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Background: Although the incidence and case-fatality of subarachnoid haemorrhage (SAH) vary within countries, few countries have reported nationwide rates, especially for multi-ethnic populations. We assessed the nationwide incidence and case-fatality of SAH in New Zealand (NZ) and explored variations by sex, district, ethnicity and time., Methods: We used administrative health data from the national hospital discharge and cause-of-death collections to identify hospitalised and fatal non-hospitalised aneurysmal SAHs in NZ between 2001 and 2018. For validation, we compared these administrative data to those of two prospective Auckland Regional Community Stroke Studies. We subsequently estimated the incidence and case-fatality of SAH and calculated adjusted rate ratios (RR) with 95% confidence intervals to assess differences between sub-populations., Findings: Over 78,187,500 cumulative person-years, we identified 5371 SAHs (95% sensitivity and 85% positive predictive values) resulting in an annual age-standardised nationwide incidence of 8.2/100,000. In total, 2452 (46%) patients died within 30 days after SAH. Compared to European/others, Māori had greater incidence (RR = 2.23 (2.08-2.39)) and case-fatality (RR = 1.14 (1.06-1.22)), whereas SAH incidence was also greater in Pacific peoples (RR = 1.40 (1.24-1.59)) but lesser in Asians (RR = 0.79 (0.71-0.89)). By domicile, age-standardised SAH incidence varied between 6.3-11.5/100,000 person-years and case fatality between 40 and 57%. Between 2001 and 2018, the SAH incidence of NZ decreased by 34% and the case fatality by 12%., Interpretation: Since the incidence and case-fatality of SAH varies considerably between regions and ethnic groups, caution is advised when generalising findings from focused geographical locations for public health planning, especially in multi-ethnic populations., Funding: NZ Health Research Council., Competing Interests: IR received research grants from the Sigrid Juselius Foundation, the Finnish Medical Foundation, the Sakari Alhopuro Foundation, the Finnish Foundation for Cardiovascular Research and the Maud Kuistila Foundation. AR received grant funding from the New Zealand Health Research Council and the Ministry of Health. JD is funded from grants awarded by the New Zealand Health Research Council and the New Zealand Royal Society Marsden Fund. PAB report a leadership or fiduciary role as a President of Australia and New Zealand Association of Neurologists. The authors report no other declarations., (© 2024 The Author(s).)

BACKGROUND With the advent of antibiotics, petrous apicitis (PA), inflammation of the petrous temporal bone, has become a rare complication of otitis media. Even more uncommon is Gradenigo syndrome (GS), a result of PA, characterized by a triad of otitis media or purulent otorrhea, pain within the regions innervated by the first and second division of the trigeminal nerve, and ipsilateral abducens nerve palsy. Recent literature has demonstrated increasing reports of Fusobacterium necrophorum isolated in cases of GS. CASE REPORT A 21-year-old man presented with otalgia, reduced hearing, and severe headache. Examination revealed right-sided purulent otorrhea, anesthesia within the trigeminal nerve distribution, and an ipsilateral abducens nerve palsy. F. necrophorum was isolated from an ear swab and a blood culture. Computed tomography and magnetic resonance imaging (MRI) demonstrated otomastoiditis, PA, cavernous sinus thrombosis, and severe stenosis of the petrous internal carotid artery. He was treated with intravenous benzylpenicillin, underwent a mastoidectomy and insertion of a ventilation tube, and was started on a 3-month course of dabigatran. Interval MRI showed improved internal carotid artery caliber, persistent petrous apex inflammation, and normal appearance of both cavernous sinuses. Follow-up clinical review noted persistent abducens and trigeminal nerve dysfunction. CONCLUSIONS We identified 190 cases of PA; of these, 80 presented with the classic Gradenigo triad. Fusobacterium sp. were cultured in 10% of GS cases, making them the most frequent isolates. Due to the fastidious nature of F. necrophorum, it may be underrepresented in the historical literature, and we recommend that empiric antibiotics cover anaerobic organisms.

