Feasibility of using self-reported ethnicity in pregnancy according to the gestation-related optimal weight classification: a cross-sectional study.

OBJECTIVE: To evaluate the feasibility of self-reported ethnicity using the gestation-related optimal growth (GROW) classification in a contemporary multicultural antenatal population. DESIGN: Cross-sectional study. SETTING: Tertiary obstetric hospital in Melbourne, Australia. POPULATION: Pregnant women attending the antenatal clinic. METHODS: We surveyed pregnant women during April-June 2016 regarding their understanding of the term 'ethnicity', and how they would classify the ethnicity of themselves, their partner, and family members according to the Australian GROW classification. RESULTS: Two hundred and thirty-five women completed the survey. When describing 'ethnicity', most women (103, 44%) chose multiple descriptors, most frequently country of birth (54%) and region of ancestry (47%). Interpretation of 'ethnicity' varied significantly between ethnic groups: those choosing 'country of birth' were more likely to identify as Indian (odds ratio, OR 3.5, P = 0.03), whereas those choosing 'physical appearance' were more likely to identify as Chinese (OR 3.0, P = 0.047). Thirty participants (13%) were unable to describe their ethnicity from the available GROW options. Sixty-one (26%) respondents' ethnicity was inconsistent with that of their parents' heritage. A further 35% had a partner of different ethnicity. The agreement between country of birth and self-reported ethnicity was only fair (kappa 0.73, 95% confidence interval, 95% CI 0.64-0.82). CONCLUSION: This study confirms the complexity of defining ethnicity in contemporary multicultural settings. Self-reported ethnicity is often inaccurate, concepts of ethnicity vary by ethnic group, and country of birth is a poor descriptive surrogate. Adjustment for maternal ethnicity should be undertaken with caution in the customised assessment of fetal growth. TWEETABLE ABSTRACT: Is self-reported maternal ethnicity reliable? We think not.

A mobile health intervention promoting healthy gestational weight gain for women entering pregnancy at a high body mass index: the txt4two pilot randomised controlled trial.

OBJECTIVE: To determine the feasibility and effectiveness of an mHealth intervention promoting healthy diet, physical activity and gestational weight gain in pregnant women. DESIGN: Randomised controlled trial (RCT). SETTING: Australian tertiary obstetric hospital. POPULATION: One hundred pregnant women who were overweight or obese prior to pregnancy. METHODS: Women recruited at the first antenatal clinic visit were randomised to either an intervention or a control group. The intervention consisted of a tailored suite of strategies delivered (from first antenatal visit until 36 weeks' gestation) via multiple modalities available on mobile devices. MAIN OUTCOME MEASURES: The primary outcome was intervention feasibility and secondary outcomes were objectively measured changes in gestational weight gain (GWG) and self-reported dietary intake and physical activity. RESULTS: Ninety-one women completed the study. Delivery to protocol provides evidence of program feasibility. Most women engaged regularly with the program, with the majority (97.6%) reporting that the intervention was helpful. Secondary outcomes demonstrated a significantly lower GWG in the intervention group (7.8 kg ± 4.7 versus 9.7 kg ± 3.9; P =0.041) compared with the control group at intervention completion. Intervention group women reported significantly smaller reductions in total, light- and moderate-intensity physical activity from baseline to completion of the intervention (P = 0.001) compared with the control group, but no differences in consumption frequencies of key food groups. CONCLUSION: An intervention that aimed to deliver healthy diet, physical activity and GWG guidance utilising innovative technology can be feasibly implemented and produce positive physical activity and GWG outcomes. TWEETABLE ABSTRACT: txt4two mHealth study improved gestational weight gain and physical activity in pregnant women with high BMIs.

Self-weighing and simple dietary advice for overweight and obese pregnant women to reduce obstetric complications without impact on quality of life: a randomised controlled trial.

