.1% +/- 2.0% of baseline body weight (n = 15). Samples were obtained every 30 minutes during insulin withdrawal for substrate and counterregulatory hormone levels and rates of glucose production and disposal. Fasting resulted in reduced plasma glucose concentrations compared with the control study, while dehydration resulted in increased plasma glucose concentrations compared with the control study (P < .001). Glucose production and disposal were decreased during the fasting study and increased during the dehydration study compared with the control study. Glucagon concentrations and rates of development of ketosis and metabolic acidosis were increased during both fasting and dehydration compared with control. These data suggest that fasting and dehydration have differential effects on glycemia during insulin deficiency, with dehydration favoring the development of hyperglycemia and fasting resulting in reduced glucose concentrations. This finding is probably attributable to the differing effect of these conditions on endogenous glucose production, as well as to differences in substrate availability and counterregulatory hormone concentrations. The severity of pre-existing fasting and dehydration likely explains much of the variability in plasma glucose concentrations observed in DKA.

Increased pulsatility, process irregularity, and nocturnal trough concentrations of growth hormone in amenorrheic compared to eumenorrheic athletes.

Amenorrheic athletes exhibit a spectrum of neuroendocrine disturbances, including alterations in the GH-insulin-like growth factor I (IGF-I) axis. Whether these changes are due to exercise or amenorrhea is incompletely characterized. The present study investigates spontaneous (overnight) and exercise-stimulated GH secretion and associated IGF-binding proteins (IGFBPs) in amenorrheic (AA; n = 5), and eumenorrheic athletes ( n = 5) matched for age, percent body fat (dual energy x-ray absorptiometry), training history, and maximal oxygen consumption. Each volunteer participated in two hospital admissions consisting of a 50-min submaximal exercise bout (70% maximal oxygen consumption) and an 8-h nocturnal sampling period. Deconvolution analysis of serum GH concentration time series revealed increases in the half-life of GH (60%) and the number of secretory bursts (85%) as well as a decrease in their half-duration (50%) and the mass of GH secreted per pulse (300%) in the AA cohort. Time occupancy at elevated trough GH concentrations was significantly increased, and GH pulsatility (approximate entropy) was more irregular in the AA group. During exercise, AA exhibited a reversal of the normal relationship between IGF-I and GH, and a 4- to 5-fold blunting of stimulated peak and integrated GH secretion. Fasting levels of plasma IGF-I, IGFBP-3, and IGFBP-1 appeared to be unaffected by menstrual status. In ensemble, this phenotype of GH release in amenorrheic athletes suggests disrupted neuroregulation of episodic GH secretion, possibly reflecting decreased somatostinergic inhibition basally, and reduced GHRH output in response to exercise compared with eumenorrheic athletes. Accordingly, we postulate that the amenorrheic state, beyond the exercise experience per se, alters the neuroendocrine control of GH output in amenorrheic athletes.

The rising incidence of adenocarcinoma relative to squamous cell carcinoma of the uterine cervix in the United States--a 24-year population-based study.

