Periapical infection may affect birth outcomes via systemic inflammation.

OBJECTIVES: Maternal dental periapical infections are associated with preterm birth and intrauterine growth restriction. This study investigates whether the association is mediated through bacterial spread from periapical lesions to placenta (direct pathway) or systemic inflammatory reaction (indirect pathway). MATERIALS AND METHODS: We compared birth outcomes in Malawian mothers with and without periapical infection. As markers of a direct pathway, we identified placental bacteria using a 16S rDNA approach and assessed histological evidence of inflammation in the placenta and amniotic membranes. We measured C-reactive protein, alpha-1-acid glycoprotein, and salivary cortisol as markers of an indirect pathway. We used regression models to associate the predictor variables with duration of pregnancy and newborn size. RESULTS: Of 1,024 women, 23.5% had periapical infection. There was no association of periapical infection with either bacterial DNA or histological inflammation in placenta or membranes. Periapical infection was associated with C-reactive protein, alpha-1-acid glycoprotein, and cortisol concentrations in a dose-dependent manner at 36 weeks. Addition of alpha-1-acid glycoprotein or cortisol concentration into regression models attenuated the association between periapical infection and pregnancy outcomes. CONCLUSION: There was no evidence of direct spread of periapical bacteria to the placenta. Periapical infections and adverse pregnancy outcomes are in part mediated through systemic inflammation.

Seizure identification in the ICU using quantitative EEG displays.

OBJECTIVE: To evaluate the diagnostic accuracy of 2 quantitative EEG display tools, color density spectral array (CDSA) and amplitude-integrated EEG (aEEG), for seizure identification in the intensive care unit (ICU). METHODS: A set of 27 continuous EEG recordings performed in pediatric ICU patients was transformed into 8-channel CDSA and aEEG displays. Three neurophysiologists underwent 2 hours of training to identify seizures using these techniques. They were then individually presented with a series of CDSA and aEEG displays, blinded to the raw EEG, and asked to mark any events suspected to be seizures. Their performance was compared to seizures identified on the underlying conventional EEG. RESULTS: The 27 EEG recordings contained 553 discrete seizures over 487 hours. The median sensitivity for seizure identification across all recordings was 83.3% using CDSA and 81.5% using aEEG. However, among individual recordings, the sensitivity ranged from 0% to 100%. Factors reducing the sensitivity included low-amplitude, short, and focal seizures. False-positive rates were generally very low, with misidentified seizures occurring once every 17-20 hours. CONCLUSIONS: Both CDSA and aEEG demonstrate acceptable sensitivity and false-positive rates for seizure identification among critically ill children. Accuracy of these tools would likely improve during clinical use, when findings can be correlated in real-time with the underlying raw EEG. In the hands of neurophysiologists, CDSA and aEEG displays represent useful screening tools for seizures during continuous EEG monitoring in the ICU. The suitability of these tools for bedside use by ICU nurses and physicians requires further study.

Maternal supplementation with vitamin A or ß-carotene and cardiovascular risk factors among pre-adolescent children in rural Nepal.

Vitamin A plays an important role in fetal renal and cardiovascular development, yet there has been little research on its effects on cardiovascular risk factors later in childhood. To examine this question, we followed the children of women who had been participants in a cluster-randomized, double blind, placebo-controlled trial of weekly supplementation with 7000 µg retinol equivalents of preformed vitamin A or 42 mg of ß-carotene from 1994 to 1997 in rural Nepal. Women received their assigned supplements before, during and after pregnancy. Over a study period of 3 years, 17,531 infants were born to women enrolled in the trial. In 2006-2008, we revisited and assessed 13,118 children aged 9-13 years to examine the impact of maternal supplementation on early biomarkers of chronic disease. Blood pressure was measured in the entire sample of children. In a subsample of 1390 children, venous blood was collected for plasma glucose, Hb1Ac and lipids and a morning urine specimen was collected to measure the ratio of microalbumin/creatinine. Detailed anthropometry was also conducted in the subsample. The mean ± s.d. systolic and diastolic blood pressure was 97.2 ± 8.2 and 64.6 ± 8.5 mm Hg, respectively, and about 5.0% had high-blood pressure (⩾120/80 mm Hg). The prevalence of microalbuminuria (⩾30 mg/g creatinine) was also low at 4.8%. There were no differences in blood pressure or the risk of microalbuminuria between supplement groups. There were also no group differences in fasting glucose, glycated hemoglobin, triglycerides or cholesterol. Maternal supplementation with vitamin A or ß-carotene had no overall impact on cardiovascular risk factors in this population at pre-adolescent age in rural Nepal.

Size at birth is associated with blood pressure but not insulin resistance in 6-8 year old children in rural Nepal.

