Apparent diffusion coefficient histogram analysis of neonatal hypoxic–ischemic encephalopathy

Background

Diffusion-weighted imaging is a valuable tool in the assessment of the neonatal brain, and changes in diffusion are seen in normal development as well as in pathological states such as hypoxic–ischemic encephalopathy (HIE). Various methods of quantitative assessment of diffusion values have been reported. Global ischemic injury occurring during the time of rapid developmental changes in brain myelination can complicate the imaging diagnosis of neonatal HIE.

Objective

To compare a quantitative method of histographic analysis of brain apparent coefficient (ADC) maps to the qualitative interpretation of routine brain MR imaging studies. We correlate changes in diffusion values with gestational age in radiographically normal neonates, and we investigate the sensitivity of the method as a quantitative measure of hypoxic–ischemic encephalopathy.

Materials and methods

We reviewed all brain MRI studies from the neonatal intensive care unit (NICU) at our university medical center over a 4-year period to identify cases that were radiographically normal (23 cases) and those with diffuse, global hypoxic–ischemic encephalopathy (12 cases). We histographically displayed ADC values of a single brain slice at the level of the basal ganglia and correlated peak (s-sD_av) and lowest histogram values (s-sD_lowest) with gestational age.

Results

Normative s-sD_av values correlated significantly with gestational age and declined linearly through the neonatal period (r ²?=?0.477, P?<?0.01). Six of 12 cases of known HIE demonstrated significantly lower s-sD_av and s-sD_lowest ADC values than were reflected in the normative distribution; several cases of HIE fell within a 95% confidence interval for normative studies, and one case demonstrated higher-than-normal s-sD_av.

Conclusion

Single-slice histographic display of ADC values is a rapid and clinically feasible method of quantitative analysis of diffusion. In this study normative values derived from consecutive neonates without radiographic evidence of ischemic injury are correlated with gestational age, declining linearly throughout the perinatal period. This method does identify cases of HIE, though the overall sensitivity of the method is low.     

The decline of grip strength in the menopause: relationship to physical activity, estrogen use and anthropometric factors

The focus of this study was the relationship of grip strength to age, physical activity and anthropometric factors, in a population of 255 post-menopausal women not on estrogen therapy (mean age = 57.6) and 55 women currently on estrogen replacement therapy (mean age = 56.9). Grip strength was measured as an indicator of muscular strength in the upper limbs. The grip strength of the estrogen users was significantly higher than that of the estrogen abstainers. Grip strength was related to age (r = -0.25, p less than 0.01), and the body habitus parameters of height (r = 0.36, p less than 0.01) and weight (r = 0.18, p less than 0.01). Although estrogen use was univariately correlated with strength (r = 0.16, p less than 0.05), multiple regression analyses revealed that only the height, age and physical activity were independent determinants of grip strength. These data suggest: height is the major determinant of upper body strength in older women; the reduction in physical activity with advancing age may contribute to strength decline, and modest increase in physical activity may retard the loss of strength that accompanies aging; the loss of ovarian estrogen in menopause may be related to the loss of strength in postmenopausal women.     

Older women with diabetes have an increased risk of fracture: a prospective study

To determine whether type 2 diabetes is associated with fracture in older women, we analyzed data from 9654 women, age 65 yr or older, in the Study of Osteoporotic Fractures. Diabetes with age at onset 40 yr or older was reported by 657 women, of whom 106 used insulin. A total of 2624 women experienced at least one nonvertebral fracture during an average follow-up of 9.4 yr, and 388 had at least one vertebral fracture during an average interval of 3.7 yr. Although diabetes was associated with higher bone mineral density, it was also associated with a higher risk of specific fractures. Compared with nondiabetics, women with diabetes who were not using insulin had an increased risk of hip [relative risk (RR), 1.82; 95% confidence interval (CI), 1.24-2.69] and proximal humerus (RR, 1.94; 95% CI, 1.24-3.02) fractures in multivariate models controlling for age, body mass index, bone density, and other factors associated with fractures and diabetes. Insulin-treated diabetics had more than double the risk of foot (multivariate adjusted RR, 2.66; 95% CI, 1.18-6.02) fractures compared with nondiabetics. This study indicates that diabetes is a risk factor for hip, proximal humerus, and foot fractures among older women, suggesting that fracture prevention efforts should be a consideration in the treatment of diabetes.     

Recombinant LH supplementation to recombinant FSH during induced ovarian stimulation in the GnRH-antagonist protocol: a meta-analysis

This study aims to compare the efficacy of recombinant LH (rLH) supplementation for ovarian stimulation in gonadotrophin-releasing hormone-antagonist protocol for IVF/intracytoplasmic sperm injection cycles. Search strategies included online surveys of databases. The fixed effects model was used for odds ratio (OR) and effect size (weighted mean difference, WMD). Five trials fulfilled the inclusion criteria. When the meta-analysis was carried out, advantages were observed for the LH supplementation protocol with respect to higher serum oestradiol concentrations on the day of human chorionic gonadotrophin administration P < 0.0001; WMD: 514, 95% CI 368, 660) and higher number of mature oocytes (P = 0.0098; WMD: 0.88, 95% CI 0.21, 1.54). However, these differences were not observed in the total amount of recombinant FSH (rFSH) administered, days of stimulation, number of oocyets retrieved, the clinical pregnancy rate per oocyte retrieval, the implantation rate and miscarriage rate. This result demonstrates that the association of rLH with rFSH may prevent any decrease in oestradiol after antagonist administration and that a significantly higher number of mature oocytes was available for laboratory work. Nevertheless, it failed to show any statistically significant difference in clinically significant end-points in IVF (implantation and pregnancy rates). Additional randomized controlled trials are needed to confirm these results further.     