Pneumocephalus is the pathologic collection of air in the intracranial cavity. In sufficient volumes, it can contribute to symptoms ranging from headaches to death. For conservative treatment, oxygen use is commonplace. Although this is an accepted tenet of clinical practice, it is not necessarily founded on robust trials. An electronic search of databases EMBASE and MEDLINE and the Cochrane Library was undertaken as per the 2020 Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) statement. Three articles were included. Although the modes of oxygen delivery were heterogenous (non-rebreather versus endotracheal versus hyperbaric chamber), all studies concluded favorably on the use of oxygen therapy for increased reabsorption of pneumocephalus., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: There is a need for long-term evidence of immediate function dental implants inserted in grafted bone. The aim of this retrospective study was to investigate the outcome of full-arch rehabilitations supported by implants in grafted bone. Methods: Thirty-six patients (women: 24; men: 12; average age: 53.5 years) were included (225 implants). Primary outcome measure: to assess implant cumulative success rates evaluated through life tables. Secondary outcome measures: to evaluate implant and prosthetic survival, marginal bone loss, and the incidence of both biological and mechanical complications. Results: Twenty-five implants were unsuccessful giving a dental implant CS rate of 88.1% at 14 years and a 76.8% survival estimation (Kaplan−Meier) using the patient as the unit of analysis. No prosthesis was lost. Average MBL at 10 years was 2.01 mm. The incidence of biological complications was 36%, with smoking affecting it significantly (p < 0.001). The incidence of mechanical complications was 86.1% (45.2% and 54.8% in provisional and definitive prosthesis, respectively. Conclusions: The rehabilitation of atrophic maxillae through dental implants in immediate function inserted in grafted bone is a valid treatment alternative, despite the relevant rate of implant failures and incidence of complications.

The current data on climate change and environmental degradation are dramatic. The consequences of these changes are already having a significant impact on people's health. Physicians - as advocates of the patients, but also as citizens - have an ethical obligation to be involved in efforts to stop these changes. The European Federation of Internal Medicine (EFIM) strongly encourages the Internal Medicine societies and internists across Europe to play an active role in matters related to climate change and environmental degradation. At a national level, this includes advocating the adoption of measures that reduce greenhouse gas (GHG) emissions and environmental degradation and contributing to policy decisions related to these issues. At a hospital level and in clinical practice, supporting actions by the health sector to reduce its ecological footprint is vital. At the level of EFIM and its associated internal societies, promoting educational activities and developing a toolkit to prepare internists to better care for citizens who suffer from the consequences of climate change. In addition to advocating and implementing effective actions to reduce the ecological footprint of the health industry, recommending the introduction of these themes in scientific programs of Internal Medicine meetings and congresses and the pre- and postgraduate medical training. At a personal level, internists must be active agents in advocating sustainable practices for the environment, increasing the awareness of the community about the health risks of climate change and environmental degradation, and being role models in the adoption of environmentally friendly behaviour., Competing Interests: Declaration of Competing Interest The authors declare they have no conflicts of interest., (Copyright © 2022. Published by Elsevier B.V.)

Introduction: Although the prevalence of allergic diseases, including food allergies, has increased over recent decades, relevant information on this topic is still lacking, particularly in younger children living in small cities., Objective: To investigate the prevalence of reported food allergies in preschoolers in Limoeiro/Pernambuco, Brazil., Methods: This was a cross-sectional study with preschoolers. Parents/guardians of all preschoolers enrolled at municipal schools between March and June 2019 (total of 619) were invited to complete a screening questionnaire (total of 619). Another 151 questionnaires were applied on the streets of the town. For positive responses, a second, more detailed and validated questionnaire was completed., Results: A total of 412 questionnaires were returned, of which, 47 presented a positive response to food allergies and only 29 (7.04%) identified a particular food. The most frequently reported food items were shrimp, mollusks, pork, fruit and milk. Of the 29 who identified foods, 22 responded to the detailed questionnaire, resulting in only 4 (0.97%) positive responses. Of these, two were later discarded through clinical examinations and an open oral provocation test, resulting in a final prevalence of 0.48% of confirmed food allergies., Conclusion: The prevalence of reported food allergies was lower than that described in previous studies. The most commonly mentioned foods were shrimp, mollusks and pork, with more reports of multiple food allergies, even in children who had never been previously exposed to these possible allergens, which highlights the relevance of perception in reported food allergy studies., (© 2022. The Author(s).)

Aim: To present feedback, after applying national and international urodynamic study (UDS) recommendations for safe practice during the COVID-19 pandemic., Methods: We created a checklist to assess the feasibility of performing UDS recommendations for safe practice during the COVID-19 pandemic from the first week of May 2021 to the last week of July 2021., Results: One hundred patients were analyzed during the study period. We observed that all preventive recommendations for the steps that precede UDS could be followed in full. However, some guidelines for performing the exam were not feasible in all patients. We have successfully adopted other safety measures for all patients., Conclusions: The COVID-19 pandemic will likely persist for several more years. We believe that continuous improvement, revision, and updating of existing protocols and guidelines for the safe practice of UDS in times of COVID-19, as we propose in this study, should be encouraged., (© 2022 Wiley Periodicals LLC.)

