Lanthanum-induced neurotoxicity: solving the riddle of its involvement in cognitive impairment?

The conclusion of a series of recent reports highlights the significant neurotoxic effects that rare earth elements, such as lanthanum (La), can have during neurodevelopment. These findings are, herein, combined and presented using a simplified schematic overview that provides a putative solution to the riddle of La-induced cognitive impairment. Our commentary also highlights potential targets for further investigations into the mechanisms which underpin La-induced neurotoxicity, with a focus on the crucial role of the hippocampus. Within this context, a central role for the cyclic-adenosine monophosphate signalling pathway is proposed.     

Perceived Susceptibility to Addiction among Adolescent Smokers

Previous research demonstrates that adolescent smokers are aware of smoking’s health consequences yet perceive they are less susceptible to harm than other smokers, thereby exhibiting an optimistic bias. The present study extends such research to consider whether optimistic bias is present in relation to the addictive consequences of smoking. To explore this, 416 adolescents responded to a questionnaire about the consequences of smoking. As predicted, there was a significant association between regular, experimental, and non-smokers’ perceptions about their personal susceptibility to addiction. Regular smokers showed the greatest bias about their ability to quit smoking. Implications for prevention campaigns are discussed.     

Inpatient Costs of Routine Endovascular Repair of Abdominal Aortic Aneurysm

RATIONALE AND OBJECTIVES: The purpose of this study was to determine the inpatient cost of routine (ie, without emergent conversion to open repair during the hospital stay) endovascular stent-graft placement in a consecutive series of patients undergoing elective endovascular repair of abdominal aortic aneurysm (AAA) at a single institution. MATERIALS AND METHODS: Inpatient hospital costs of 91 patients who underwent initial elective endovascular repair of AAA were analyzed retrospectively. All patients had participated in clinical trials at the authors' institution during the previous 6 years. Financial data were derived from the hospital's cost-accounting system; additional procedural data were collected from a departmental database and with chart review. Stent-graft and professional costs were excluded. RESULTS: The mean total cost for endovascular repair was $11,842 (standard deviation [SD], $5,127), mean procedure time was 149 minutes (SD, 79 minutes), and mean length of stay was 3.5 days (SD, 2.3 days). Total cost depended on stent-graft type (means, $12,428 [bifurcated] vs $9,622 [tube]; P = .0002) and strongly correlated with procedure time and length of hospital stay (r = 0.78 and 0.66, respectively; P < .0001). Ninety-six percent of total costs for all patients were attributable to the following departments: operating theater (31%), radiology (31%), nursing (22%), and anesthesia (12%). CONCLUSION: Overall costs are greater with bifurcated than with tube stent-grafts. Total procedure-related costs are divided relatively equally between the operating theater, the radiology department, and the combination of the nursing and anesthesia departments.     

Prognosis of patients turned down for conventional abdominal aortic aneurysm repair in the endovascular and sonographic era: Szilagyi revisited?

PURPOSE: The United Kingdom Small Aneurysm study has demonstrated the low risk of rupture in aneurysms less than 5.5 cm in diameter. With the advent of endoluminal techniques, patients considered unfit to undergo laparotomy are now considered for endovascular repair. However, the natural history of aneurysms larger than 5.5 cm remains uncertain, especially when severe comorbidity is present. In our center, we prospectively maintain records of all patients for whom elective aneurysm surgery was refused. This study documented the outcome of all patients referred with abdominal aortic aneurysms (AAAs) larger than 5.5 cm in diameter who were turned down for elective open repair and determined the cause of death and risk of rupture in all patients. METHODS: Details of all patients with AAAs from January 5, 1989, to January 5, 1999, were recorded, and demographic details on all patients with AAAs larger than 5.5 cm were collected. Copies of death certificates were obtained from the Office of National Statistics, local in-hospital patient records, and general practitioner records. Results of postmortem examinations were also obtained. Aneurysms were stratified according to their size at presentation (5.5-5.9 cm, 6.0-7.0 cm, and > 7.0 cm), and the reasons no intervention was made were documented. RESULTS: A total of 106 patients were turned down for elective aneurysm surgery in the 10-year period (10.6 per year). The mean age of the patients was 78.4 years (SD, 7.4), and 70 were men and 36 were women. At the end of the study, 76 patients (71.7%) had died. Overall, the 3-year survival rate was 17%. Patients with AAAs larger than 7.0 cm lived a median of 9 months. A ruptured aneurysm was certified as a cause of death in 36% of the patients with an AAA of 5.5 to 5.9 cm, in 50% of the patients with an AAA of 6 to 7.0 cm, and 55% of the patients with an AAA larger than 7.0 cm. Reasons given for not intervening were patient refusal (31 cases), the patient being "unfit for surgery" (18 cases), the "advanced age" of the patient (18 cases), cardiac disease (9 cases), cancer (9 cases), respiratory disease (6 cases), and other (15 cases). CONCLUSION: Although we recognize the problems with death certification, we found that rupture was a significant cause of death in patients with an untreated AAA that was larger than 5.5 cm. Although little difference in outcome was observed in aneurysms in the 5.5 to 7.0 cm size range, patients with an AAA that was larger than 7.0 cm seemed to have a much poorer prognosis.     

