Evidence of prolonged disturbances in the haemostatic,hemorheologic and inflammatory profiles in transmural myocardial infarction survivors

Haemostatic, hemorheologic and inflammatory disturbances have been associated with acute coronary syndromes. Most knowledge is reported in cross sectional studies and are without time dependent evolution of these profiles. The aim of this study was to evaluate, during the first year, the evolution of the haemostatic, hemorheologic and inflammatory profiles determined at hospital discharge in survivors with transmural myocardial infarction (MI). Eighty eight (79 male; 9 female) mean age of 58 +/- 11 years, survivors of a transmural MI were prospectively studied at discharge, 6 months and one year after the event. Haemostatic (protein C, antithrombin III and plasminogen activator inhibitor 1), hemorheologic (blood fluidity and components) and inflammatory profiles (polymorphonuclear elastase and leukocyte count) were determined using standard methodology. The results of the study can be summarized as follows: (1) Protein C decreased (p < 0.05) over time while PAI-1 only varied significantly until 6(th) month. (2) Plasma viscosity and fibrinogen (p < 0.001) decrease over time, while erythrocyte aggregation (p < 0.001) and haematocrit increased. Whole blood viscosity did not vary. (3) Leukocyte decreased (p < 0.001) and elastase did not (4). Those patients with cardiovascular events (n = 7) had higher PAI-1 concentration (p < 0.05) and leukocyte count (p < 0.01), at discharge (5) Left ventricle ejection fraction correlated significantly with plasma viscosity (r = 0.35 p < 0.05). The results of this longitudinal study show dynamic modifications of the haemostatic, hemorheologic and inflammatory profiles during the first year of a transmural myocardial infarction. In addition, there are interrelations between them and the clinical profile that could help to explain the clinical evolution of this group of patients.     

Severe acute respiratory distress syndrome in a child with malaria: favorable response to prone positioning

We present the case of a 4-year-old boy with malaria who developed acute respiratory distress syndrome with severe hypoxemia refractory to mechanical ventilation and inhaled nitric oxide. Placing the patient in prone position immediately and persistently improved oxygenation: the ratio of P(aO(2)) to fraction of inspired oxygen rose from 47 to 180 mm Hg and the oxygenation index decreased from 40 to 11. The patient survived, with no respiratory sequelae.     

Feasibility of flow cytometry for measurements of Plasmodium falciparum parasite burden in studies in areas of malaria endemicity by use of bidimensional assessment of YOYO-1 and autofluorescence

The detection and quantification of Plasmodium falciparum in studies of malaria endemicity primarily relies upon microscopy. High-throughput quantitative methods with less subjectivity and greater reliability are needed for investigational studies. The staining of parasitized erythrocytes with YOYO-1 for flow cytometry bears great potential as a tool for assessing malaria parasite burden. Capillary blood was collected from children presenting to the pediatric ward of the Manhiça District Hospital in Mozambique for parasitemia assessment by thick and thin blood films, flow cytometry (YOYO-1_530/585), and quantitative real-time PCR (qRT-PCR). Whole blood was fixed and stained with YOYO-1 for acquisition on a cytometer to assess the frequency of infected erythrocyte events. qRT-PCR was used as the gold standard for the detection of P. falciparum. The YOYO-1_530/585 method was as sensitive and specific as conventional microscopy (area under the receiver operating characteristic, 0.9 for both methods). The interrater mean difference for YOYO-1_530/585 was near zero. Parasite density using flow cytometry and complete blood counts returned density estimates with a mean difference 2.2 times greater than results by microscopy (confidence interval, 1.46 to 3.60) but with limits of agreement between 10 times lower and 50 times higher than those of microscopy. The YOYO-1_530/585 staining pattern was established exactly as demonstrated in animal models, but the assay was limited by the lack of appropriate negative-control samples for establishing background levels and the definition of positives in areas in which malaria is endemic. YOYO-1_530/585 is a high-throughput tool with great potential if the limitations of negative controls and heterogeneous levels of background signal can be overcome.     

Acquired Immunity to Malaria

Naturally acquired immunity to falciparum malaria protects millions of people routinely exposed to Plasmodium falciparum infection from severe disease and death. There is no clear concept about how this protection works. There is no general agreement about the rate of onset of acquired immunity or what constitutes the key determinants of protection; much less is there a consensus regarding the mechanism(s) of protection. This review summarizes what is understood about naturally acquired and experimentally induced immunity against malaria with the help of evolving insights provided by biotechnology and places these insights in the context of historical, clinical, and epidemiological observations. We advocate that naturally acquired immunity should be appreciated as being virtually 100% effective against severe disease and death among heavily exposed adults. Even the immunity that occurs in exposed infants may exceed 90% effectiveness. The induction of an adult-like immune status among high-risk infants in sub-Saharan Africa would greatly diminish disease and death caused by P. falciparum. The mechanism of naturally acquired immunity that occurs among adults living in areas of hyper- to holoendemicity should be understood with a view toward duplicating such protection in infants and young children in areas of endemicity.     

