Sympathetic reinnervation after heart transplantation, assessed by iodine-123 metaiodobenzylguanidine imaging, and heart rate variability.

OBJECTIVE: Complete allograft denervation occurs during heart transplantation. Partial ventricular sympathetic reinnervation may develop one year or later after transplantation and can be measured with iodine-123-meta-iodobenziylguanidine (MIBG) uptake. Aim of this study was to assess sinus node sympathetic reinnervation measured with heart rate variability and ventricular sympathetic reinnervation evaluated with MIBG. METHODS: Twelve patients and 14 healthy controls were included. In patients, MIBG scintigraphy with early and late imaging was performed. Heart to mediastinum ratio (HMR) was calculated and patients were divided in groups with (HMR>1.3) and without left ventricular reinnervation (HMR<1.3). Bipolar ECG with high sampling rate and resolution was recorded over 8.5 min in supine position and in upright position after 10 min interval. R-R intervals in time domain and heart rate variability in frequency domain through spectral power analysis of R-R intervals were analysed to evaluate sinus node reinnervation. Spectral power in low frequency range (0.04-0.15 Hz) above 4.5 ms(2) was considered as sinus node sympathetic reinnervation. RESULTS: Six (50%) patients had evidence of left ventricular sympathetic reinnervation on scintigraphy. Sinus node sympathetic reinnervation based on heart rate variability was detected in 6 (50%) patients in supine, and in 4 (33%) patients in upright body position. Four patients groups were discerned: (1) with ventricular and sinus node sympathetic reinnervation, (2) with sinus node sympathetic reinnervation, (3) with ventricular sympathetic reinnervation and (4) without atrial or ventricular sympathetic reinnervation. Ventricular reinnervation process was time dependent and sinus node reinnervation was not. CONCLUSIONS: Simultaneous ventricular sympathetic reinnervation assessed by MIBG and sinus node sympathetic reinnervation assessed by heart rate variability in supine as in upright position were detected only in two patients (17%). The results of our study show that eventual sinus node sympathetic reinnervation and left ventricular sympathetic reinnervation do not occur simultaneously.     

Ritually induced growth disturbances and deformities of the orofacial system – A contribution to cranial morphogenesis

Numerous ritual acts involving the skull result in orofacial changes. The present study focuses on ritual acts of Brazilian Zoé Indians. A distinct deformation effect of the ritual act (wearing a lip-plug) on the morphology of the orofacial system is demonstrated and documented using jaw models. The studies show that the lip-plug significantly influences tooth position and jaw growth. While the maxilla displays palatal displacement of the lateral incisors and elevation of the palate, retraction occurs in the mandible depending upon plug size. Additionally, both the plug and the nutritional habits of the Indians induce marked abrasion of all teeth. Moreover, it is shown that the duration of lip-plug wear is an essential determinant of sustained orofacial changes.     

Successful use of sirolimus for refractory atrial ectopic tachycardia in a child with cardiac rhabdomyoma

Cardiac rhabdomyomas are common in tuberous sclerosis. We report a child who developed rhabdomyoma related arrhythmia refractory to antiarrhythmic drug therapy. Reversion of the atrial ectopic tachycardia was achieved with mammalian target of rapamycin pathway (mTOR) inhibitor sirolimus. As per our knowledge, this is the first time that sirolimus has been successfully used in this setting.     

Addressing the Challenges of Research With Small Populations

Public health policy relies on accurate data, which are often unavailable for small populations, especially indigenous groups. Yet these groups have some of the worst health disparities in the United States, making it an ethical imperative to explore creative solutions to the problem of insufficient data.We discuss the limits of widely applied methods of data aggregation and propose a mixed-methods approach to data borrowing as a way to augment sample sizes. In this approach, community partners assist in selecting related populations that make suitable “neighbors” to enlarge the data pool.The result will be data that are substantial, accurate, and relevant to the needs of small populations, especially for health-related policy and decision-making at all levels.When President Obama signed US Executive Order 13515, he declared that no community should be invisible.1 Yet for policymakers, the health status of small population groups, especially the indigenous peoples of the United States, remains largely hidden from view. Consistent epidemiological data are needed to inform policy decisions and resource allocation from the community level to the national level. For small population groups, such as American Indians, Alaska Natives, and Native Hawaiians, national reports and public data sets typically fail to provide sufficiently detailed information. Amassing enough accurate data requires innovative solutions, especially because small groups tend to have the largest health disparities. The scarcity of high-quality data means that these groups are often omitted from research agendas—or as the president put it, “Smaller communities in particular can get lost, their needs and concerns buried in a spreadsheet.”1As academics who conduct health research in small populations, we use community-based participatory methods within a theoretical framework that encompasses the social determinants of health. Our experience suggests some useful ways to address the problem of scarce data. One approach is to disaggregate data that lump together dissimilar populations, such as Native Hawaiians and Asian Americans, because aggregation can mask health disparities. Another approach is to augment data on extremely small populations by using statistical methods that borrow data from other groups with pertinent similarities to the population of interest. However, given the pitfalls inherent in data borrowing, we recommend qualitative methods that empower small communities to partner with academic researchers in selecting appropriate “neighbors,” whose adoption will maintain both the relevance and the distinctiveness of the resulting data pool. In the next sections, we describe a collaborative, multiperspective approach with broad application for small groups throughout the United States.     