OBJECTIVE: The aim of this study was to compare the age-adjusted incidence and survival for invasive adenocarcinoma and squamous cell carcinoma of the uterine cervix using population-based data. METHODS: The SEER database was used to identify all cases of cervical cancer registered between 1973 and 1996. Stage was defined as localized, regional, or distant. Age-adjusted incidence rates were analyzed statistically using the Jonchkeere-Terpstra exact test for trends. Relative and observed survival rates, respectively, were compared using z tests and log-rank tests. RESULTS: The age-adjusted incidence rates per 100,000 for all invasive cervical cancers decreased by 36.9% over 24 years [12.35 (1973-1977) vs 7.79 (1993-1996)]. Similarly, the age-adjusted incidence rates for squamous cell carcinoma declined by 41.9% [9.45 (1973-1977) vs 5.49 (1993-1996)]. In contrast, the age-adjusted incidence rates for adenocarcinoma increased by 29.1% [1.34 (1973-1977) vs 1.73 (1993-1996)]. The proportion of adenocarcinoma increased 107.4% relative to all cervical cancer, 95.2% relative to squamous cell carcinoma, and 49.3% relative to the population of women at risk [10. 8% vs 22.4% (P < 0.001), 12.4% vs 24.0% (P < 0.001), and 1.40 vs 2. 09 per 100,000 women (P < 0.001), respectively]. Observed survival rates for adenocarcinoma vs squamous cell carcinoma were poorer for regional (P = 0.04), but not localized or distant disease. CONCLUSIONS: Over the past 24 years, the incidence of all cervical cancer and squamous cell carcinoma has continued to decline. However, the proportion of adenocarcinoma relative to squamous cell carcinoma and to all cervical cancers has doubled, and the rate of adenocarcinoma per population at risk has also increased. These results suggest that current screening practices in the United States are insufficient to detect a significant proportion of adenocarcinoma precursor lesions.

Low-dose epinephrine supports plasma glucose in fasted elderly patients with type 2 diabetes.

Recent studies indicate that endogenous epinephrine provides protection against hypoglycemia in fasted elderly patients with type 2 diabetes treated with sulfonylureas. To establish a dose-response relationship and further characterize this hormonal action, 10 subjects with type 2 diabetes aged 67 +/- 1.3 years and receiving glyburide 20 mg daily were studied on 3 separate occasions. Saline placebo, half dose epinephrine ([Epi] 0.375 microg/min), and full dose Epi (0.75 microg/min) were infused during the final 10 hours of a 28-hour fast in a paired, randomized single-blind study to simulate physiologic epinephrine levels. Substrate and hormonal parameters and glucose production (Rd), disposal (Rd), and metabolic clearance rates were determined every 30 minutes. In the placebo study, the mean decline in plasma glucose during the final 10 hours of fasting was -2.7 +/- 0.6 mmol/L, compared with -0.3 +/- 0.3 mmol/L in the half dose Epi study and an actual increase in glucose of 1.0 +/- 0.8 mmol/L in the full dose Epi study (P < .001). There was a similar decline in the glucose Ra in all 3 studies, and the glucose Rd was not significantly different among the 3 study conditions. The baseline-adjusted metabolic clearance rate of glucose was significantly decreased during the epinephrine studies compared with the placebo study (P = .01). The concentration of other counterregulatory hormones did not differ between the studies. We conclude that low physiologic concentrations of epinephrine prevent the progressive decline in plasma glucose observed during fasting in elderly sulfonylurea-treated patients with type 2 diabetes. This finding may be attributable to a relative insulin resistance induced by epinephrine, resulting in a decreased rate of glucose clearance by cells.

Acute optic neuritis: association with paranasal sinus inflammatory changes on magnetic resonance imaging.

The authors compared the frequency of paranasal sinus inflammatory changes (SIC) on brain magnetic resonance imaging (MRI) obtained from 23 patients with new onset acute optic neuritis (ON) and 48 control patients who underwent outpatient MRI of the brain for reasons other than ON. The authors found a higher frequency of paranasal SIC in patients with ON (83%) than in controls (54%) (p = 0.02). The distribution of paranasal SIC (in ON and in controls) was maxillary (83% and 52%), ethmoid (4% and 2%), frontal (9% and 14%), and sphenoid (4% and 10%). Frequency of the maxillary SIC was significantly higher (p = 0.02) in patients with ON than in controls. Further evaluation of maxillary paranasal SIC with a grading system showed the presence of thickened mucosal lining of the sinuses (grade I) in 17% (ON) and 23% (controls), mucous retention cysts within the sinuses (grade II) in 48% (ON) and 25% (controls), and severe mucosal thickening with complete or near-complete filling of the sinus or an air-fluid level within the sinus (grade III) in 17% (ON) and 4% (controls). Combined frequency of grade II and grade III SIC was significantly higher in the ON group than in controls (p = 0.005), as was the frequency of grade III SIC alone (p = 0.02). Grade I SIC did not significantly differ between the groups. There was a trend (p = 0.09) toward a higher prevalence of bilateral sinus inflammatory changes in patients with bilateral ON. These findings suggest that ON may be associated with sinus inflammatory changes.

