Venous thromboembolism in carriers of the Factor V Leiden mutation and in patients without known thrombophilic risk factor; prediction of recurrence and APC-PCI complex concentration and/or soluble thrombomodulin antigen and activity

BACKGROUND: The complex between activated protein C (APC) and the protein C inhibitor (PCI) is a sensitive indicator of the degree of activation of blood coagulation and higher concentrations have been measured in carriers of the FV Leiden mutation who were in the recovery phase after treatment for venous thromboembolism (VTE). OBJECTIVES: The main purpose of this study was to correlate the APC-PCI complex concentration to thrombomodulin activity and antigen concentration in the same group of patients. We also add a prospective clinical follow-up of the VTE recurrence after 1 year to investigate if the markers can predict the risk for a new VTE. PATIENTS/METHODS: Blood samples were collected from 50 patients with the FV Leiden mutation and 132 without any known risk factor for thrombophilia after finished treatment. RESULTS: The APC-PCI complex, s-TM activity and the quotient (s-TM activity)/(s-TM antigen) were higher in VTE patients with FV Leiden. In total, there were 19 VTE recurrences (10%) after 1 year. The OR for recurrence was 1.9 (95% CI 0.68-5.0) in all VTE patients with elevated APC-PCI complex (above 75th percentile) and 3.6 (95% CI 1.1-12) in VTE patients without any known risk factor for thrombophilia and with elevated s-TM activity. CONCLUSION: The APC-PCI complex concentration, s-TM activity and the quotient (s-TM activity)/(s-TM antigen) were higher in VTE patients with FV Leiden. The s-TM activity showed higher OR for recurrence of VTE in patients without known thrombophilic risk factor. Both methods could be sensitive markers of increased risk for venous thrombosis.     

Evaluation of the role of black carbon in attenuating bioaccumulation of polycyclic aromatic hydrocarbons from field-contaminated sediments

The significance of black carbon (BC) for the bioavailability of polycyclic aromatic hydrocarbons (PAHs) was examined by using historically contaminated intact sediment cores in laboratory exposure experiments with the deposit-feeding amphipod Monoporeia affinis. Log values of amphipod biota-sediment accumulation factors (BSAFs) were significantly related to log BC, whereas log BSAFs were related to log octanol-water partition coefficients only in background sediments containing less BC. In the background sediments, the BSAF for polycyclic aromatic hydrocarbons (PAHs) was 1 to 2 for phenanthrene, with lower values for more hydrophobic PAHs, indicating an increase in nonequilibrium conditions with increasing PAH molecular size. For the near-equilibrated phenanthrene and fluoranthene, higher BSAFs were measured during exposure to background sediments, with BSAF decreasing to <0.1 in contaminated sediments in the Stockholm waterways. In situ caged mussels (Dreissena polymorpha) exhibited field BSAF values (relative to sediment-trap-collected suspended matter) for polychlorinated biphenyls (PCBs) of 0.1 to 0.4, but for PAHs of similar hydrophobicity and molecular size, the field BSAFs were much lower and in the range 0.002 to 0.05. This PAH-PCB dichotomy is consistent with recently reported much stronger binding to diesel soot (a form of BC) for PAHs than for PCBs of equal hydrophobicities. Lower BSAFs for the near-equilibrated PAHs (phenanthrene and fluoranthene) in the urban sediments relative to the background sediments were consistent with the larger presence of BC in the urban sediments. This study provides the first linked BSAF-BC field data that supports a causal relationship between strong soot sorption and reduced bioavailability for PAHs.     