Background: Māori and Pasifika populations in New Zealand have a higher incidence and prevalence of intracranial meningioma (IM). We sought to evaluate the volumetric growth rate of meningiomas under surveillance in these populations., Methods: From July 2002 to October 2020, 336 patients with a total of 408 IM underwent conservative management with serial radiological surveillance at Auckland City Hospital and met the criteria for the study. Inclusion criteria included: age >16 at diagnosis, ≥2 appropriate scans one or more years apart. Exclusion criteria included previous cranial irradiation, a diagnosis of Neurofibromatosis and prior treatment of meningioma. Demographic and clinical data were obtained from the electronic medical records. Imaging data were recorded from the first and last scans. We utilized open-source image processing software (3D Slicer) for semi-automated segmentation and volume calculation. Consistent with previous literature, we calculated the relative growth rate (RGR, %/year) and annual volume change (AVC, cm 3 /year) over time., Results: Four hundred and eight meningiomas were volumetrically characterized for a mean duration of 6.2 years. The Māori and Pasifika populations (n = 134/393) demonstrated a higher RGR (31.41 versus 14.33%/year) (P = 0.026) and AVC (2.05 versus 0.95 cm 3 ) (P = 0.025) compared to the control population. They also presented at a younger age and had a higher rate of tumour multiplicity. Males represented only 17.6% of the cohort but exhibited a higher growth rate (AVC = 2.52 cm 3 /year) than females (AVC = 0.99 cm 3 /year) (P = 0034)., Conclusions: Māori and Pasifika populations in New Zealand have a higher incidence and volumetric growth rate of IM compared to a control population. This warrants further clinical, histopathological and genomic analysis., (© 2022 Royal Australasian College of Surgeons.)

Demyelination causes slowed or failed neuronal conduction and is a driver of disability in multiple sclerosis and other neurological diseases. Currently, the gold standard for imaging demyelination is MRI, but despite its high spatial resolution and sensitivity to demyelinated lesions, it remains challenging to obtain specific and quantitative measures of molecular changes involved in demyelination. To understand the contribution of demyelination in different diseases and to assess the efficacy of myelin-repair therapies, it is critical to develop new in vivo imaging tools sensitive to changes induced by demyelination. Upon demyelination, axonal K + channels, normally located underneath the myelin sheath, become exposed and increase in expression, causing impaired conduction. Here, we investigate the properties of the K + channel PET tracer [ 18 F]3F4AP in primates and its sensitivity to a focal brain injury that occurred three years prior to imaging. [ 18 F]3F4AP exhibited favorable properties for brain imaging including high brain penetration, high metabolic stability, high plasma availability, high reproducibility, high specificity, and fast kinetics. [ 18 F]3F4AP showed preferential binding in areas of low myelin content as well as in the previously injured area. Sensitivity of [ 18 F]3F4AP for the focal brain injury was higher than [ 18 F]FDG, [ 11 C]PiB, and [ 11 C]PBR28, and compared favorably to currently used MRI methods.

Urinary tract infection (UTI) is a common condition in women. There is an increased concern on reduction of bacterial susceptibility resulting from wrongly prescribing antimicrobials. This paper summarizes the recommendations of four Brazilian medical societies (SBI - Brazilian Society of Infectious Diseases, FEBRASGO - Brazilian Federation of Gynecology and Obstetrics Associations, SBU - Brazilian Society of Urology, and SBPC/ML - Brazilian Society of Clinical Pathology/Laboratory Medicine) on the management of urinary tract infection in women. Asymptomatic bacteriuria should be screened at least twice during pregnancy (early and in the 3rd trimester). All cases of significant bacteriuria (≥10 5 CFU/mL in middle stream sample) should be treated with antimicrobials considering safety and susceptibility profile. In women with typical symptoms of cystitis, dipsticks are not necessary for diagnosis. Urine cultures should be collected in pregnant women, recurrent UTI, atypical cases, and if there is suspicion of pyelonephritis. First line antimicrobials for cystitis are fosfomycin trometamol in a single dose and nitrofurantoin, 100mg every 6hours for five days. Second line drugs are cefuroxime or amoxicillin-clavulanate for seven days. During pregnancy, amoxicillin and other cephalosporins may be used, but with a higher chance of therapeutic failure. In recurrent UTI, all episodes should be confirmed by urine culture. Treatment should be initiated only after urine sampling and with the same regimens indicated for isolated episodes. Prophylaxis options of recurrent UTI are behavioral measures, non-antimicrobial and antimicrobial prophylaxis. Vaginal estrogens may be recommended for postmenopausal women. Other non-antimicrobial prophylaxis, including cranberry and immunoprophylaxis, have weak evidence supporting their use. Antimicrobial prophylaxis may be offered as a continuous or postcoital scheme. In pregnant women, options are cephalexin, 250-500mg and nitrofurantoin, 100mg (contraindicated after 37 weeks of pregnancy). Nonpregnant women may use fosfomycin trometamol, 3g every 10 days, or nitrofurantoin, 100mg (continuous or postcoital)., (Copyright © 2020 Sociedade Brasileira de Infectologia. Published by Elsevier España, S.L.U. All rights reserved.)