OBJECTIVE: To determine the effect of serial weighing and dietary advice compared with standard antenatal care on obstetric outcomes. DESIGN: Randomised controlled clinical trial. SETTING: Australian tertiary obstetric hospital. POPULATION: Three hundred and eighty-two overweight or obese non-diabetic pregnant women at less than 20 weeks gestation with a singleton pregnancy. METHODS: Women were randomised to targeted, serial self-weighing and simple dietary advice, (intervention), or standard antenatal care (control). MAIN OUTCOMES MEASURES: The primary outcome was a reduction in a composite of obstetric complications: gestational hypertension, pre-eclampsia, diabetes, assisted or caesarean birth, shoulder dystocia, severe perineal trauma, postpartum haemorrhage and maternal high dependency care. Secondary outcomes were gestational weight gain at 36 weeks' gestation, quality of life (QOL) and maternal serum levels of 28-week leptin, adiponectin and C-reactive protein (CRP). RESULTS: There was no difference in the rate of the primary composite outcome of obstetric complications: 124/184 (67% control), 124/187 (66% intervention) [relative risk 0.98 (95% confidence interval (CI) 0.85-1.14)]. There was no difference in mean gestational weight gain [-0.9 kg (95% CI -2.0, 0.25)], QOL or leptin, adiponectin or CRP levels between intervention and control groups. CONCLUSIONS: This low-cost, pragmatic intervention failed to prevent obstetric complications or modify maternal biochemistry or gestational weight gain in overweight or obese pregnant women. Participation in the study did not impair participants' QOL. TWEETABLE ABSTRACT: Serial self-weighing and dietary advice failed to reduce obstetric complications in overweight pregnant women.

Factors affecting success of thymus transplantation for complete DiGeorge anomaly.

Thymus transplantation shows promise for the treatment of athymia in complete DiGeorge anomaly. This report reviews the effects of dose of thymus tissue, ABO compatibility, HLA matching, culture conditions, age of donor and immunosuppression of recipient on immune outcomes at 1 year after transplantation. Forty-nine athymic subjects have been treated with cultured postnatal allogeneic thymus tissue; 36 (73%) survive with only one subject on immunosuppression at 1.5 years. Of 31 surviving subjects more than 1 year after transplantation, 30 (97%) developed naive T cells, T-cell proliferative responses to mitogens and a diverse T-cell receptor beta variable (TCRBV) repertoire. The dose of thymus tissue, HLA matching and use of immunosuppression had nonsignificant effects on these outcome variables. Removal of deoxyguanosine from culture medium and length of culture did not adversely affect outcomes. Use of thymus tissue from donors over 1 month of age, versus under 1 month, resulted in higher total T-cell numbers (p = 0.03). However, this finding must be confirmed in a prospective trial. Although subtle immune effects may yet be associated with some of the factors tested, it is remarkable that consistently good immune outcomes result despite variation in dose, HLA matching and use of immunosuppression.

Regular ventricular rhythms in patients with symptomatic paroxysmal atrial fibrillation.

Paroxysmal atrial fibrillation is a grossly irregular tachycardia. Forty-nine patients with paroxysmal atrial fibrillation who were taking a variety of antiarrhythmic medications including the class IC agents propafenone and flecainide were followed up for a median of 371 days with use of transtelephonic electrocardiogram (ECG) monitoring to document symptomatic rhythms. Eighteen patients had 96 episodes of regular tachycardia; the cumulative incidence rate was 25% at 6 months, 33% at 1 year and 41% at 18 months. Eighty of the 96 episodes occurred with a heart rate less than or equal to 180 beats/min and could have been explained by atrial flutter with 2:1 block. However, nine patients had a total of 16 episodes with a rate greater than 180 beats/min that were probably not due to atrial flutter with block; the cumulative incidence rate of these fast regular tachycardias was 14% at 6 months, 17% at 1 year and 25% at 18 months. QRS duration during the first episode of regular tachycardia was significantly longer in patients taking a class IC drug (median 105 vs 90 ms, p less than 0.001 Wilcoxon rank sum test). In contrast to drug therapy with amiodarone or the combination of digoxin and verapamil, the QRS duration of regular tachycardias during class IC therapy was directly related to the tachycardia heart rate (Spearman's rank, p less than 0.01). All episodes of fast, regular tachycardias with a QRS duration greater than 120 ms occurred in patients taking a class IC drug. Clinicians treating patients with paroxysmal atrial fibrillation should expect a substantial incidence of regular tachycardia in addition to atrial fibrillation.

