Gestational Diabetes and Hypertensive Disorders of Pregnancy as Vascular Risk Signals: An Overview and Grading of the Evidence

The occurrence of common pregnancy-related medical disorders identifies women at high risk of developing future vascular disease. Systematic reviews of cohort studies demonstrate that gestational diabetes confers a 7-fold risk increase for type 2 diabetes, and preeclampsia confers a 1.8-fold risk increase for type 2 diabetes and 3.4-fold risk increase for hypertension. Gestational diabetes and hypertensive disorders of pregnancy (HDP) increase the risk of premature vascular disease, but the 2-fold risk increase associated with preeclampsia is only partially explained by the development of traditional vascular risk factors. Despite the compelling evidence for gestational diabetes and HDP as vascular risk indicators, there are no published Canadian vascular prevention guidelines that recognize these postpartum women. In contrast, the 2011 American Heart Association guidelines on cardiovascular disease in women include gestational diabetes and HDP in their vascular risk assessment. Studies indicate that the importance surveillance of vascular risk factors in these women after pregnancy is underappreciated by the women themselves and their physicians. Although a prudent diet and physically active lifestyle were demonstrated to reduce diabetes risk in women with a gestational diabetes history in the American Diabetes Prevention Program trial, adoption of these health behaviours is low; qualitative studies confirm a need for tailored strategies that address barriers and provide social support. Further research is also needed on approaches to reduce vascular risk in women with a history of gestational diabetes and HDP. Otherwise, an early window of opportunity for chronic disease prevention in young, high-risk women will be missed.     

An evaluation of five different dressing materials on split‐thickness skin graft donor site and full‐thickness cutaneous wounds: an experimental study

The objective of this study was to investigate the healing effect of five different products on split‐thickness skin graft (STSG) donor sites and full‐thickness cutaneous wounds (FTCWs) using an occlusive dressing model. Six groups were included: 1 control and 5 experimental groups, with a total of 24 rats, using an occlusive dressing model. STSG donor sites and FTCWs were established in two separate areas, to the right and left on the animals' backs. Wound sites were dressed with one of the following materials: fine mesh gauze, microporous polysaccharide hemosphere (MPH), clinoptilolite, alginate, hydrogel or biosynthetic wound dressing (Biobran^®). These materials were compared in terms of healing rate, healing quality and histopathological findings. Occlusive dressings were applied to each wound on days 0, 3, 5, 7, 10 and 14. Area measurements were taken using images of each dressing. The alginate and clinoptilolite groups gave the best healing rate results for both STSG donor sites (P = 0·003) and FTCWs (P = 0·003). MPH came third in each group. The alginate group produced better results in terms of healing quality criteria, followed by hydrogel, MPH, clinoptilolite and Biobran^®, in that order. Statistically significant results were obtained in all groups compared to the control group (P < 0·0007). Rapid and good healing quality for both the STSG donor sites and FTCWs were obtained with alginate. Healing with clinoptilolite and MPH was rapid, but poor quality, while slower but good healing quality was obtained with hydrogel. Slower and worse quality healing was obtained with Biobran^®.     

CD4 trajectory adjusting for dropout among HIV-positive patients receiving combination antiretroviral therapy in an East African HIV care centre

Objective

Estimates of CD4 response to antiretroviral therapy (ART) obtained by averaging data from patients in care, overestimate population CD4 response and treatment program effectiveness because they do not consider data from patients who are deceased or not in care. We use mathematical methods to assess and adjust for this bias based on patient characteristics.

Design

We examined data from 25,261 HIV-positive patients from the East Africa IeDEA Consortium.

Methods

We used inverse probability of censoring weighting (IPCW) to represent patients not in care by patients in care with similar characteristics. We address two questions: What would the median CD4 be “had everyone starting ART remained on observation?” and “were everyone starting ART maintained on treatment?”

Results

Routine CD4 count estimates were higher than adjusted estimates even under the best-case scenario of maintaining all patients on treatment. Two years after starting ART, differences between estimates diverged from 30 cells/µL, assuming similar mortality and treatment access among dropouts as patients in care, to over 100 cells/µL assuming 20% lower survival and 50% lower treatment access among dropouts. When considering only patients in care, the proportion of patients with CD4 above 350 cells/µL was 50% adjusted to below 30% when accounting for patients not in care. One-year mortality diverged 6–14% from the naïve estimates depending on assumptions about access to care among lost patients.

Conclusions

Ignoring mortality and loss to care results in over-estimation of ART response for patients starting treatment and exaggerates the efficacy of treatment programs administering it.     

Ochronosis diagnosed after knee arthroscopy

INTRODUCTION

Ochronosis is a rare disorder which is defined as the deposition of metabolites of oxidation and polymerization of homogentisic acid, which have high affinity to collogen, in the connective tissues. It is a clinical condition characterized with ochronotic pigmentation of tissues, degenerative arthropathy of especially large joints and black discoloration of urine. In this paper we present a case of ochronosis diagnosed with biopsy and additional tests when a black discoloration of menisci and joint cartilage were detected during arthroscopic intervention for a degenerative meniscus tear.

PRESENTATION OF CASE

A forty two year-old male patient was operated for lateral meniscus tear of his right knee. The arthroscopic examination of right knee revealed black colored synovial hypertrophy and torn lateral meniscus. Partial meniscectomy was performed. The diagnosis of ochronosis was made after histopathologic examination.