Context: On October 1, 2015, the United States transitioned from using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to ICD-10-CM. Continuing to monitor the burden of neonatal abstinence syndrome (NAS) after the transition presently requires use of data dependent on ICD-9-CM coding to enable trend analyses. Little has been published on the validation of using ICD-9-CM codes to identify NAS cases., Objective: To assess the validity of hospital discharge data (HDD) from selected Florida hospitals for passive NAS surveillance, based on ICD-9-CM codes, which are used to quantify baseline prevalence of NAS., Design: We reviewed infant and maternal data for all births at 3 Florida hospitals from 2010 to 2011. Potential NAS cases included infants with ICD-9-CM discharge codes 779.5 and/or 760.72 in linked administrative data (ie, HDD linked to vital records) or in unlinked HDD and infants identified through review of neonatal intensive care unit admission logs or inpatient pharmacy records. Confirmed infant cases met 3 clinician-proposed criteria. Sensitivity and positive predictive value were calculated to assess validity for the 2 ICD-9-CM codes, individually and combined., Results: Of 157 confirmed cases, 134 with 779.5 and/or 760.72 codes were captured in linked HDD (sensitivity = 85.4%) and 151 in unlinked HDD (sensitivity = 96.2%). Positive predictive value was 74.9% for linked HDD and 75.5% for unlinked HDD. For either HDD types, the single 779.5 code had the highest positive predictive value (86%), lowest number of false positives, and good to excellent sensitivity., Conclusions: Passive surveillance using ICD-9-CM code 779.5 in either linked or unlinked HDD identified NAS cases with reasonable validity. Our work supports the use of ICD-9-CM code 779.5 to assess the baseline prevalence of NAS through 2015.

Aims: To perform a comparative evaluation of Valsalva maneuver techniques, in an attempt to identify the most suitable one for achieving leak point pressure (LPP) during the cystometric phase of the urodynamic study (UDS), in order to propose a method for technical standardization., Methods: Urodynamic data from women with stress urinary incontinence at three urogynecological medical centers were randomly selected and prospectively analyzed. Valsalva maneuver was executed through forceful attempted exhalation against the dorsal surface of the hand (Group 1), through abdominal strain (Group 2), or through low-elasticity latex balloon-blowing (Group 3). Patients were classified based on age and higher vesical pressure value, as well as time to perform Valsalva maneuver., Results: Initially, 1358 urodynamic studies were identified as eligible for analysis. Among these, 340 belonged to Group 1, 318 to Group 2, and 700 to Group 3. Valsalva maneuver accomplished through abdominal straining was more effective, inducing increased vesical pressure, across age groups. The same maneuver may be sustained for longer than the other two techniques., Conclusion: When performed through abdominal strain, the Valsalva maneuver was more effective for stress urinary incontinence urodynamic's investigation., (© 2018 Wiley Periodicals, Inc.)