Incidence of symptomatic atrial fibrillation in patients with paroxysmal supraventricular tachycardia.

OBJECTIVES: This study was performed to determine the incidence of symptomatic, sustained atrial fibrillation in a group of patients with paroxysmal supraventricular tachycardia. The effects of the mechanism of paroxysmal supraventricular tachycardia (atrioventricular [AV] node reentry vs. AV reentry through an accessory pathway) and heart rate during the tachycardia on the occurrence of atrial fibrillation were also assessed. BACKGROUND: There is a substantial incidence of atrial fibrillation in patients with paroxysmal supraventricular tachycardia, but the precise incidence and the factors that determine it are unknown. METHODS: One hundred sixty-nine patients with paroxysmal supraventricular tachycardia were followed up by regular clinic visits and transtelephonic electrocardiographic monitoring during symptomatic episodes of arrhythmia. The Kaplan-Meier product-limit method was used to estimate the proportion of patients remaining free of atrial fibrillation during the observation period. The Cox proportional hazards model was used to assess the effect of mechanism and heart rate during paroxysmal supraventricular tachycardia on the atrial fibrillation-free period. RESULTS: Thirty-two (19%) of the 169 patients had an episode of atrial fibrillation during a mean follow-up period of 31 months. The cumulative percent of patients experiencing an episode of atrial fibrillation was 6% within 1 month, 9% within 4 months and 12% within 1 year. The mechanism of paroxysmal supraventricular tachycardia was not associated with the time to occurrence of atrial fibrillation; the hazard ratio corresponding to classification in the AV node reentry group was 0.8 (p > 0.6). The heart rate during paroxysmal supraventricular tachycardia was not associated with the time to occurrence of atrial fibrillation; the hazard ratio associated with an increase in heart rate of 50 beats/min during the tachycardia was 1.15 (p > 0.5). CONCLUSIONS: This study suggests that atrial fibrillation will develop in approximately 12% of patients with paroxysmal supraventricular tachycardia during a 1-year follow-up period. The occurrence of atrial fibrillation is not related to the mechanism or heart rate of the paroxysmal supraventricular tachycardia.

Incidence of symptomatic tachycardia in untreated patients with paroxysmal supraventricular tachycardia.

The purpose of this article is to investigate the occurrence of symptomatic paroxysmal supraventricular tachycardia (PSVT) in untreated patients and to assess factors that influenced its occurrence. We studied 34 patients with this arrhythmia during an observation period in which they received no antiarrhythmic drug therapy for up to 90 days. Recurrence of PSVT was documented by telephone transmission of the electrocardiogram. Each patient was allowed to have exactly one episode of tachycardia before being removed from the study. We measured how long patients remained free of their tachycardia (the tachycardia-free period) and heart rate during tachycardia. Twenty-nine of the 34 patients had an attack of symptomatic tachycardia within the 90-day observation period. The proportion of patients who had not had any symptomatic PSVT by each day of follow-up was calculated using the Kaplan-Meier method as follows: 75% by day 3, 50% by day 19, 25% by day 36, and 17% by day 90. Patients with any other heart or lung disease had significantly shorter tachycardia-free periods. The mean heart rate during spontaneous tachycardia was 203.5 +/- 34.9 beats per minute (range, 142 to 288 beats per minute). Patients with longer tachycardia-free periods had significantly faster heart rates during tachycardia.

Effects of bolus injection of esmolol in healthy, exercising subjects.