Prevention of group B streptococcus early-onset neonatal sepsis: comparison of the Center for Disease Control and prevention screening-based protocol to a risk-based protocol in infants at greater than 37 weeks' gestation.

OBJECTIVE: To compare the Center for Disease Control consensus guidelines' screening-based strategy to a risk-based strategy as regards the incidence of early-onset group B streptococcus (GBS) infection among term infants. STUDY DESIGN: A cohort of university hospital prenatal clinic mother-infant pairs who were screened for GBS at 35 to 37 weeks' gestation were compared to a matched control group of unscreened mother-infant pairs from the outreach satellite prenatal clinics who delivered at the same institution during the same time period. GBS screening was carried out with rectovaginal cultures plated on selective media. GBS-positive women received antimicrobial prophylaxis in labor whereas women of unknown GBS status were only treated intrapartum if they had a risk factor for GBS infection. Principal outcome variables included incidence of cases of neonatal early-onset GBS sepsis (blood, urine, or cerebrospinal fluid positive for GBS), incidence of cases of strongly suspected GBS sepsis (culture negative), and incidence of neonatal sepsis with non-GBS organisms. RESULTS: There were 3164 screened mother-infant pairs who were compared to 2684 unscreened pairs. The incidence of GBS carriage was 13.3%. A random sample of 420 screened women were compared to a matched sample of 407 women of unknown GBS carrier status for characterization of demographics and risk factors. No cases of documented GBS sepsis occurred in the infants of the screened women, but four cases occurred among the infants of the women who did not undergo screening (incidence 1.5/1000) (p = 0.04), only one of whom had a risk factor for GBS infection. Cases of suspected but culture negative sepsis were not more common in the screened population when compared to the unscreened. There was one case of Escherichia coli sepsis in an infant of a mother in the unscreened group. CONCLUSIONS: GBS screening at 35 to 37 weeks, with intrapartum antimicrobial prophylaxis of carriers, decreased the incidence of neonatal early-onset GBS sepsis and appears to have advantages over treatment based on risk factors alone in term infants.

Lung biopsy: is it necessary?

OBJECTIVE: Lung biopsy is associated with substantial mortality rates. We reviewed our experience with this operation, primarily in patients with immunocompetence, to determine whether the results justify the continued performance of this procedure. METHODS: We conducted a retrospective review of all diagnostic lung biopsies performed at 3 university-affiliated hospitals between July 1, 1992, and December 31, 1998. RESULTS: There were 75 patients: 25 patients were treated electively, 17 were treated on an urgent basis, 27 patients on an emergency basis, and the urgency was unclear in 6 patients. Significant beneficial therapeutic changes were made in 15 of 25 elective procedures (60%), in 16 of 17 urgent procedures (94%), and in 11 of 27 emergency procedures (41%; P =.001). Significant beneficial therapeutic changes consisted of immunosuppression in 13 of 15 (87%) patients treated on an elective basis, in 9 of 16 (56%) treated on an urgent basis, and in 9 of 11 (82%) treated on an emergency basis in whom therapy was altered (P =.14). Operative death was 0 of 25 for elective operations (0%), 3 of 17 for urgent operations (18%), and 14 of 26 for emergency operations (54%). Multivariable analysis of operative death showed urgency to be the only significant predictor of death (P =.002). CONCLUSIONS: In patients with immunocompetence, elective and urgent lung biopsies have acceptable operative mortality rates and frequently result in important beneficial therapeutic changes. Consequently biopsies are appropriate in these patients. Emergency biopsies are associated with high operative mortality rates and rarely result in a therapeutic change other than immunosuppression. These patients should not undergo lung biopsy if they are in stable condition and should be treated empirically with immunosuppression without operation if their condition is deteriorating.