HLA class II allele polymorphism in an outbreak of chikungunya fever in Middle Andaman,India

A sudden upsurge of fever cases with joint pain was observed in the outpatient department, Community Health Centre, Rangat during July–August 2010 in Rangat Middle Andaman, India. The aetiological agent responsible for the outbreak was identified as chikungunya virus (CHIKV), by using RT‐PCR and IgM ELISA. The study investigated the association of polymorphisms in the human leucocyte antigen class II genes with susceptibility or protection against CHIKV. One hundred and one patients with clinical features suggestive of CHIKV infection and 104 healthy subjects were included in the study. DNA was extracted and typed for HLA‐DRB1 and DQB1 alleles. Based on the amino acid sequences of HLA‐DQB1 retrieved from the IMGT/HLA database, critical amino acid differences in the specific peptide‐binding pockets of HLA‐DQB1 molecules were investigated. The frequencies of HLA‐DRB1 alleles were not significantly different, whereas lower frequency of HLA‐DQB1*03:03 was observed in CHIKV patients compared with the control population [P = 0·001, corrected P = 0·024; odds ratio (OR)  = 0, 95% confidence interval (95% CI) 0·0–0·331; Peto's OR = 0·1317, 95% CI 0·0428–0·405). Significantly lower frequency of glutamic acid at position 86 of peptide‐binding pocket 1 coding HLA‐DQB1 genotypes was observed in CHIKV patients compared with healthy controls (P = 0·004, OR = 0·307, 95% CI 0·125–0·707). Computational binding predictions of CD4 epitopes of CHIKV by NetMHCII revealed that HLA‐DQ molecules are known to bind more CHIKV peptides than HLA‐DRB1 molecules. The results suggest that HLA‐DQB1 alleles and critical amino acid differences in the peptide‐binding pockets of HLA‐DQB1 alleles might have role in influencing infection and pathogenesis of CHIKV.     

Delinquency in incarcerated male adolescents is associated with single parenthood,exposure to more violence at home and in the community,and poorer self-image

Aim

To assess the relationships between delinquency and demographic and family variables, academic performance, war stressors, home/community, school, and media violence exposure, self-image, and psychopathology.

Methods

This cross-sectional study included 100 delinquent, incarcerated male adolescents and 100 matched schoolchildren from Croatia. It lasted from January 2008 to June 2009, and used socio-demographic questionnaire, questionnaire on children’s stressful and traumatic war experiences, exposure to violence scale, the Offer Self-Image Questionnaire, and Youth Self-Report Questionnaire.

Results

Logistic regression analysis showed that delinquency in incarcerated adolescents was more likely related to having parents who did not live together (odds ratio [OR] 2.40; confidence interval [CI] 1.18-4.90, P = 0.015), being more exposed to violence at home/community (OR 3.84; CI 1.58-9.34, P = 0.003), and having poorer self-image (OR 1.09; CI = 1.03-1.16, P < 0.002).