Background: Risk factors for medication-related osteonecrosis of the jaw (MRONJ) are well known, although few studies evaluate the factors that influence treatment outcomes in MRONJ and whether discontinuing antiresorptive medication influences healing., Purpose: (1) Describe the characteristics of a population of patients with MRONJ. (2) Identify the factors associated with favourable outcomes. (3) Identify a temporal correlation between discontinuation of antiresorptives and healing time., Methods: A retrospective longitudinal cohort study was carried out, including 77 patients with MRONJ treated between 2004 and 2016. Primary outcome was defined as healed/improved vs. worse/stable. Time to healing was set as the secondary outcome. Statistical significance was defined as p < 0.05., Results: Primary disease, route of administration, lesion location, and development of complications influenced the outcome of treatment. Significant differences in outcomes according to primary disease (p < 0.05) were found when staging, gender, and lesion location were held constant. Time to healing was longer for patients who discontinued medication more than 3 months after diagnosis than for those who discontinued at diagnosis or before - respectively, 36, 9, and 7 months (p = 0.01)., Conclusions: The outcome of MRONJ treatment may be influenced by primary disease and route of administration of antiresorptives. Antiresorptive medication discontinuation contributes to reduce healing time in MRONJ., (Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Context: Birth defects prevention, research, education, and support activities can be improved through surveillance systems that collect high-quality data., Objective: To estimate the overall and defect-specific accuracy of Florida Birth Defects Registry (FBDR) data, describe reasons for false-positive diagnoses, and evaluate the impact of statewide case confirmation on frequencies and prevalence estimates., Design: Retrospective cohort evaluation study., Participants: A total of 8479 infants born to Florida resident mothers between January 1, 2007, and December 31, 2011, and diagnosed with 1 of 13 major birth defects in the first year of life., Main Outcome Measures: Positive predictive value: calculated overall (proportion of FBDR-identified cases confirmed by medical record review, regardless of which of the 13 defects were confirmed) and defect-specific (proportion of FBDR-identified cases confirmed by medical record review with the same defect) indices., Results: The FBDR's overall positive predictive value was 93.3% (95% confidence interval, 92.7-93.8); however, there was variation in accuracy across defects, with positive predictive values ranging from 96.0% for gastroschisis to 54.4% for reduction deformities of the lower limb. Analyses suggested that International Classification of Diseases, Ninth Edition, Clinical Modification, codes, upon which FBDR diagnoses are based, capture the general occurrence of a defect well but often fail to identify the specific defect with high accuracy. Most infants with false-positive diagnoses had some type of birth defect that was incorrectly documented or coded. If prevalence rates reported by the FBDR for these 13 defects were adjusted to incorporate statewide case confirmation, there would be an overall 6.2% rate reduction from 82.6 to 77.5 per 10 000 live births., Conclusions: A statewide birth defects surveillance system, relying on linkage of administrative databases, is capable of achieving high accuracy (>93%) for identifying infants with any one of the 13 major defects included in this study. However, the level of accuracy and the ability to minimize false-positive diagnoses vary depending on the defect.