Divalproex in posttraumatic stress disorder: an open-label clinical trial.

Posttraumatic stress disorder (PTSD) is characterized by intrusive, avoidance, and hyperarousal symptoms. This study was conducted to investigate the effectiveness of divalproex in reducing PTSD symptoms, depression, and anxiety in patients with PTSD. Sixteen patients with a DSM-IV diagnosis of PTSD at the Albuquerque VAMC outpatient PTSD treatment program received an open-label trial of divalproex. The patients were evaluated at baseline and at 8 weeks by a trained rater using the Clinician Administered PTSD Scale (CAPS), the Hamilton Rating Scale for Depression (HAM-D) and the Hamilton Rating Scale for Anxiety (HAM-A). Plasma valproate levels were measured at the 8-week post-treatment assessment. Three patients stopped the medications due to side effects. Intrusion and hyperarousal symptoms decreased significantly, while no significant change was seen in avoidance/numbing symptoms. Depressive symptoms, as measured by the HAM-D, unexpectedly decreased at post-treatment assessment. HAM-A scores also decreased significantly. Controlled trials are needed to further study the efficacy of divalproex in the treatment of PTSD.

Aortic root disease and valve disease associated with ankylosing spondylitis.

OBJECTIVES: This study sought to determine the prevalence, characteristics, relation to clinical features and evolution of aortic root disease and valve disease associated with ankylosing spondylitis (AKS). BACKGROUND: Aortic root disease and valve disease are common in patients with AKS, but their clinical and prognostic implications have not been well defined. METHODS: Forty-four outpatients with AKS and 30 age- and gender-matched healthy volunteers underwent initial transesophageal echocardiography and rheumatologic evaluations. Twenty-five patients underwent clinical and echocardiographic follow-up 39+/-10 months later. RESULTS: Aortic root disease and valve disease were common in patients (82%) as compared with controls (27%; p < 0.001). Aortic root thickening, increased stiffness and dilatation were seen in 61%, 61% and 25% of patients, respectively. Valve thickening (41% for the aortic and 34% for the mitral valve) manifested predominantly (74%) as nodularities of the aortic cusps and basal thickening of the anterior mitral leaflet, forming the characteristic subaortic bump. Valve regurgitation was seen in almost half of patients, and 40% had moderate lesions. Except for the duration of AKS, aortic root disease and valve disease were unrelated to the activity, severity or therapy of AKS. During follow-up of 25 patients, in up to 24% new aortic root or valve abnormalities developed, in 12% existing valve regurgitation worsened significantly and in 20% abnormalities resolved. Twenty percent of patients developed heart failure, underwent valve replacement, had a stroke or died, as compared with 3% of control subjects. CONCLUSIONS: Aortic root disease and valve disease are common in patients with AKS, are unrelated to clinical features of AKS, can resolve or progress over time and are associated with clinically important cardiovascular morbidity.

Is amniotic fluid analysis the key to preterm labor? A model using interleukin-6 for predicting rapid delivery.

OBJECTIVE: Our purpose was to create a model for predicting amnionitis and rapid delivery in preterm labor patients by use of amniotic fluid interleukin-6 and clinical parameters. STUDY DESIGN: Amniotic fluid was cultured and analyzed, and a clinical score (incorporating gestational age, amniotic fluid Gram stain, glucose, leukocyte esterase, and maternal serum C-reactive protein) was determined in 111 patients diagnosed with preterm labor. Statistical analysis involved t tests, chi2, logarithmic regression, and multivariate regression analysis (P < or = .05). RESULTS: The incidence of positive amniotic fluid cultures was 8.7% (9 of 103 patients). Patients with positive cultures of the amniotic fluid had a shorter delivery interval (4.8 +/- 7.5 vs 28.9 +/- 25.4 days, P < .001). Patients with elevated amniotic fluid interleukin-6 (> or = 7586 pg/ml) were more likely to have a positive amniotic fluid culture (relative risk = 8.8, 95% confidence interval = 1.6 to 47.4, P < .001) and to be delivered within 2 days (relative risk = 16.8, 95% confidence interval = 4.5 to 62.7, P < .001). Stepwise multivariate regression analysis yielded a model using interleukin-6, cervical dilatation, and gestational age (r2 = 0.63, P < .001) with a specificity of 100% for predicting delivery within 2 days of amniocentesis. CONCLUSIONS: A mathematical model using maternal amniotic fluid interleukin-6 seems to be a useful clinical tool for quantifying the interval to preterm birth for patients in preterm labor.