DISCUSSION

Ochronotic pigment can accumulate in hyaline cartilage, tendon, skin, teeth, nail, sclera, tympanic membrane, heart valves, renal tubular cells, duramater, pancreas and walls of large arteries. In ochronosis the most frequently involved joints are knee and hip. In ochronotic arthropathy, articular cartilage become more sensitive to mechanical stresses. Our patient had meniscal tear, cartilage damage and black discoloration of synovial tissues and meniscus.

CONCLUSION

Arthroscopy may be helpful in diagnosis of ochronotic arthropathy.     

Arthroscopic treatment of synovial chondromatosis in the ankle joint

INTRODUCTION

Synovial chondromatosis is characterized by the presence of metaplastic cartilage nodules originating from the synovia, bursa and tendon sheaths. Although it is extremely rare in the ankle joint, malignant transformation is possible. The choice of treatment is usually open surgery for excision of loose bodies and synovectomy. Limited data is available concerning arthroscopic approaches.

PRESENTATION OF CASE

A 28-year-old male patient was evaluated for pain and swelling of the right ankle joint. Based on the findings of physical examination and radiographic investigations, arthroscopic surgery was performed due to ankle impingement syndrome. A diagnosis of synovial osteochondromatosis was made following the pathological survey.

DISCUSSION

Synovial chondromatosis is slowly progressive and is considered to be a self-limiting situation. Treatment strategies are decided on according to the patient''s complaints, age and disease stage. Open or arthroscopic surgery. can be performed. Some advantages of arthroscopic surgery are wide visualization areas, easy access to areas difficult to reach, lower morbidity, no necessity for casting and immobilization, early rehabilitation and quick recovery period.

CONCLUSION

In conclusion, arthroscopic management can be successful in selected patients with synovial osteochondromatosis localized to the ankle joint.     

Mortality From Sexually Transmitted Diseases in Reproductive-Aged Women: United States, 1999–2010

Objectives. I estimated the sexually transmitted disease–related mortality among US reproductive-aged women from 1999 to 2010.Methods. I estimated mortality from National Center for Health Statistics’ Multiple Cause of Death data. I defined reproductive age as 15 to 44 years. For diseases partially caused by sexual transmission, I estimated the proportion attributable to sexual transmission from the literature. To calculate mortality rates, I estimated number of deaths from each disease and Census Bureau population for reproductive-aged women for 1999 to 2010.Results. From 1999 to 2010, the cumulative sexually transmitted disease–related mortality rate decreased by 49%, from 5.3 to 2.7 deaths per 100 000. The primary contributors were HIV and human papilloma virus infections. Mortality from sexually transmitted HIV infection decreased by 62%, from 3.4 to 1.3 deaths per 100 000. Mortality from human papilloma virus–associated gynecologic cancers decreased by 19%, from 1.6 deaths per 100 000 in 1999 to 1.3 deaths per 100 000 in 2010.Conclusions. Screening and treatment for sexually transmitted diseases may reduce mortality. Research is needed to determine whether sexually transmitted disease–related morbidity among reproductive-aged women has decreased over the past decade.Deaths from sexually transmitted diseases (STDs) often occur long after acute infection, making their incidence difficult to estimate.1–3 Some infections, such as syphilis, may directly result in death. By contrast, human papilloma virus (HPV), HIV, and hepatitis more commonly cause death because of secondary sequelae. Genital herpes, gonorrheal infection, and chlamydial infection may cause death from primary infection (e.g., disseminated herpes simplex virus or pelvic inflammatory disease [PID]) or secondary sequelae (e.g., ectopic pregnancy). Because death certificates usually list only the prevalent conditions, STDs are often not recorded on death certificates. In addition, some causes of death, such as liver cancer, may or may not be STD related. STD-related deaths cannot always be counted directly; therefore, direct and indirect methods of estimation must be used.The methodology for estimating STD-related mortality in women in the United States has evolved. Early estimates used measures of reproductive health mortality.1 Subsequently, a more comprehensive approach used direct and indirect measures of deaths from all STD-related diseases.2 Most recently, disability-adjusted life-years lost because of sexual behaviors were found to be threefold higher in the United States than in other developed countries. Women carry a disproportionately high proportion of the health burden.3Between 1955 and 1975, STDs such as syphilis and PID were responsible for 20% to 30% of reproductive mortality among women aged 15 to 44 years.1 Since then, mortality from syphilis and PID has decreased. Cervical carcinoma, HIV, and viral hepatitis infection were the top 3 contributors to STD-related mortality among all women older than 15 years as of 1992.2 I have updated the estimated annual STD-related mortality among reproductive-aged women in the United States for 1999 to 2010.     

PTSD Symptoms and Pain in Canadian Military Veterans: The Mediating Roles of Anxiety,Depression, and Alcohol Use

Symptoms of posttraumatic stress disorder (PTSD) and pain are often comorbid among veterans. The purpose of this study was to investigate to what extent symptoms of anxiety, depression, and alcohol use mediated the relationship between PTSD symptoms and pain among 113 treated male Canadian veterans. Measures of PTSD, pain, anxiety symptoms, depression symptoms, and alcohol use were collected as part of the initial assessment. The bootstrapped resampling analyses were consistent with the hypothesis of mediation for anxiety and depression, but not alcohol use. The confidence intervals did not include zero and the indirect effect of PTSD on pain through anxiety was .04, CI [.03, .07]. The indirect effect of PTSD on pain through depression was .04, CI [.02, .07]. These findings suggest that PTSD and pain symptoms among veterans may be related through the underlying symptoms of anxiety and depression, thus emphasizing the importance of targeting anxiety and depression symptoms when treating comorbid PTSD and pain patients.