Esmolol is an investigational ultra-short-acting beta-adrenergic blocker that has potential application in many clinical cardiology settings. The purpose of this study was to investigate the effect of a bolus dose of esmolol on heart rate, blood pressure, and PR interval in healthy, exercising male subjects. We gave a single esmolol bolus over 30 seconds to 13 men who exercised to a predetermined target heart rate. Each subject performed the exercise protocol twice, receiving a different dose between 10 and 300 mg each time. An additional eight subjects received two esmolol boluses 5 minutes apart while performing the same exercise protocol. Esmolol doses of 180 mg or greater caused a 13% to 18% decrease in heart rate, an 11% to 18% decrease in blood pressure, and a 13% to 22% prolongation of the PR interval. The median time to peak esmolol effect was 1 minute for heart rate, 2 minutes for blood pressure, and 4 minutes for PR interval. The median time required to recover 50%, 75%, and 90% of the decrement in heart rate was 8, 10, and 13 minutes, respectively. The rapid onset and disappearance of esmolol effects may make it an appealing drug in acute care settings.

Treatment of paroxysmal supraventricular tachycardia with oral diltiazem.

Symptomatic paroxysmal supraventricular tachycardia is a troubling arrhythmia for many patients. To test the efficacy of oral diltiazem to reduce symptomatic recurrences of paroxysmal supraventricular tachycardia, we enrolled 17 patients in a double-blind, placebo-controlled crossover study. Sixteen of 17 patients completed a dose-ranging phase and were entered into the randomized phase. Although the time to first recurrence of tachycardia was slightly longer when patients took diltiazem, the difference was not significant (p = 0.15). The hazard ratio of the time to first recurrence on placebo compared with oral diltiazem was 2.7 (95% confidence interval, 0.8 to 9.1). Of the patients who had a recurrence of tachycardia in both treatment periods, the median reduction in heart rate in patients receiving diltiazem was 20 beats/min. (p less than 0.01; 95% confidence interval, 6 to 42).

Pharmacodynamics and pharmacokinetics of oral pirmenol.

The efficacy, pharmacokinetics, and pharmacodynamics of pirmenol, a class Ia antiarrhythmic agent, were studied in patients with frequent symptomatic premature ventricular complexes (PVCs). Pirmenol was given every 12 hours to eight patients in a dose-ranging protocol, and median PVC suppression of 94% (range 72% to 100%) was achieved. The median effective pirmenol dose was 300 mg/day (range 200 to 500 mg/day), and mean (+/- SD) trough plasma pirmenol concentration at the effective dose was 0.98 +/- 0.29 micrograms/ml. The mean half-life of elimination was 10.5 +/- 2 hours. There was considerable overlap among patients with respect to plasma pirmenol concentration and times at which PVC frequency returned to 25%, 50%, and 75% of baseline during drug washout trials. Altering pirmenol's dose interval (while maintaining a constant daily dose) from 12 to 6 hours did not improve drug efficacy. Pirmenol was given to seven patients for long-term therapy (24 to 44 months). Median PVC suppression at 24 months was 70%. Pirmenol is safe and well tolerated, and it can be administered twice daily for PVC suppression.

Clinical behavior of paroxysmal atrial tachycardia.

Paroxysmal atrial tachycardia is a familiar arrhythmia that has been studied extensively for the past decade using intracardiac recording and programmed electrical stimulation. These studies have thoroughly documented the mechanisms of this arrhythmia and its associated atrioventricular conduction abnormalities, but little is known about the spontaneous clinical behavior of this arrhythmia. A group of 34 patients with paroxysmal atrial tachycardia were studied using telephone transmission of the electrocardiogram to document recurrent tachycardia. When antiarrhythmic therapy was withdrawn, median time to the first recurrence of tachycardia was 19 days, mean heart rate during spontaneous tachycardia was 203.5 +/- 34.9 beats/min, and the median duration of an attack was 20 minutes. In a group of patients who were followed while many consecutive attacks were documented, the time intervals between attacks were found to be uncorrelated and to fit an exponential probability distribution (i.e., the occurrence of paroxysmal atrial tachycardia behaved like a Poisson process). Paroxysmal atrial tachycardia does not occur in a chaotic and unpredictable fashion; it is an event that occurs according to common probability models.