Effect of adjustment of maternal serum alpha-fetoprotein levels in insulin-dependent diabetes mellitus.

Our objective was to determine the effect of the 20% upward adjustment of maternal serum alphafetoprotein (MSAFP) in patients with insulin-dependent diabetes mellitus (IDDM) on the number of patients that would be classified at increased risk for pregnancy complicated by either Down syndrome (DS) or neural tube defect (NTD). We retrospectively evaluated a database containing 63,110 patients who underwent multiple serum marker screening between 14 and 22 weeks gestation; 620 patients with IDDM had measurements of MSAFP of which 479 also had measurements of beta-HCG, allowing calculation of DS risk. Increased NTD risk was defined as MSAFP >2.5 MOM while increased DS risk was defined as a calculated risk > or =1/270. One IDDM patient delivered an infant with a NTD; it was not detected on serum screening. No infants were born with DS. Of the 620 patients with MSAFP determinations, 9 had values >2.5 MOM before adjustment. After upward adjustment, 7 additional patients were identified. Sixteen patients were identified at increased risk for DS before and after adjustment. Our data suggest that the 20% upward adjustment of MSAFP increases by 78%, the number of patients who would require further evaluation for NTD's. Although we were able to identify 620 women with IDDM who underwent serum screening for NTD, the low prevalence of NTD's did not allow us to demonstrate an increased detection rate. The effect of upward adjustment of MSAFP on the number of patients categorized at increased DS risk appears to be minimal.

Risks of complication following thyroidectomy.

OBJECTIVE: Because hypoparathyroidism is a serious complication of thyroidectomy, we attempted to elucidate factors determining the risk of this postoperative outcome. SETTING: Four tertiary care hospitals in Albuquerque, New Mexico. PATIENTS: A retrospective study of 142 patients who underwent total or subtotal thyroidectomy between 1988 and 1995. MEASUREMENTS AND MAIN RESULTS: Permanent hypoparathyroidism was defined as hypocalcemic symptoms plus a requirement for oral vitamin D or calcium 6 months after thyroidectomy. Factors analyzed to determine their contribution to the risk of persistent postoperative hypoparathyroidism were the indication for thyroidectomy, performance of a preoperative thyroid needle biopsy, type of surgery, postoperative pathology, presence and stage of thyroid carcinoma, resident surgeon involvement, and specialty of the surgeon performing the procedure. Surgical specialty and stage of thyroid carcinoma were independent risk factors for persistent postoperative hypoparathyroidism by multivariate analysis. Nine (29%) of 31 patients who had thyroidectomy by otolaryngologists met criteria for permanent hypoparathyroidism, and 6 (5%) of 111 patients who had thyroidectomy by general surgeons met the same criteria (p < .001). Adjustment for the effect of stage did not eliminate the effect of specialty (p = .006), and adjustment for the effect of specialty did not eliminate the effect of stage (p = .02), on the occurrence of postoperative hypoparathyroidism. CONCLUSIONS: We conclude from our data that patients undergoing thyroidectomy by an otolaryngologist may be at a higher risk of permanent postoperative hypoparathyroidism than patients who undergo thyroidectomy by a general surgeon. This may reflect differences in case selection or surgical approach or both.