Association of hemostatic variables with MRI-detected cerebral abnormalities: the atherosclerosis risk in communities study

OBJECTIVES: Population-based and clinical prospective studies have shown independent associations of several hemostatic factors with ischemic heart disease and stroke. MRI-detected cerebral infarcts and white matter lesions are often detected in elderly individuals without clinical disease. It has been hypothesized that these types of lesions are often the consequence of cerebral ischemic damage and may be the precursors of clinical stroke. METHODS: This study examined the relation between a range of hemostatic factors measured at baseline in middle-aged participants who were free of diagnosed cardiovascular disease in the Atherosclerosis Risk in Communities Study and MRI-detected cerebral abnormalities at a 6-year follow-up examination. RESULTS: Plasma fibrinogen and perhaps von Willebrand factor were associated positively, and protein C was associated negatively, with cerebral infarctions. Adjusted for other risk factors, the odds ratio for cerebral infarction was 1.21 (95% confidence interval, CI = 1.02-1.44) per standard deviation increment for fibrinogen, 1.15 (95% CI = 0.97-1.37) per standard deviation increment for von Willebrand factor, and 0.77 (95% CI = 0.62-0.95) per standard deviation increment for protein C. No hemostatic factor, however, was associated with white matter disease. CONCLUSIONS: This study has only a follow-up MRI, and it is likely that some MRI lesions were present at baseline. Nevertheless, increased levels of fibrinogen and von Willebrand factor and reduced levels of protein C appear to be associated with cerebral infarction identified by MRI.     

Identification of neonatal hearing impairment: auditory brain stem responses in the perinatal period

OBJECTIVES: 1) To describe the auditory brain stem response (ABR) measurement system and optimized methods used for study of newborn hearing screening. 2) To determine how recording and infant factors related to the screening, using well-defined, specific ABR outcome measures. DESIGN: Seven thousand one hundred seventy-nine infants, 4478 from the neonatal intensive care unit (NICU) and the remaining from the well-baby nursery, were evaluated with an automated ABR protocol in each ear. Two channel recordings were obtained (vertex to mastoid or channel A and vertex to nape of neck or channel B) in response to click stimuli of 30 and 69 dB nHL in all infants as well as 50 dB nHL in infants who did not meet criteria for response at 30 dB. Criteria for response included F(SP) > or =3.1 and a tester-judgment of response. Criteria could be met in the first or repeat test with a maximum of 6144 accepted sweeps per test. RESULTS: More than 99% of infants could complete the ABR protocol. More than 90% of NICU and well-baby nursery infants "passed" given the strict criteria for response, whereas 86% of those with high risk factors met criterion for ABR response detection. The number of infants who did not meet ABR response criteria in one or both ears was systematically related to stimulus level with the largest group not meeting criteria at 30 dB followed by 50 and 69 dB nHL. Meeting criteria on the ABR was positively correlated with the amplitude of wave V, with low noise and low electrode impedance. Factors that predicted how many sweeps would be needed to reach criterion F(SP) included noise level of the test site, state of the baby (for example, quiet sleep versus crying), recording noise, electrode impedance and response latency. Channel A (vertex to mastoid) reached criterion more often than channel B (vertex to nape of neck) due to higher noise in channel B. Average total test time for 30 dB nHL screening in both ears was under 8 minutes. Well babies with risk factors took slightly longer to evaluate than other groups with this automated ABR procedure and have higher noise levels. CONCLUSIONS: ABR implemented with an automated detection algorithm using a 30 dB nHL click stimulus is reliable technique for rapid assessment of auditory status in newborns. Factors other than hearing loss that influenced the test result include infant state, electrode location and impedance, testing site, and infant risk status. Even so, ABRs were reliably recorded in the vast majority of babies under circumstances in which most babies are found in the perinatal period.     

Determinants of population changes in fibrinogen and factor VII over 6 years: the Atherosclerosis Risk in Communities (ARIC) Study

Although numerous cross-sectional studies have identified possible determinants of plasma fibrinogen and factor VII levels, few prospective studies exist. We assessed the longitudinal relation of changes in fibrinogen and factor VII over 6 years with changes to other cardiovascular risk factors in a sample of 440 men and 549 women from the Atherosclerosis Risk in Communities (ARIC) study. Fibrinogen increased more in older participants, those with or who developed diabetes, those who at any time smoked, and those whose plasma HDL cholesterol or triglycerides decreased and increased less in female participants who started hormonal replacement therapy. Factor VII coagulant activity increased more in younger participants, women, those who gained greater weight or developed diabetes, those who quit smoking, those in whom plasma triglycerides decreased, and female participants who received hormonal replacement therapy. Thus, our longitudinal data suggest with some exceptions that adverse changes in cardiovascular risk factors are accompanied by increases in plasma levels of fibrinogen and factor VII.     

Tracheo-esophageal puncture (TEP) for voice rehabilitation in laryngectomised patients blom-singer® Vs Provox® Prosthesis: Our experience

Background: Stage III and IV cancers of larynx and hypopharynx often require total laryngectomy which leaves the patient with severe communication handicap. In such laryngectomised patients tracheo-esophageal puncture is the best way for voice rehabilitation using either Blom-Singer® prosthesis or Provox® indwelling valve.     