Observations on the occurrence of atrial fibrillation in paroxysmal supraventricular tachycardia.

Paroxysmal supraventricular tachycardia (PSVT) and atrial fibrillation (AF) are both supraventricular arrhythmias, but their mechanisms are completely different. This study determines the incidence of symptomatic AF in a group of patients followed closely during routine outpatient care for PSVT. Thirty-nine patients with PSVT were followed for up to 4 years using telephone transmission of the electrocardiogram to document symptomatic arrhythmias. The cumulative proportion of patients who had AF was calculated using the Kaplan-Meier life-table method. In addition, we examined the importance of clinical variables traditionally believed to influence the occurrence of AF. The cumulative proportion of patients who had AF during follow-up was 13% at 3 months, 16% at 6 months, 22% at 1 year and 29% at 2 years. In most patients the start of AF was documented during an attack of PSVT rather than de novo as another primary arrhythmia. PSVT occurred significantly earlier during an observation period without treatment in patients in whom AF developed (p = 0.03). The occurrence of AF was not related to age, number of years of PSVT, heart rate during tachycardia or coexistent heart disease.

Random and nonrandom behavior of symptomatic paroxysmal atrial fibrillation.

Little is known about the behavior of symptomatic paroxysmal atrial fibrillation (AF). The nature of the process formed by the successive occurrences of this arrhythmia was studied in 8 patients with a history of symptomatic paroxysmal AF. Trans-telephonic monitoring of the electrocardiogram was used to document the cardiac rhythm during symptoms. Patients were followed while successive attacks of paroxysmal AF were documented. A minimum of 12 and a maximum of 26 consecutive episodes of symptomatic paroxysmal AF were recorded from the 8 patients during 66 to 332 days. Methods developed in industrial reliability theory were used to show that, for the overall group of 8 patients, the interevent times between successive occurrences of symptomatic AF were not independent. However, for a subgroup including 6 of the patients, the interevent times were independent and governed by an exponential probability distribution. Differences in observed behavior of symptomatic AF may relate to differences in underlying mechanism within patients.

Effects of sustained intravenous diltiazem infusion in healthy persons.

A 3-stage infusion of diltiazem was tested in 8 subjects for up to 48 hours: a bolus injection (10 mg over 3 minutes), a rapid loading infusion (20 mg over 30 minutes) and a maintenance infusion (10 mg/hour to the end of the study). This regimen produced stable median plasma diltiazem concentrations of approximately 150 ng/ml. The median half-life of elimination for diltiazem was 206 minutes (range 144 to 452) and median total clearance was 980 ml/min (range 665 to 1,907). The PR interval lengthened 10 to 18% during the maintenance infusion in 7 subjects; in 1 subject atrioventricular nodal Wenckebach conduction was recorded during the rapid loading infusion. Systolic blood pressure decreased from 124 +/- 7 mm Hg (mean +/- standard deviation) during the control period to 121 +/- 8 mm Hg during the rapid loading infusion (p = 0.03 compared with control) and to 117 +/- 7 mm Hg (p = 0.04 compared with control) during the maintenance infusion. Heart rate did not change. PR interval and blood pressure returned to control levels within 4 hours after the infusion was stopped. Loading and maintenance infusion may be an attractive method of administering diltiazem when stable drug concentrations are required for prolonged periods.

Life-table methods for evaluating antiarrhythmic drug efficacy in patients with paroxysmal atrial tachycardia.

