Carotid transient ischemic attacks and normal investigations: a follow-up study

Reports on the long-term prognosis of patients with transient ischemic attacks and normal angiograms have revealed variable results, some suggesting a good prognosis while others report an outcome no different from that of patients with transient ischemic attacks and atherosclerotic vascular narrowing. Normal cerebral angiograms do not exclude disease in the heart or hematologic disorders. The prognosis for patients with transient ischemic attacks, normal angiograms, and normal results of cardiac and hematologic investigations is not known. We report our experience with 43 patients (26 men and 17 women, mean age 55.6 years) with transient ischemic attacks and normal findings on all investigations (including angiography, cranial computed tomography, echocardiography, and Holter monitoring). The patients were followed for a mean of 4.43 years. Six patients had recurrent transient ischemic attacks and six developed angina pectoris. No patient developed a stroke. In the presence of normal cerebral, cardiac, and hematologic findings, the long-term prognosis of patients with transient ischemic attacks is good. However, the development of cardiac disease during follow-up could not be predicted using the available diagnostic methods.     

An ongoing Confidential Enquiry into asthma deaths in the Eastern Region of the UK, 2001-2003.

INTRODUCTION: The Eastern Region Confidential Enquiry into asthma deaths started in 2001. It incorporates the Norwich and East Anglian Enquiries started in 1988 and 1992, respectively. The aim of this study was to analyse all asthma deaths in the Eastern region between 2001 and 2003, to elicit any factors contributing to the patients' deaths, and to make comparisons with the previous Norwich and East Anglian data. METHOD: Patient details were obtained for all deaths in the Eastern Region under the age of 65 with asthma recorded in the first part of the death certificate. Patients' notes were reviewed by members of the Working Group - a consultant chest physician and a general practitioner (GP). In most cases, the patient's GP was contacted. Data were obtained on the patients' asthma care, asthma severity, terminal attack, psychosocial and behavioural factors, allergies, precipitating factors, and post-mortem findings. The quality of medical care was assessed and compared with national guidelines. RESULTS: Total study population was 5.25 million. Only 57/95 notified deaths (60%) were confirmed as asthma deaths. 311 asthma deaths have been studied between 1988 and 2003. In 2001-2003, male:female ratio was 3:2. Further data were unavailable on three cases. 53% of patients had severe asthma and 21% moderately severe disease. In 19 cases (33%) at least one significant co-morbid disease was present. Monthly death rates peaked in August, with a smaller peak in April. In 11 cases (20%), mostly males aged under 20, the final attack was sudden and 10/11 occurred between April and August. In 81% of cases there were significant behavioural and/or psychosocial factors such as poor compliance (61%), smoking (46%), denial (37%), depression (20%) and alcohol abuse (20%). The overall medical care of the patient was appropriate in 33% of cases. CONCLUSIONS: Between 1988 and 2003 there was a downward trend in asthma mortality rate in East Anglia. In 2001-2003, misclassification of deaths attributed to asthma was still common. Most patients who die of asthma have severe asthma. In 81% of cases, behavioural and psychosocial factors contributed to the patient's death. In 80% of deaths the final attack was not sudden, and may have been preventable. Almost all sudden deaths occurred between April and August, suggesting a seasonal allergic cause. In two-thirds of asthma deaths, medical management failed to comply with national guidelines. 'At-risk' asthma registers in primary care may improve recognition and management of 'at-risk' patients.     

Evaluation of health workforce competence in maternal and neonatal issues in public health sector of Pakistan: an Assessment of their training needs

Background  

More than 450 newborns die every hour worldwide, before they reach the age of four weeks (neonatal period) and over 500,000 women die from complications related to childbirth. The major direct causes of neonatal death are infections (36%), Prematurity (28%) and Asphyxia (23%). Pakistan has one of the highest perinatal and neonatal mortality rates in the region and contributes significantly to global neonatal mortality. The high mortality rates are partially attributable to scarcity of trained skilled birth attendants and paucity of resources. Empowerment of health care providers with adequate knowledge and skills can serve as instrument of change.     

Seizures in Migraine: Warning of an Underlying Cerebral Infarction?

SYNOPSIS
Reports of an association between migraine and seizures have existed for a long time. A syndrome of basilar artery migraine, seizures and abnormal EEG's has also been published. We now report four patients with seizures and migraine in whom we feel the seizures were secondary to cerebral infarctions. Migraine was of the classical type in all patients and the auras were predominantly visual, Neurological symptoms associated with the cerebral infarctions were mild or transient and could have easily been dismissed as "complex migraine". CT scans showed cerebral infarctions involving the occipital cortex in all four cases. Two-dimensional echocardiography revealed mitral valve prolapse (MVP) in two cases and a bicuspid aortic valve in one case. In two cases, both with MVP, there were more than one cerebral infarctions.
Seizures may be an early warning of cerebral infarctions in patients with migraine and should alert the physician towards such a possibility.     