Earlier, we reported that antenatal micronutrient supplementation reduced the risk of metabolic syndrome and microalbuminuria among offspring at 6-8 years of age in rural Nepal. In the same birth cohort, we examined associations of size at birth (weight, length and ponderal index), and gestational age, with cardiometabolic risk factors in childhood across all antenatal micronutrient interventions. There was an inverse association between birth weight and systolic blood pressure (SBP, ß = -1.20 mm Hg/kg; 95% confidence interval (CI): -1.93, -0.46) and diastolic blood pressure (DBP, ß = -1.24 mm Hg/kg; 95% CI: -2.00, -0.49). Current child body mass index was positively associated with SBP but not with DBP. Birth weight was unassociated with insulin resistance, but each kilogram of increase was associated with a reduced risk of high triglycerides (odds ratio (OR) = 0.64/kg; 95% CI: 0.41, 0.97) and an increased risk of high waist circumference (OR = 3.16/kg; 95% CI: 2.47, 4.41). In this rural Nepalese population of children 6-8 years of age with a high prevalence of undernutrition, size at birth was inversely associated with blood pressure and triglycerides and positively associated with waist circumference.

Major lower limb amputation following failed infrainguinal vascular bypass surgery: a prospective study on amputation levels and stump complications.

The effect of failed vascular bypass surgery on final amputation level and stump complications is the subject of debate. The aim of this prospective cohort study was to assess the influence of previous infrainguinal bypass surgery on amputees in the authors' centre. Over a three-year period, 234 amputations (219 patients) were performed for critical ischemia. The cause of ischemia was either peripheral obstructive arterial disease (POAD) or diabetes mellitus (DM). Forty-eight percent (48%) (113 amputations) had ipsilateral vascular bypass surgery prior to amputation and 52% (121 amputations) had not. Final amputation level and the post-operative complications of infection, significant stump pain and delayed wound healing were used as the outcome measures for this study. At the end of the study period these outcome measures were used to compare the influence of previous bypass surgery on the two groups of amputees. There was a significantly higher rate of transfemoral amputations (TFA) (32.7%) vs. 16.5%; p < 0.05) and stump infection rate (42% vs. 23%; p < 0.05) in the bypass group. Significant stump pain (p = 0.23) and delayed wound healing (p = 0.24) was more prevalent in the bypass group although statistical significance could not be demonstrated.

Limb amputation on renal replacement therapy.

Ten (10) diabetic and 7 non-diabetic patients on renal replacement therapy have undergone limb amputation in the authors' unit in the 1988 to 1996 period. The article examines the course of illness and survival patterns in this distinct and increasing sub-set in the amputee population. Rehabilitation and survival were significantly better in the diabetic group and it is recommended that it would be helpful for both prognosis and analysis if the sub-set of amputees on treatment for chronic renal failure is further divided into diabetic and non-diabetic sub-sets.

An epidemiological study of war amputees and the cost to society.

The purpose of this study was to assess the overall financial cost of the prosthetic care which war amputees have incurred since the injury occurred. Records of 98 war veteran amputees who had attended the Dundee Limb Fitting Centre were scrutinised, they revealed 52 survivors and 46 who had died by 1997 and represented all the records available at the time of the review. The number and nature of visits, the number of prosthetic limbs ordered were counted and using today's costs, the cost of these services calculated. The costs of stump socks, transport and social security payments were not included. The cost of the artificial limbs was calculated at Pound Sterling(GBP)69 million with the recognition that it is an underestimate and approximation. Despite this it shows that the cost, allowing for the underestimation, has been relatively insignificant in the total cost of a major war and the war machinery. The cost however to the individuals has been considerable with a substantial disability occurring at the prime of life resulting in a significant handicap. It is a continuing legacy that society is responsible for, as a direct result of armed conflict.

Reduction of skin problems at the Alpha socket/skin interface.

Two cases are presented in whom the provision of an Alpha Liner relieved the patients' stump discomfort but developed a skin eruption at the top of the liner. This was resolved satisfactorily by cutting scallops into the top of the liner.

Diabetes and lower-limb amputations in the community. A retrospective cohort study. DARTS/MEMO Collaboration. Diabetes Audit and Research in Tayside Scotland/Medicines Monitoring Unit.