Conclusion

Preventive and therapeutic interventions in incarcerated delinquents should be specifically targeted toward single parenthood, family factors, trauma oriented interventions, and focused on multiple dimensions of self-concept of adolescents.Delinquency is associated with many risk factors, including demographic, genetic, and family characteristics (single parenthood) or academic performance. Many studies have focused on exposure to various forms of violence – in the family or home; community and neighborhood; in school and peer groups; and the media, but other risk factors have also found to be important, such as poorer self-image, various forms of psychopathology, and social characteristics (neighborhoods characterized by poverty) (1-15). Most of the studies dealing with delinquency aim to develop therapeutic interventions in relation to the obtained factors or mediators (9,11,16).There are relatively few studies on incarcerated adolescents. Many report on delinquents’ traumatic experiences, posttraumatic stress disorder, and importance of developmental tasks of adolescence and parental monitoring (14,17,18). Therapeutic interventions are specifically directed toward assessment and intervention of trauma and psychopathology, and family interventions are used very often.There are not many studies on delinquents in Croatia and most of them deal with a model that takes into account the interplay between protective and risk factors (19-21). Factors that are often mentioned are parental distrust and punishment, and family dysfunctionality (22-24). The prevalence of delinquency in the last few years has not been reducing (25), which suggests that the current preventive and therapeutic efforts have not been sufficient (25). Another important factor that has to be considered when studying delinquency in Croatia is the influence of Croatian War for Independence 1991-1995. The relationship between war experiences (direct or indirect) and the development of delinquency in adolescents has been relatively rarely described, with contradictory findings. Some studies found no association between the impact of war and bullying (26), whereas others found a relationship between aggressiveness in child refugees and their past war experiences (27) or experiences of their parents, war veterans (28). Besides war-related violence, we expected that delinquency was related to the exposure to other types of violence, eg, violence at home (29). Finally, we also expected an association with poorer self-image (8) and the presence of significant psychopathological syndromes (7).Our aim was therefore to examine the relationship between demographic, family factors, academic performance, exposure to violence in different contexts (home, community, school, media, war related stress), psychopathology, and delinquency.     

Parametrized rectal dose and associations with late toxicity in prostate cancer radiotherapy

Objective:

We investigated possible associations between planned dose–volume parameters and rectal late toxicity in 170 patients having radical prostate cancer radiotherapy.

Methods:

For each patient, the rectum was outlined from anorectal junction to sigmoid colon, and rectal dose was parametrized using dose–volume (DVH), dose–surface (DSH) and dose–line (DLH) histograms. Generation of DLHs differed from previous studies in that the rectal dose was parametrized without first unwrapping onto 2-dimensional dose–surface maps. Patient-reported outcomes were collected using a validated Later Effects in Normal Tissues Subjective, Objective, Management and Analytic questionnaire. Associations between dose and toxicity were assessed using a one-sided Mann–Whitney U test.

Results:

Associations (p < 0.05) were found between equieffective dose (EQD2₃) and late toxicity as follows: overall toxicity with DVH and DSH at 13–24 Gy; proctitis with DVH and DSH at 25–36 Gy and with DVH, DSH and DLH at 61–67 Gy; bowel urgency with DVH and DSH at 10–20 Gy. None of these associations met statistical significance following the application of a Bonferroni correction.

Conclusion:

Independently confirmed associations between rectal dose and late toxicity remain elusive. Future work to increase the accuracy of the knowledge of the rectal dose, either by accounting for interfraction and intrafraction rectal motion or via stabilization of the rectum during treatment, may be necessary to allow for improved dose–toxicity comparisons.

Advances in knowledge:

This study is the first to use parametrized DLHs to study associations with patient-reported toxicity for prostate radiotherapy showing that it is feasible to model rectal dose mapping in three dimensions.     

Early Diagnosis of Colonic Anastomotic Leak With Peritoneal Endoscopy

Background and Objectives:

At present, we do not have a reliable method for the early diagnosis of colorectal anastomotic leakage (AL). We tested peritoneal flexible endoscopy through a port placed in the abdominal wall in the early postoperative course, as a new diagnostic method for detection of this complication and evaluated the suggested method for safety, feasibility, and accuracy.

Methods:

Ten swine were randomized into 2 groups: group A, colorectal anastomosis without leakage; and group B, colorectal anastomosis with leakage. A button gastrostomy feeding tube was inserted percutaneously into the peritoneal cavity. Colorectal anastomosis (with or without defect) was created 48 hours after the first operation. The swine were examined by peritoneal flexible endoscopy 8 and 24 hours after the colonic operation, by a consultant surgeon who was blinded to both the presence and the allocated location of the of the anastomotic defect.

Results:

None of the animals showed signs of illness 48 hours after the intraperitoneal gastrostomy tube placement. More than half of the anastomosis circumference was identified in 60 and 10% of the animals at endoscopy 8 and 24 hours, respectively, after the anastomosis was created. Excessive adhesion formation was observed in all animals, irrespective of AL. The sensitivity and specificity of endoscopy in detecting peritonitis 24 hours after AL were both 60%.

Conclusions:

Peritoneal endoscopy is a safe and simple procedure. Visualization of the peritoneal cavity in the early postoperative course was limited due to adhesion formation. Further studies are needed to clarify the accuracy of the procedure and to address additional methodological concerns.