Cerebral Infarction in Patients With Migraine Accompaniments

SYNOPSIS
Migraine accompaniments (MA) are transient visual, sensory, motor or behavioral symptoms that are identical to the auras of classical migraine and are thought to have a similar underlying mechanism but which do not occur in association with headache. Cerebral infarction may rarely occur during an episode of migraine and if no other more obvious etiology can be found the infarct is thought to be related to migraine. Cerebral infarction, to our knowledge, has not been reported in association with MA. We now report four patients with a history of MA who developed cerebral infarction. Infarctions were occipital in two cases, frontoparietal in one case and parietal and cerebellar in one case. All patients showed good recovery. The mechanism for cerebral infarction in MA is probably similar to that of infarcts seen with classical migraine.     

Effects of chronic estrogen treatment on modulating age‐related bone loss in female mice

While female mice do not have the equivalent of a menopause, they do undergo reproductive senescence. Thus, to dissociate the effects of aging versus estrogen deficiency on age‐related bone loss, we sham‐operated, ovariectomized, or ovariectomized and estrogen‐replaced female C57/BL6 mice at 6 months of age and followed them to age 18 to 22 months. Lumbar spines and femurs were excised for analysis, and bone marrow hematopoietic lineage negative (lin–) cells (enriched for osteoprogenitor cells) were isolated for gene expression studies. Six‐month‐old intact control mice were euthanized to define baseline parameters. Compared with young mice, aged/sham‐operated mice had a 42% reduction in lumbar spine bone volume/total volume (BV/TV), and maintaining constant estrogen levels over life in ovariectomized/estrogen‐treated mice did not prevent age‐related trabecular bone loss at this site. By contrast, lifelong estrogen treatment of ovariectomized mice completely prevented the age‐related reduction in cortical volumetric bone mineral density (vBMD) and thickness at the tibial diaphysis present in the aged/sham‐operated mice. As compared with cells from young mice, lin– cells from aged/sham‐operated mice expressed significantly higher mRNA levels for osteoblast differentiation and proliferation marker genes. These data thus demonstrate that, in mice, age‐related loss of cortical bone in the appendicular skeleton, but not loss of trabecular bone in the spine, can be prevented by maintaining constant estrogen levels over life. The observed increase in osteoblastic differentiation and proliferation marker gene expression in progenitor bone marrow cells from aged versus young mice may represent a compensatory mechanism in response to ongoing bone loss. © 2010 American Society for Bone and Mineral Research.     

Association between birth outcomes and aflatoxin B1 biomarker blood levels in pregnant women in Kumasi,Ghana

Objective To investigate the association between birth outcomes and blood levels of aflatoxin B₁ (AFB1)‐lysine adduct in pregnant women in Kumasi, Ghana. Method A cross‐sectional study of 785 pregnant women attending antenatal clinic was conducted. Aflatoxin B₁ (AFB₁)‐lysine adduct levels were determined by high performance liquid chromatography (HPLC) on blood taken after delivery. The birth outcomes considered were small for gestation age, low birthweight, preterm delivery and stillbirth. Participants were divided into quartiles based on the distribution of aflatoxin B₁‐lysine adducts in pg/mg albumin (‘low’: ≤2.67, ‘moderate’: >2.67 to ≤4.97, ‘high’: >4.97 to ≤11.34, ‘very high’: >11.34). Statistical analysis involved models that included socio‐demographic variables and other potential confounders. Results The average AFB₁‐lysine adduct level in maternal serum was 10.9 ± 19.00 pg/mg albumin (range = 0.44–268.73 pg/mg). After adjusting for socio‐demographic variables and potential confounding factors, participants in the highest AFB₁‐lysine quartile with ‘very high’ AFB₁‐lysine level (>11.34 pg/mg) were more likely to have low birthweight babies (OR, 2.09; 95% CI, 1.19–3.68), and showed a trend of increasing risk for low birthweight (P_trend = 0.007) compared to participants in the lowest quartile. Conclusion This study adds to the growing body of evidence that aflatoxins may increase the risk of adverse birth outcomes. The findings have implications for targeted nutritional education of pregnant women in areas with high levels of aflatoxin contamination of foods.