Aversion to geographic inequality and geographic variation in preferences in the context of healthcare

Background

It is now widely accepted that social values have a role to play in terms of healthcare resource allocation decisions. Furthermore, with the recent focus on decentralization, geographic variation in preferences has become a pertinent issue. However, the geographic dimension of inequality in the distribution of health gains across different regions has received little attention in the literature.

Objectives

To elicit the general public’s preferences regarding inequality in the distribution of health gains across regions and to test the assumption of variation in preferences across regions.

Methods

A questionnaire was developed to elicit social and personal preferences. The first preference questions focused on the criteria of maximization of health gain and geographic equality of health gain. Person trade-off questions were used to assess trade-offs and inequality aversion. The latter preference questions focused on attributes of healthcare delivery. The questionnaire was administered in two Portuguese municipalities. Samples from both localities were defined by quotas based on the composition of local populations. Overall, 70 respondents (half from each municipality) self-completed the questionnaire.

Results

Respondents agreed or strongly agreed that both maximization of health gain and geographic equality of health gain should be considered in resource allocation decisions; when they were asked to make trade-offs, 70–80% were prepared to do so. Of those making trade-offs, most people were willing to forego 10–30% of total health gain to keep geographic equality of health gain in return. Regarding inequality aversion, the results indicate that there was some aversion to inequality in the sample. Regarding preference variation, the results do not corroborate the hypothesis of variation in preferences across regions.

Conclusion

These results suggest that the general public supports the principles of maximization of health gain and geographic equality in the distribution of health gain. The results further suggest the existence of aversion to inequality, subject to a maximum opportunity cost. Further research is required into preference variation; in particular, in larger samples, and in other regions of Portugal.     

Health-Related Quality of Life for Eating Disorders questionnaire version-2 was responsive 1-year after initial assessment

OBJECTIVES: To assess the responsiveness of the Health-Related Quality of Life for Eating Disorders questionnaire version-2 (HeRQoLEDv2) and present the psychometric characteristics of a new binge domain. STUDY DESIGN AND SETTING: Patients with an eating disorder completed the HeRQoLEDv2, the Eating Attitudes Test-26, Short Form Health Survey-12, and two items from the Eating Disorder Inventory-2, at baseline and after 1 year. At the second assessment, patients completed the HeRQoLEDv2, as part of the battery of tests, along with health transitional questions. Validity and reliability analyses of the new binge domain were performed. Responsiveness was evaluated using distributional and anchor-based approaches, comparison of mean changes, mean change correlations, the minimal detectable change (MDC) at the individual and group level, and the minimal important difference (MID). RESULTS: Items in the binge domain loaded above 0.40. Cronbach alpha was 0.82. Regarding responsiveness, the mean changes detected by the HeRQoLEDv2 correlated above 0.30 with the criterion measures. Patients who reported improvement showed significant changes, and effect sizes above 0.30. The MDC(90%ind) was larger than the MID. CONCLUSION: The HeRQoLEDv2 includes the new binge domain. It responded to change at the group level. Further research regarding the MID is needed.     

Intrapartum transperineal ultrasound as a predictor of instrumentation difficulty with vacuum-assisted delivery in primiparous women

Objectives: To assess the capability of different intrapartum transperineal ultrasound parameters to predict the difficulty of vacuum extraction. This is a prospective observational study performed between 04/2012 and 03/2013 on 72 primiparous-women, ≥37-weeks with singleton pregnancies at full dilatation that underwent transperineal ultrasound before vacuum placement for foetal extraction. Working in a transperineal longitudinal plane we evaluated: progression-angle, progression-distance and head direction; in a transverse plane: midline-angle and head-perineum distance. The vacuum extractions were classified as easy-group (EG) (≤3 vacuum pulls), difficult/impossible-group (DG)(≥4 pulls). Occiput-posterior presentations were not assessed.

Results: Fifty-two (52) patients were studied (26 patients per study group). No differences were observed in obstetric, neonatal or intrapartum characteristics between the study groups, with the following exceptions: new-born (NB) weight (3147?g versus 3540?g) and the number of vacuum pulls (1.4 EG versus 4.3 DG; p?<?0.0005). The progression angle was 133.1° (123°–143°) in EG and 109.2° (97.2°–121.2°) in DG (p?<?0.0005); up direction of foetal head was 88% versus 34.5% (p?<?0.0005); progression distance was 37?mm (26.6–47.4) versus 29.9?mm (8.8–51; p?=?0.003); midline angle was 35° (15.4°–54.6°) versus 59.7° (34.5°–84.9°; p?=?0.0005); head-perineum distance was 41.9?mm (35.2–48.6) versus 48.9?mm (40.5–57.3; p?=?0.017). The area under the Receiver Operating Characteristic (ROC) curve for the progression angle was 0.9 (95%CI, 0.82–0.99), and the midline angle was 0.8 (95%CI, 0.67–0.92).

Conclusion: If previous to the placement of the vacuum cup the progression angle is ≤120°, the foetal head direction is horizontal or down, and the midline angle is ≥35°, there is an 85% chance that the delivery will require more than 4 vacuum pulls.