Investigating the Relationship between Vitamin D and Persistent Symptoms Following SARS-CoV-2 Infection

The emergence of persistent symptoms following SARS-CoV-2 infection, known as long COVID, is providing a new challenge to healthcare systems. The cardinal features are fatigue and reduced exercise tolerance. Vitamin D is known to have pleotropic effects far beyond bone health and is associated with immune modulation and autoimmunity. We hypothesize that vitamin D levels are associated with persistent symptoms following COVID-19. Herein, we investigate the relationship between vitamin D and fatigue and reduced exercise tolerance, assessed by the Chalder Fatigue Score, six-minute walk test and modified Borg scale. Multivariable linear and logistic regression models were used to evaluate the relationships. A total of 149 patients were recruited at a median of 79 days after COVID-19 illness. The median vitamin D level was 62 nmol/L, with n = 36 (24%) having levels 30–49 nmol/L and n = 14 (9%) with levels <30 nmol/L. Fatigue was common, with n = 86 (58%) meeting the case definition. The median Borg score was 3, while the median distance covered for the walk test was 450 m. No relationship between vitamin D and the measures of ongoing ill-health assessed in the study was found following multivariable regression analysis. These results suggest that persistent fatigue and reduced exercise tolerance following COVID-19 are independent of vitamin D.     

Evaluation of the Mortality in Emergency Department Sepsis score combined with procalcitonin in septic patients

Objective

To determine an effective method for predicting severity of sepsis and 28-day mortality of emergency department (ED) patients, we compared the Mortality in Emergency Department Sepsis (MEDS) score with procalcitonin (PCT), interleukin-6 (IL-6), and C-reactive protein (CRP) and evaluated the MEDS score combined with relevant biomarkers.

Methods

A total of 501 adult ED patients with sepsis were selected for this prospective clinical study. The optimal combination was assessed by logistic regression. All cases were divided into the sepsis group (319 cases) and the severe sepsis and septic shock group (182 cases) according to the severity of sepsis, as well as the survivor group (367 cases) and nonsurvivor group (134 cases) according to the 28-day outcomes.

Results

The area under the curve of the MEDS score, PCT, IL-6, and CRP was 0.793, 0.712, 0.695, and 0.681 for severity of sepsis and 0.776, 0.681, 0.692, and 0.661 for 28-day mortality, respectively. Only PCT was an independent predictor when combined with the MEDS score. The new combination of the MEDS score with PCT improved the area under the curve for severity (0.852) and mortality (0.813). This new combination for evaluation of severity had better sensitivity (63.2%), specificity (92.2%), and positive predictive (82.1%) and negative predictive (81.4%) values.

Conclusions

The predictive ability of the MEDS score for severity and 28-day mortality of septic ED patients is better than PCT, IL-6, and CRP levels. The MEDS score combined with PCT enhances the ability of risk stratification and prognostic evaluation.     

Near miss maternal morbidity

Audit of severe maternal morbidity is a potent tool in determining standards of maternity care. This study determines the incidence of severe acute maternal morbidity in our population, identifies the underlying organ dysfunction and associated obstetric risk factors, and compares them to published international reports. Over a 5 year period, 1999-2003, data were collected prospectively from patients with severe acute maternal morbidity. There were 36,802 women who delivered infants weighing more than 500 g over the 5 years with 53 cases of severe maternal morbidity. There were two indirect maternal deaths yielding an incidence of 1.4/1000 for severe maternal morbidity and 5.4/100,000 for maternal mortality. The severe maternal morbidity to mortality ratio was 26.5:1. Massive obstetric haemorrhage requiring acute blood transfusion of > or = 5 units of packed red cells occurred in 77% of cases. This study identifies the feasibility of audit of severe maternal morbidity using simple defined clinical criteria. The incidence and underlying aetiology of severe maternal morbidity in our unit is comparable to other developed countries. It is essential that data on severe maternal morbidity are reviewed and analysed continuously at local hospital and national level to assess, maintain and improve clinical standards.     

Quantitation of leukocyte gene expression in cetaceans

Real-time quantitation of cytokine mRNA is a routine immunologic technique, especially fitting for use in those species for which monoclonal antibodies are not available. Quantitative gene expression assays were developed to assist in the immunologic assessment of three cetacean species including bottlenosed dolphins, Pacific white-sided dolphins and beluga whales. Nine cytokine genes (IL-2, -4, -10, -12, -13, -18, TNFalpha, TGFbeta and IFNgamma) and Cox-2 were selected for analysis. Most mitogen-induced mononuclear leukocyte responses were similar between the three cetacean species with either up- or down-regulation of cytokine genes. IL-10 expression was highly variable between species. No T(H)/1T(H)2 polarization was evident. Cytokine gene analysis has the potential to identify immune system perturbations induced by environmental insult as well as providing diagnostic tools for characterizing immune responses to environmental antigens and vaccines.