We investigate uncertainty in estimates of pregnant women's exposure to ambient PM2.5 and benzene derived from central-site monitoring data. Through a study of live births in Florida during 2000-2009, we discuss the selection of spatial and temporal scales of analysis, limiting distances, and aggregation method. We estimate exposure concentrations and classify exposure for a range of alternatives, and compare impacts. Estimated exposure concentrations were most sensitive to the temporal scale of analysis for PM2.5, with similar sensitivity to spatial scale for benzene. Using 1-12 versus 3-8 weeks of gestational age as the exposure window resulted in reclassification of exposure by at least one quartile for up to 37% of mothers for PM2.5 and 27% for benzene. The largest mean absolute differences in concentration resulting from any decision were 0.78 µg/m(3) and 0.44 ppbC, respectively. No bias toward systematically higher or lower estimates was found between choices for any decision., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: A growing number of studies have investigated the association between air pollution and the risk of birth defects, but results are inconsistent. The objective of this study was to examine whether maternal exposure to ambient PM2.5 or benzene increases the risk of selected birth defects in Florida., Methods: We conducted a retrospective cohort study of singleton infants born in Florida from 2000 to 2009. Isolated and non-isolated birth defect cases of critical congenital heart defects, orofacial clefts, and spina bifida were identified from the Florida Birth Defects Registry. Estimates of maternal exposures to PM2.5 and benzene for all case and non-case pregnancies were derived by aggregation of ambient measurement data, obtained from the US Environmental Protection Agency Air Quality System, during etiologically relevant time windows. Multivariable Poisson regression was used to estimate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) for each quartile of air pollutant exposure., Results: Compared to the first quartile of PM2.5 exposure, higher levels of exposure were associated with an increased risk of non-isolated truncus arteriosus (aPR4th Quartile, 8.80; 95% CI, 1.11-69.50), total anomalous pulmonary venous return (aPR2nd Quartile, 5.00; 95% CI, 1.10-22.84), coarctation of the aorta (aPR4th Quartile, 1.72; 95% CI, 1.15-2.57; aPR3rd Quartile, 1.60; 95% CI, 1.07-2.41), interrupted aortic arch (aPR4th Quartile, 5.50; 95% CI, 1.22-24.82), and isolated and non-isolated any critical congenital heart defect (aPR3rd Quartile, 1.13; 95% CI, 1.02-1.25; aPR4th Quartile, 1.33; 95% CI, 1.07-1.65). Mothers with the highest level of exposure to benzene were more likely to deliver an infant with an isolated cleft palate (aPR4th Quartile, 1.52; 95% CI, 1.13-2.04) or any orofacial cleft (aPR4th Quartile, 1.29; 95% CI, 1.08-1.56). An inverse association was observed between exposure to benzene and non-isolated pulmonary atresia (aPR4th Quartile, 0.19; 95% CI, 0.04-0.84)., Conclusion: Our results suggest a few associations between exposure to ambient PM2.5 or benzene and specific birth defects in Florida. However, many related comparisons showed no association. Hence, it remains unclear whether associations are clinically significant or can be causally related to air pollution exposures., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: The Florida Birth Defects Registry (FBDR) relies predominantly on a statewide, population-based, passive surveillance system constructed by linking together multiple administrative and clinical databases. With funding limitations and data restrictions a reality in public health, it is imperative for disease registries to have ongoing evaluation of existing and new data sources. This study quantifies the impact of expanding the FBDR case ascertainment net to include infant death certificates (IDCs) and emergency department (ED) discharge data on the reported prevalence of birth defects., Methods: Between 2008 and 2011, the FBDR identified cases using various data sources: inpatient and outpatient discharge data (2008-2011), Regional Perinatal Intensive Care Center data (2008), Early Steps program data (2008), IDCs (2009-2011), and ED data (2010-2011). Using hypothetical reconstructions of the FBDR, we examined the overall and unique contribution of each data source in identifying infants with birth defects. This permitted evaluation of a changing FBDR data source mix during the 4-year study period. The effect of adding both IDCs and ED data was investigated by constructing the 2010-2011 FBDR with and without these data sources, and then comparing frequencies and prevalence rates across each scenario. Analyses were conducted for all FBDR cases and for specific birth defect categories; improvements in ascertainment were assessed across sociodemographic and perinatal characteristics., Results: Overall, IDCs captured 3.4% of all infants with at least 1 birth defect studied, ED data captured 3.9% of the cases, and together the 2 data sources captured 7.2%. However, IDCs uniquely identified 0.8% of all cases, ED data uniquely identified 0.7% of all cases, and collectively they identified only 1.4% of cases that would otherwise have been missed. The unique contribution of IDC and ED data to case identification varied by defect and across sociodemographic and perinatal subgroups, with the largest impact among infants with anencephalus (64.7%), trisomy 13 (52.0%), trisomy 18 (22.2%), and encephalocele (13.3%), or those who were born weighing less than 1,500 grams or less than 32 weeks' gestation, or whose mothers' education was eighth grade or less., Discussion: Although their unique contribution is small when all defects are considered together, IDCs and ED data contribute cases that would otherwise have been disproportionately lost and are thus an important addition to surveillance activities. The FBDR continues to strive to create a comprehensive, accurate, and efficient statewide birth defects surveillance system.

Introduction: State-based surveillance programs play a key role in birth defects planning, prevention, education, support, and research activities. High-quality data are essential to all of these functions, and a key indicator of quality is timeliness. The Florida Birth Defects Registry (FBDR)-one of the largest population-based state registries in the United States-faces challenges with timeliness, as evidenced by its 18-month lag time. The goal of this study was to determine if the timeliness of the FBDR could be improved without significantly reducing the completeness of birth defect ascertainment., Methods: Using 2006-2011 data from the FBDR, we first investigated the timing of diagnosis of birth defects by estimating the effect of different periods of follow-up on prevalence rates reported by the FBDR. We achieved this through retrospective reconstructions of the FBDR under 5 different scenarios with progressively narrower follow-up windows for each infant, and by comparing recalculated rates to the rate of the current FBDR with 1 year of follow-up. We then considered scenarios in which the time lag used to construct the FBDR was reduced (15, 12, 9, and 6 months) by using less data (from 7 to 4 quarters). Recalculated rates were again compared to the current FBDR constructed with 2 years of data and an 18-month lag. Analyses were performed overall and for 44 specific defects., Results: During the 6-year study period, the FBDR identified more than 27,000 infants with a defect detected during the first year of life. Restricting follow-up from 1 year to 9 months would only result in a loss of 1.4% of cases. Cutting follow-up in half to 6 months would miss 3.2% of cases, although there was significant variation across defects. Improving timeliness had a small impact on completeness of ascertainment. Overall, compiling the FBDR with only 6 quarters of Florida Agency for Health Care Administration data (as opposed to 8 quarters) would improve timeliness by approximately 6 months, resulting in a registry that is 99.4% complete., Discussion: Six-to-nine month improvements in timeliness were achievable with a minimal sacrifice in completeness (0.6%-1.7%). Efforts to enhance data quality through the assessment of timeliness and completeness indicators are not unique to birth defects surveillance programs. Other programs, particularly those with similar passive case ascertainment protocols, can use our findings to consider a more timely release of registry data, or to design similar investigations of their own.