OBJECTIVE: There are few U.K. data on the incidence rates of amputation in diabetic subjects compared with the nondiabetic population. RESEARCH DESIGN AND METHODS: We performed a historical cohort study of first lower-extremity amputations based in Tayside, Scotland (population 364,880) from 1 January 1993 to 31 December 1994. The Diabetes Audit and Research in Tayside Scotland (DARTS) database was used to identify a prevalence cohort of 7,079 diabetic patients on 1 January 1993. We estimated age-specific and standardized incidence rates of lower-limb amputations in the diabetic and nondiabetic cohorts. Results were compared with a previous study that evaluated lower-extremity amputations in diabetic patients in Tayside in 1980-1982. RESULTS: There were 221 subjects who underwent a total of 258 nontraumatic amputations. Of the 221 subjects, 60 (27%) patients were diabetic (93% NIDDM), and 63% were first amputations. The median duration of diabetes was 6 years (range: newly diagnosed to 41 years). Nonhealing ulceration (31%) and gangrene (29%) were the two main indications for amputation in the diabetic subjects. Of the 161 nondiabetic subjects, 140 (80%) underwent first amputations. The adjusted incidences in the diabetic and nondiabetic groups were 248 and 20 per 100,000 person-years, respectively. Tayside patients with diabetes thus had a 12.3-fold risk of an amputation compared with nondiabetic residents (95% CI 8.6-17.5). The estimated proportion of diabetic patients in the population rose from 0.81% in 1980-1982 to 1.94% in 1993-1994, whereas the absolute rate of amputation in diabetic subjects was unchanged from that in 1980-1982. CONCLUSIONS: These population-based U.K. amputation data are similar to amputation rates in the U.S. Amputation rates appear to have decreased significantly since 1980-1982. The impact of diabetes education and prevention programs that target the processes leading to amputation can now be evaluated.

Congenital limb anomalies and amputees Tayside, Scotland 1965-1994.

The purpose of this study was to review the 68 patients who had been referred to Dundee Limb Fitting Centre during the period 1965-1994, with a congenital anomaly of a major limb requiring prosthetic replacement. A profile of the incidence of congenital anomalies, amputation levels and prosthetic fitting was obtained. During the period only 68 cases with 80 congenital anomalies were referred. During these 29 years, 20 cases required surgical amputation and overall 35 surgical procedures were performed in these cases, only 3 were in the upper limb. The incidence of upper and lower limb deficiency was similar. The patients represented a small proportion (1.6%) of the patients who were reported to have congenital anomalies. Figures indicated that about 8% of all live/still births have some form of anomaly. Prosthetic fitting and use was successful in all 68 cases but long term life follow-up is necessary to ensure continued prosthetic use.

Transtibial amputation using a medially based flap.

A technique is described which allows salvage of the knee joint in dysvascular patients who have marginal skin viability at below-knee level and who would otherwise require an above-knee amputation. The rationale for this technique is based on the vascular assessment which shows that there is frequently a significant medical to lateral skin blood flow gradient below the knee. Thus, a flap based on the more vascular medial skin is advocated. In 27 out of 34 'at risk' patients treated by the technique, the knee joint was successfully salvaged allowing early prosthetic fitting and mobilization.

A survey of marginal wheelchair users.

Significant numbers of wheelchair users experience difficulties with propulsion due to impaired upper limb function (termed marginal users for this study). A survey of wheelchair users in Tayside, Scotland, was carried out to identify and describe the marginal user population and their propulsion difficulties. Subjects for the survey were identified from the records of National Health Service wheelchair users at Dundee Limb Fitting Centre. Subjects were interviewed at home about their wheelchair-propelling experiences. Survey results indicated that marginal users represent approximately 15% of the occupant-propelled wheelchair population. The average age of the marginal users surveyed was 48 years and the modal diagnosis was multiple sclerosis. Fifty-nine percent of the marginal users questioned felt that their wheelchairs were not adequate for their requirements.

Dundee revisited--25 years of a total amputee service.

The Dundee Limb Fitting Centre has provided an integrated rehabilitation programme for the amputee since 1965. A review of 1846 primary amputees is discussed. During this period a dramatic change in the above-knee/below-knee (AK/BK) ratio has been achieved with 71% BK and 26% AK occurring in 1989. Over 80% of all amputees, the majority being elderly with peripheral vascular disease, were successfully fitted with a prosthesis. Final discharge home or to a residential home for the elderly was achieved in 76.2% of cases with 3.6% dying in the Unit. Bilateral amputation occurred in 18% of cases of whom 48% were BK-BK. Overall 66% were successfully fitted with a prosthesis. The results demonstrate the advantages of an integrated approach to the amputation and consequent rehabilitation.

Cause of death of lower limb amputees.

A study was carried out on the cause of death of 100 lower limb amputees who had been admitted to the Dundee Limb Fitting Centre, Tayside, Scotland for prosthetic management or wheelchair training. A comprehensive database has been established in the Centre for 25 years and the database is updated regularly. The date of death was collected and recorded. One hundred sequential deaths were investigated to review the cause of their death and compare this with the recorded causes of death for the Tayside population for the year of study. Ninety three per cent had an amputation for vascular related causes, with 73% having a below-knee amputation and 17% above-knee. Heart disease was the most frequent recorded cause of death (51%) of the amputee whereas only 28.1% of the Tayside group died from this pathology (p less than 0.01). Carcinomatosis was reported as a cause of death in 14% of the amputees and 23.5% of the Tayside group. Cerebrovascular disease caused death in 6% of the amputees and in 12.3% of the Tayside group (both p less than 0.01). These findings confirm earlier suggestions that vascular amputees die from heart disease more often than the general population.