Midwifery care: development of an instrument to measure quality based on the World Health Organization's classification of care in normal birth

Aims and objectives. The aim of the study was to develop an instrument to measure midwifery care in relation to World Health Organization's classification of care in normal birth and to test the instrument for content validity and inter‐rater reliability. Methods. The Delphi method was used for development of the instrument and to elicit evidence of content validity. Six experts from three different geographical regions in Sweden, representing clinically working midwives, lecturers in midwifery and obstetricians, participated in the first part of the study. The instrument was tested for inter‐rater reliability in an exploratory study by two midwives and one of the authors. Data were analysed using percentage of agreement level and the Kappa coefficient. Results. Five expert rounds were needed to reach consensus for content validity. The inter‐rater reliability test showed high agreement levels (95.9, 94.2 and 95.7%) and good to very good Kappa coefficients (0.74–1.0). The final instrument consisted of 78 items divided into five sections: background (five items); practices which are demonstrably useful and should be encouraged (55 items); practices which are clearly harmful or ineffective and should be eliminated (five items); practices for which insufficient evidence exists to support a clear recommendation and which should be used with caution while further research clarifies the issue (four items); and finally practices which are frequently used inappropriately (nine items). Conclusions and relevance to clinical practice. The instrument can be used at a labour ward to measure documented care and quality of midwifery care. The results can be used to identify areas for improvements, to develop guidelines towards evidence‐based care and to improve documentation. However, the present study should be regarded as an exploratory study and the feasibility of the instrument remains to be tested in empirical studies.     

Inflammatory cell and cytokine patterns in patients with chronic polyarthritis and temporomandibular joint involvement

The aim of this investigation was to describe some tooth-related histological features of prepubertal periodontitis. Teeth extracted during treatment of two Papillon-Lefèvre syndrome patients were processed by means of the sawing and grinding technique. Light microscopy examination revealed little or no cementum in the coronal parts of the roots. Resorptions of various depths (0.02 to 1.5 mm) and to various extents (affecting up to 1/3 of the root surface) were observed in the 5 investigated teeth. Some resorptive defects on 1 of the examined incisors showed signs of spontaneous repair. Extrinsic fibers were inserted into the new cellular intrinsic fiber cementum which had formed directly on the bottom of the defect. Intact acellular extrinsic fiber cementum was found where fibers were still attached. Here, the characteristic of pristine cementum, a hyaline layer of peripheral dentin, could be identified. If resorption was not present, the cementum did not show any signs of hypoplasia. Thus, histological features of prepubertal periodontitis in the current material were (i) areas of extensive resorption, (ii) signs of spontaneous repair, and (iii) healthy cementum.     

A family's perspective on living with a highly malignant brain tumor

The purpose of the study is to describe what it like to live with a highly malignant brain tumor from a family perspective. It is a qualitative study in which 3 families, 3 patients, and 5 next of kin have described their experiences in 15 interviews. The study is prospective, with interviews occurring 2-3 weeks after surgery and 3 and 6 months after the onset of the illness. Inductive content analysis has been employed. The results indicate that when a highly malignant brain tumor is diagnosed, the effect on the family is devastating and there is a state of crisis. Characteristically, there is distancing and a sense of helplessness. The members of the family live from day to day in a state of constant anxiety and fear of losing the patient. The affliction limits the patient's capacity regarding activities of daily life, which increases the burden of the next of kin. The next of kin attempt to cope with their grief by occupying themselves with practical tasks and activities that they believe are meaningful. The family members have only good words to say about their encounter with healthcare staff and about the information given. Negative information that the family have not asked for can cause a long period of frustration and anxiety, and they believe that their hope has been taken away from them.     

Sonographic Visualization of the Rectoanal Inhibitory Reflex in Children Suspected of Having Hirschsprung Disease

Objective. To date, for detection of the absence of peristalsis in children with chronic constipation and a suspicion of Hirschsprung disease (HD), children have been investigated with a contrast enema. If the radiographic investigation is inconclusive, anometry and a rectal biopsy are performed. A new noninvasive real‐time sonographic method for examination of the rectoanal inhibitory reflex (RAIR) was compared with anometry. Methods. The rectum and anal canal of children were visualized transperineally on sonography. The RAIR was elicited by injecting water into the rectum, and the events in the bowel were recorded on video for offline analysis. Results. Injection of water initiated a peristaltic wave that moved the rectal contents into the proximal part of the anal canal in healthy children. Among 28 children with suspected HD, 3 showed aganglionosis in their biopsy samples. These 3 children lacked the RAIR according to both sonography and anometry. Both methods had a negative predictive value of 100%. In 17 children, the RAIR was present according to both sonography and anometry, and all of these children had normal histologic findings. In 8 children, sonography did not show the reflex despite normal histologic findings; in 2 of these, the quality of the investigation made the evaluation uncertain. Conclusions. This pilot study indicates that in children with chronic constipation, a transperineal sonographic examination of the RAIR is comparable to anometry and can facilitate the diagnose of HD.     