Spontaneous variability in the occurrence of paroxysmal arrhythmias has made it difficult to apply objective and quantitative methods to describe their clinical course. In this study of paroxysmal atrial tachycardia, the "tachycardia-free interval" was used as a quantitative measure of drug efficacy during treatment with oral verapamil. The tachycardia-free interval is the time a patient remains free from an episode of tachycardia after drug treatment is begun. We documented recurrent tachycardia by telephone transmission of the electrocardiogram. Improvement caused by increasing the drug dose (360 versus 480 mg/day) or by comparing verapamil with placebo treatment was demonstrated by upward shifts in the cumulative tachycardia-free interval curves. The tachycardia-free interval is an easily measured clinical variable that has substantial promise in the study of paroxysmal arrhythmias.

Treatment of the psychiatrically ill patient in the medical bed of a general hospital.

Disorders of the mind are disorders of a vulnerable physical organ: the brain. Psychiatry has a tradition of considering all factors involved in mental illness including psychologic, sociologic, environmental, and spiritual influence. However, we do well not to lose sight of the physical factors involved in mental illness. Admission of the psychiatrically ill patient to the medical bed of a general hospital is often the clear treatment of choice.

Pharmacokinetic evaluation of aconiazide, a potentially less toxic isoniazid prodrug.

STUDY OBJECTIVE: To determine the bioavailability and renal elimination of isoniazid, acetylisoniazid, monoacetylhydrazine, diacetylhydrazine, aconiazide, and 2-formylphenoxyacetic acid. STUDY DESIGN: Randomized, double-blind, two-period, crossover phase I study. SETTING: Pharmacokinetics unit at a referral hospital that specializes in the treatment of mycobacterial infections. SUBJECTS: Twelve healthy volunteers selected from the hospital staff. INTERVENTIONS: Subjects received aconiazide tablets 650 mg (containing isoniazid 300 mg) and isoniazid tablets 300 mg. Blood and urine samples were collected over 24 hours after the dose. MEASUREMENTS AND MAIN RESULTS: Intact aconiazide and 2-formylphenoxyacetic acid were not detected in the serum. Compared with isoniazid tablets, aconiazide's relative bioavailability (based on the area under the serum concentration-time curve) was 50.7%; its relative maximum serum concentration was 13.4%. CONCLUSIONS: Isoniazid is less bioavailable after aconiazide tablets than after isoniazid tablets. The optimum dose of aconiazide remains to be determined.

A sex comparison of the anatomy and function of the main olfactory bulb-medial amygdala projection in mice.

We previously reported that some main olfactory bulb (MOB) mitral/tufted (M/T) cells send a direct projection to the "vomeronasal" amygdala in female mice and selectively respond to volatile male mouse urinary odors. We asked whether MOB M/T cells that project to the vomeronasal amygdala exist in male mice and whether there is a sexually dimorphic response of these neurons to volatile male urinary pheromones. Gonadectomized male and female mice received bilateral injections of the retrograde tracer, Cholera toxin-B (CTb) into the medial amygdala (Me), which is part of the vomeronasal amygdala. All subjects were then treated with estradiol benzoate and progesterone before being exposed to volatile male urinary odors whereupon they were sacrificed 90 min later. Sections of the MOB were immunostained for Fos protein and/or CTb. Male mice, like females, displayed a small population of MOB M/T cells that project to the Me. While the general localization of these cells was similar in the two sexes, there were statistically significant sex differences in the percentage of MOB M/T cells in the anterior and posterior medial segments of the MOB that were retrogradely labeled by CTb. Male urinary volatiles stimulated equivalent, significant increases in Fos expression by MOB M/T neurons projecting to the Me in the two sexes. By contrast, in the same mice exposure to male urinary volatiles stimulated a significant increase in Fos expression by mitral cells in the accessory olfactory bulb (AOB) only in female subjects. Thus any sexually dimorphic behavioral or neuroendocrine responses to male urinary volatiles likely depend on the differential processing of these odor inputs in the AOB and/or other downstream forebrain structures after their detection by the main olfactory system.