Variance is a statistical parameter used to characterize heterogeneity or variability in data sets. However, measurements commonly include noise, as random errors superimposed to the actual value, which may substantially increase the variance compared to a noise-free data set. Our aim was to develop and validate a method to estimate noise-free spatial heterogeneity of pulmonary perfusion using dynamic positron emission tomography (PET) scans. On theoretical grounds, we demonstrate a linear relationship between the total variance of a data set derived from averages of n multiple measurements, and the reciprocal of n. Using multiple measurements with varying n yields estimates of the linear relationship including the noise-free variance as the constant parameter. In PET images, n is proportional to the number of registered decay events, and the variance of the image is typically normalized by the square of its mean value yielding a coefficient of variation squared (CV(2)). The method was evaluated with a Jaszczak phantom as reference spatial heterogeneity (CV(r)(2)) for comparison with our estimate of noise-free or 'true' heterogeneity (CV(t)(2)). We found that CV(t)(2) was only 5.4% higher than CV(r)2. Additional evaluations were conducted on 38 PET scans of pulmonary perfusion using (13)NN-saline injection. The mean CV(t)(2) was 0.10 (range: 0.03-0.30), while the mean CV(2) including noise was 0.24 (range: 0.10-0.59). CV(t)(2) was in average 41.5% of the CV(2) measured including noise (range: 17.8-71.2%). The reproducibility of CV(t)(2) was evaluated using three repeated PET scans from five subjects. Individual CV(t)(2) were within 16% of each subject's mean and paired t-tests revealed no difference among the results from the three consecutive PET scans. In conclusion, our method provides reliable noise-free estimates of CV(t)(2) in PET scans, and may be useful for similar statistical problems in experimental data.

Neonatal abstinence syndrome (NAS) is a constellation of physiologic and neurobehavioral signs exhibited by newborns exposed to addictive prescription or illicit drugs taken by a mother during pregnancy. The number of hospital discharges of newborns diagnosed with NAS has increased more than 10-fold (from 0.4 to 4.4 discharges per 1,000 live births) in Florida since 1995, far exceeding the three-fold increase observed nationally. In February 2014, the Florida Department of Health requested the assistance of CDC to 1) assess the accuracy and validity of using Florida's hospital inpatient discharge data, linked to birth and infant death certificates, as a means of NAS surveillance and 2) describe the characteristics of infants with NAS and their mothers. This report focuses only on objective two, describing maternal and infant characteristics in the 242 confirmed NAS cases identified in three Florida hospitals during a 2-year period (2010-2011). Infants with NAS experienced serious medical complications, with 97.1% being admitted to an intensive care unit, and had prolonged hospital stays, with a mean duration of 26.1 days. The findings of this investigation underscore the important public health problem of NAS and add to current knowledge on the characteristics of these mothers and infants. Effective June 2014, NAS is now a mandatory reportable condition in Florida. Interventions are also needed to 1) increase the number and use of community resources available to drug-abusing and drug-dependent women of reproductive age, 2) improve drug addiction counseling and rehabilitation referral and documentation policies, and 3) link women to these resources before or earlier in pregnancy.

The main goals for urinary stone treatment are to preserve renal function, reduce or avoid complications related to calculi, and to render the patient free of calculi as soon as possible. Anatrophic nephrolithotomy (ANL) is a valid and useful alternative for conventional staghorn calculi excision. Although excellent stone free rates can be achieved with ANL there are some drawbacks that may be of concern. Morbidity related to intraoperative and postoperative complications is one of them. Another, great concern is the possibility of reduction on renal function related to the procedure itself. This may be related to nephron injury during nephrotomy and parenchymal closure or to ischemic injury. In this review we assess functional results after anatrophic nephrolithotomy.