Lower limb amputee survival.

A total of 1710 primary amputees have been studied over a 25 year period and their survival time has been calculated. These were all consecutive primary lower limb amputees admitted to the Dundee Limb Fitting Centre during the period 1965-1989. Overall, the median survival was 4 yr 9 mth for the below-knee amputee (1019 patients) and 4 yr 3 mth for the above-knee amputee (586 patients). The vascular related amputees had an overall median survival of 4 yr. In the two decades 1970-1979 and 1980-1989 there were significant differences between the survival time of the below-knee and above-knee amputee. The survival of the amputee has increased during the two decades from 3 yr 6 mth to 6 yr 6 mth (p greater than 0.001). For the first decade male above-knee and male below-knee amputee median survival was 3 yr 1 mth and 3 yr 11 mth respectively and for the second the survival was 5 yr 9 mth and 6 yr 11 mth for these levels of amputation. For 1970-1979 no significant differences were found between male and female peripheral vascular disease (PVD) and diabetes mellitus related amputee survival. For 1980-1989 significant differences were found between PVD related male above-knee amputees (3 yr 10 mth) and male below-knee amputees (6 yr 7 mth) (p greater than 0.01). Similar results were found for the female patients. Operative mortality was found to be 5% over the period 1975-1989 which compared favorably with previous studies.

Physiological considerations in seating.

Physiological changes occur with change of posture. Seating imposes significant effect on the cardiovascular, respiratory, abdominal, renal and neurological systems. The presence of severe skeletal deformities can significantly alter the physiological responses of the individual to changes in posture. In the case of severe kyphoscoliosis profound haemodynamic changes may occur. Lung perfusion has been shown to be posture dependent and the imposition of a specific seated position may have profound effects. This may compound existing lung problems for example bronchiectasis, which is not uncommon in these individuals, leading to hypoventilation. Abdominal compression which can occur with the patient in a flexed position can exacerbate a hiatus hernia, which can be both uncomfortable for the patient and may lead to feeding difficulties. The flexion at the hips of the lower limbs may also lead to problems of renal drainage especially where there is a catheter or other drainage appliance. Seating significantly affects many neurological reflexes. For example the presence of an extensor pattern can be helped by the adoption of a flexed position. The presence of pain can also influence the neurological response to a specific position. Those providing seating systems must consider the physiological effects that occur and compromise between these and the other requirements.

A microelectrode study of responses to secretagogues by epithelial cells on villus and crypt of rat small intestine.

The cellular origin of the response to secretagogues in small bowel epithelium was investigated by recording the effect of 5-hydroxytryptamine (5-HT, 10(-4) mol/l), acetylcholine (10(-4) mol/l), and prostaglandin E2 (PGE2, 10(-5) or 10(-4) mol/l) on apical membrane potentials (Va) of crypt and villus cells of rat ileum and jejunum in vitro using intracellular microelectrodes. Experiments were performed under visual control; addition of secretagogues and other manipulations were carried out during single impalements. Under basal conditions, apical membrane potential differences were consistently higher in jejunum than ileum (-72 +/- 1 vs. -47 +/- 2 mV, respectively, for villus impalements; -61 +/- 2 mV vs. -57 +/- 1 mV, respectively, for crypt impalements), and in jejunum villous membrane potentials exceeded those in the crypt. In the ileum, this crypt-villus gradient was reversed. The three secretagogues increased transmural potential difference and transiently reduced Va in cells in both crypt and villus regions by 8 mV or more. Fractional apical membrane resistance (FR) declined in ileum by approximately 30% in response to 5-HT and PGE2, whereas little change in FR was observed in jejunal recordings. PGE2 was ineffective in crypt and villus when Cl- was replaced by gluconate in both the luminal and serosal perfusates but depolarized the apical membrane in both regions after serosal restoration of Cl- from -76 +/- 4 to -56 +/- 8 mV in villus and from -58 +/- 4 to -45 +/- 6 mV in crypt. Rapid luminal Cl- substitution depolarized Va on the villus from -77 +/- 2 to -74 +/- 3 mV, but this effect was enhanced in the presence of PGE2, reducing Va from -65 +/- 8 to -43 +/- 12 mV. Prior to PGE2 addition, Va was -81 +/- 4 mV for this group of experiments. FR rose in the nominal absence of luminal Cl- from 0.69 +/- 0.09 to 0.77 +/- 0.06. It is concluded that because a Cl(-)-dependent depolarization of apical membrane potentials occurs in villi and crypts, net secretion in the small bowel is probably not confined to the crypts and may also occur from villous epithelium.