"New" risk factors for atherosclerotic diseases

Many potential "new" risk factors may predispose to atherosclerotic diseases. The most promising currently seem to be fibrinogen, C-reactive protein and other inflammatory markers; hyperhomocysteinemia; low vitamin E intake; insulin resistance; lipoprotein(a); and fetal undernutrition. However, clinical trial proof of a causal role between several of these risk factors and CHD may be difficult to obtain unless selective interventions are developed to lower them. Certainly, current emphasis for primary and secondary prevention needs to focus on the established risk factors, particularly those for which clinical trial evidence has demonstrated interventions are efficacious for CHD prevention.     

Does a family history of cancer increase the risk for postmenopausal endometrial carcinoma? A prospective cohort study and a nested case-control family study of older women.

BACKGROUND: As part of the hereditary nonpolyposis colon carcinoma (HNPCC) constellation of neoplasia caused by defects in mismatch repair genes, some endometrial carcinomas are known to have a genetic contribution to etiology. However, most endometrial carcinomas occur in postmenopausal women, presumably without the HNPCC defect. Consequently, the genetic contribution to these cases is unclear. The objective of this study was to determine whether family history of cancer is a risk factor for endometrial carcinoma in older women. METHODS: The authors analyzed incident endometrial carcinoma data, as well as data on family history of various cancers in first-degree relatives, from a cohort of 24,848 postmenopausal Iowa women ages 55-69 years who were cancer free at baseline in 1986. Because a positive family history is dependent on many factors, including the age of the patient, the number of relatives, and the distribution of other risk factors in relatives, the authors also conducted a nested case-control study on family members of 95 patients with endometrial carcinoma diagnosed during 1988-1989 and 91 cancer free controls who were chosen randomly from subjects matched for age (+/-1 year). RESULTS: During 10 years of follow-up of the cohort, 322 incident endometrial carcinoma cases occurred. Women who reported a positive family history of cancer overall or at any specific site (e.g., the endometrium, colon, or breast) were not at increased risk for endometrial carcinoma. Adjustment for potential confounders, such as age, obesity, parity, oral contraceptive use, and estrogen replacement therapy, did not alter these results. Analysis of the family members of the cases and controls produced little evidence to suggest that this lack of association between family history and endometrial carcinoma could be explained by unequal distribution of known risk factors among relatives. Case family members were slightly older than control family members, but no significant differences were found in body mass index (kg/m2), age at menarche, age at menopause, or number of pregnancies. Relation to a case or control was not associated with increased risk of endometrial, ovarian, breast, or colon carcinoma for family members. Controlling for a variety of potential confounders did not alter the results. CONCLUSIONS: No evidence was found that genetics contribute to the risk of postmenopausal endometrial carcinoma for women with no personal cancer history.     

IDEAL PAIN RELIEF FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY

In a previous report the effectiveness of intraperitoneal bupivacaine in reducing pain following laparoscopic cholecystectomy was demonstrated. Other methods of pain relief are commonly used but none has been compared following laparoscopic cholecystectomy. In two further studies we have compared the analgesic effect of intraperitoneal bupivacaine against wound infiltration with bupivacaine, and against intraperitoneal bupivacaine with the addition of a non-steroidal anti-inflammatory drug (NSAID) in patients undergoing laparoscopic cholecystectomy. Two consecutive studies were performed. In the first, patients in group 1 were given 20 ml of 0.25% bupivacaine into the peritoneal cavity; patients in group 2 were given 20 ml of 0.25% bupivacaine injected into the trocar wounds. In the second study, patients in group 1 were given 20 ml of 0.25% bupivacaine into the peritoneal cavity; patients in group 2 were given 20 ml of 0.25% bupivacaine into the peritoneal cavity and a diclofenac suppository (100 mg) one hour before surgery. Postoperative pain was assessed with a visual analogue pain scale. There was no difference in pain scores in the two groups in either study. Intraperitoneal bupivacaine is as effective as wound infiltration. The addition of an NSAID makes no difference in the reduction of postoperative pain following laparoscopic cholecystectomy.     

Effects of L-5HTP with and without carbidopa on plasma ß-endorphin and pain perception

L-Tryptophan (L-TP) has been used in migraine and other pain conditions. The mechanism underlying the analgesic effect is still partly undefined. In this study the effects of subchronic administration of L-5-hydroxy-tryptophan (L-5HTP) (with and without carbidopa) on plasma beta-endorphin (beta-EP) levels and subjective pain threshold and tolerance were investigated in seven healthy volunteers. To measure also an objective indicator for pain, the nociceptive flexion reflex threshold was studied. L-5HTP treatment with and without carbidopa administration increased beta-EP levels significantly (p less than 0.05). L-5HTP plus carbidopa induced an increase in beta-EP significantly (p less than 0.05) higher than that after L-5HTP alone. Neither subjective pain threshold and tolerance nor RIII threshold was modified by either treatment. Our data seem to point to the existence of a complex linkage between plasma opioid levels and pain perception.