Genetically attenuated Plasmodium berghei liver stages persist and elicit sterile protection primarily via CD8 T cells

Live-attenuated Plasmodium liver stages remain the only experimental model that confers complete sterile protection against malaria. Irradiation-attenuated Plasmodium parasites mediate protection primarily by CD8 T cells. In contrast, it is unknown how genetically attenuated liver stage parasites provide protection. Here, we show that immunization with uis3(-) sporozoites does not cause breakthrough infection in T and B-cell-deficient rag1(-/-) and IFN-gamma(-/-) mice. However, protection was abolished in these animals, suggesting a crucial role for adaptive immune responses and interferon-gamma. Although uis3(-) immunization induced Plasmodium-specific antibodies, B- cell-deficient mice immunized with uis3(-) sporozoites were completely protected against wild-type sporozoite challenge infection. T-cell depletion experiments before parasite challenge showed that protection is primarily mediated by CD8 T cells. In good agreement, adoptive transfer of total spleen cells and enriched CD8 T cells from immunized animals conferred sterile protection against malaria transmission to recipient mice, whereas adoptive transfer of CD4 T cells was less protective. Importantly, primaquine treatment completely abolished the uis3(-)-mediated protection, indicating that persistence of uis3(-)-attenuated liver stages is crucial for their protective action. These findings establish the basic immune mechanisms underlying protection induced by genetically attenuated Plasmodium parasites and substantiate their use as vaccines against malaria.     

‘What is could indeed be better’—Swedish women’s perceptions of early postnatal care

Background

studies have shown that women are more likely to be satisfied with intrapartum rather than postpartum care. The structure and organisation of care seems to be a barrier to good-quality postpartum treatment

Objective

to explore the perceived reality and the subjective importance of early postnatal care provided in hospital, and to study women’s satisfaction with different models of early postnatal care and the factors that are most strongly associated with being ‘very satisfied’ with the postnatal care received.

Method

a regional survey was conducted with 1240 women recruited in mid-pregnancy and followed-up two months after childbirth.

Results

a statistically significant difference existed between the subjective importance and the perceived reality for all studied variables, with a greater subjective importance than perceived reality for all statements. The length of postnatal stay and the content of care were related to satisfaction, while the model of postnatal care was not. The most important variables for being ‘very satisfied’ with postnatal care were that the infant received the best possible check-ups/medical care, and that the woman received sufficient support from staff.

Conclusion

further studies are needed to assess the best model of postnatal care that gives the best opportunities to provide satisfactory care for women and their families.     

Measuring the quality of documented care given by Swedish midwives during birth

Objectives

to measure the extent to which documented Swedish midwifery care for low-risk labour and birth followed the World Health Organization's (WHO) recommendations for care in normal birth, and to compare midwifery care given to women who’s labours were classified as low and high risk.

Study design

a retrospective examination of midwifery and medical records, 144 from women with low-risk births and 54 from women with high-risk births, for aspects of pregnancy, labour and birth using a validated instrument based on WHO’s recommendations.

Setting

southern Sweden.

Outcome measurements

care given in accordance with WHO’s four categories of practice and changes in risk group during the birth process.

Findings

care interventions not recommended by WHO, such as routine establishment of an intravenous route, routine amniotomy during the first stage, continuous electronic fetal monitoring and pharmacological methods of pain relief, were widespread in the records. Documented care differed little between the labours of women at low risk and high risk. The midwives at the unit under study did not routinely carry out risk assessment.

Key conclusions and implications for practice

the mode of care was one of readiness for medical intervention. The act of carrying out risk assessments at the time of the woman’s admission may affect awareness of the level of care offered to birthing women, and thus help to reduce the number and variety of practices not recommended by WHO.