Challenges and recommendations when selecting empirical antibiotics in patients with cirrhosis

There is abundant evidence that bacterial infections are severe complications in patients with cirrhosis,being the most frequent trigger of acute-on-chronic liver failure and causing death in one of every four patients during hospitalization.For these reasons,early diagnosis and effective treatment of infections are mandatory to improve patient outcomes.However,treating physicians are challenged in daily practice since diagnosing bacterial infections is not always straightforward.This situation ...     

Apolipoprotein E alleles in nonagenarian subjects in the Belfast Elderly Longitudinal Free-living Ageing Study (BELFAST)

The ApoE gene has three alleles coding for the proteins apoE2, apoE3 and apoE4. E4 has been reported to be associated with hypercholesteraemia, ischaemic heart disease, age-related cognitive decline and Alzheimer's disease. Conversely, the E2 allele has been associated with longevity in French centenarians and their siblings. In this study, we have assessed any shift in the ApoE genotypes in nonagenarian subjects from Belfast where there is a high intrinsic incidence of cardiovascular disease. ApoE phenotypes were determined by electrofocusing and immunoblotting in 114 Senieur-approximated subjects >90 years old and compared with 2071 subjects, 30--65 years of age, recruited from the same geographical area by the MONItoring of CArdiovascular trends study group in Belfast (MONICA). The E4 allele was reduced in the nonagenarian group (X(2)=11.1; P=0.0006), the E3 unchanged and E2 frequency was increased (X(2)=4.0; P=0.047). These results suggest that longevity is negatively associated with the E4 allele and may be associated with carriage of E2.     

Factors associated with 5-year risk of hip fracture in postmenopausal women

Context  The 329 000 hip fractures that annually occur in the United States are associated with high morbidity, mortality, and cost. Identification of those at high risk is a step toward prevention. Objective  To develop an algorithm to predict the 5-year risk of hip fracture in postmenopausal women. Design, Setting, and Participants  A total of 93 676 women who participated in the observational component of the Women's Health Initiative (WHI), a multiethnic longitudinal study, were used to develop a predictive algorithm based on commonly available clinical features. Selected factors that predicted hip fracture were then validated by 68 132 women who participated in the clinical trial. The model was tested in a subset of 10 750 women who had undergone dual-energy x-ray absorptiometry (DXA) scans for bone mass density assessment. Main Outcome Measure  The prediction of centrally adjudicated hip fracture, measured by the area under the receiver operator characteristic (ROC) curves. Results  During a mean (SD) follow-up of 7.6 (1.7) years, 1132 hip fractures were identified among women participating in the observational study (annualized rate, 0.16%), whereas during a mean follow-up of 8.0 (1.7) years, 791 hip fractures occurred among women participating in the clinical trial (annualized rate, 0.14%). Eleven factors predicted hip fracture within 5 years: age, self-reported health, weight, height, race/ethnicity, self-reported physical activity, history of fracture after age 54 years, parental hip fracture, current smoking, current corticosteroid use, and treated diabetes. Receiver operating characteristic curves showed that the algorithm had an area under the curve of 80% (95% confidence interval [CI], 0.77%-0.82%) when tested in the cohort of different women who were in the clinical trial. A simplified point score was developed for the probability of hip fracture. Receiver operating characteristic curves comparing DXA-scan prediction based on a 10% subset of the cohort and the algorithm among those who participated the clinical trial were similar, with an area under the curve of 79% (95% CI, 73%-85%) vs 71% (95% CI, 66%-76%). Conclusion  This algorithm, based on 11 clinical factors, may be useful to predict the 5-year risk of hip fracture among postmenopausal women of various ethnic backgrounds. Further studies are needed to assess the clinical implication of the algorithm in general and specifically to identify treatment benefits.      

Quantitative Ultrasound and Mortality: A Prospective Study

Previous studies suggest that low bone mineral density (BMD) is associated with increased mortality, but the relationship between quantitative ultrasound (QUS) and mortality is unknown. We studied 5816 women over age 70 years enrolled in the Study of Osteoporotic Fractures. QUS of the calcaneus, and BMD of the calcaneus and hip, were measured at baseline, and women were contacted every 4 months to determine vital status. All reported deaths were confirmed by review of the death certificate or hospital records, and classified by ICD-9 code. During 5.0 years of follow-up, 677 women died. Women in the lowest quintile of QUS had the highest mortality during follow-up. After adjustment for age, grip strength, weight, height, health status, estrogen use, smoking, physical activity, and history of hypertension, diabetes, cardiovascular disease, cancer and stroke, each 1 SD reduction in broadband ultrasonic attenuation (BUA) was associated with a 16% increase in mortality (RH = 1.16; 95% CI: 1.07, 1.26). Mortality from cardiovascular disease, cancer and other causes were all increased among women with low QUS, but the association with cancer deaths was not statistically significant after multiple adjustments (RH = 1.09; CI: 0.93, 1.27). Low BMD was also associated with an increased risk of total and cause-specific mortality, but we found little evidence that BUA and BMD were independent predictors of mortality. Results were similar among women who did not fracture during follow-up. In this large population-based study of older women, low QUS is associated with both total and cause-specific mortality. This relationship was independent of other factors associated with mortality, such as age and health status, and suggests QUS and BMD may reflect some aspect of aging not captured by these traditional factors. Received: 16 March 2001 / Accepted: 19 February 2002     

Recent advances in liver transplantation for metabolic disease

The indications and outcomes of liver transplantation for metabolic disease have been reviewed recently and this short review concentrates on recent developments and advances. Recently recognized metabolic causes of acute liver failure are reviewed and their implications for transplantation discussed. Newly described indications for liver transplantation in systemic metabolic diseases are described and an update is given on the role of auxiliary and domino liver transplantation.