Purpose: Implanting a transobturator male sling is a valid option to manage urinary incontinence after prostatectomy. We evaluated the trajectory of Argus T™ needles blindly introduced into the retropubic space to determine the safety and etiology of postoperative symptoms that can arise from this implant., Materials and Methods: Needles were implanted and perineal dissection was performed in 20 fixed, adult human male cadavers. The distance was measured from the upper and lower extremities of the needles in the internal pelvic wall up to the obturator neurovascular bundle. Anatomical variations identified in this area proximal to the needles were characterized. The inguinocrural region was also dissected from the needles positioned there. Statistical analysis of the results was done., Results: All needles transfixed the obturator internus muscle. Of the needles 90% were completely immersed in its fibers and not visible in the inner wall of the pelvis. The distance to the obturator neurovascular bundle and anatomical variations were noted. In the inguinocrural region the pectineus and adductor longus muscles were perforated in all cadavers., Conclusions: The needle sling implant preserves the obturator neurovascular bundle and obviates the potential for postoperative pelvic hematoma. The anatomical trajectory of the needles used for this implant account for the groin and perineal pain side effects. Based on similarities between the Argus T and other types of outside-in transobturator male slings the results of the current study could be extrapolated to the latter slings., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Hyperhomocysteinemia in breast cancer (BC) patients can be a risk factor for thromboembolic events. This study aimed to evaluate homocysteine and its cofators (folic acid and vitamin B12) concentrations and platelet count at diagnosis of BC, 3 and 6 months after the beginning of chemotherapy treatment and to correlate them with clinical data., Methods: Thirty-five BC patients were included; blood samples were obtained by venipuncture. Plasmatic Hcy and cofactors concentrations were measured by competitive chemiluminescent enzyme immunoassay method. Platelet count was done using an automated analyzer. Statistical analysis was performed using the software SPSS., Results: During chemotherapy, homocysteine (P = 0.032) and vitamin B12 (P < 0.001) concentrations increased, while folate and platelets decreased (P < 0.001). Among the clinical data, the menopausal status showed significant positive correlation (P = 0.022) with homocysteine concentration increase., Conclusions: Evaluation of homocysteine concentrations during chemotherapy is extremely important because their levels increase during chemotherapy treatment, thus increasing the risk of thromboembolism development., (© 2014 Wiley Periodicals, Inc.)

Background: Entrapment neuropathy of the ulnar nerve at the level of the elbow is the shared domain of multiple surgical specialties. A wide variety of operative methods for its surgical management have been reported. Our hospital utilizes neurolysis (NL) and subcutaneous transposition (AST). The aim of this paper was to compare the clinical outcomes in patients treated by ulnar nerve transposition versus neurolysis over a 20-year period., Methods: We included patients who underwent either neurolysis or an ulnar nerve transposition. A retrospective analysis was performed which included 480 patients at our institution between January 1992 and December 2012. In total, physical and electronic records for 480 patients were reviewed. Three-hundred and one underwent ulnar nerve transposition and 179 underwent ulnar nerve neurolysis ., Results: In the AST group 201/301 patients suffered from parasthesiae pre-operatively and 156/301 had pain at and around the cubital tunnel. Paresis of the ulnar nerve innervated muscles was present in 99/301 patients. At the 3-month follow-up appointment, 187/201 patients with parasthesiae and 113/156 patients with local pain had resolution of their symptoms. In the NL group 151/179 patients had parasthesiae pre-operatively and 126/179 had pain at and around the cubital tunnel. Paresis of the ulnar nerve innervated muscles was present in 56/179 patients. At the 3-month follow-up appointment, 141/151 patients with parasthesiae and 117/126 patients with local pain had resolution of their symptoms., Conclusions: In cases of ulnar nerve compression at the cubital tunnel, both neurolysis and transposition are effective in improving clinical outcome. The only statistically significant advantage of neurolysis over transposition seems to be relief of localized elbow pain. We recommend neurolysis as the preferred procedure.

Background: This study investigates the relationship between maternal pre-pregnancy body mass index (BMI) and 26 birth defects identified through the Florida Birth Defects Registry., Methods: Pre-pregnancy BMI (kg/m(2)) was categorised into underweight (<18.5), normal weight (18.5-24.9), overweight (25.0-29.9), and obese (≥30.0) among Florida resident mothers without pre-gestational diabetes who gave birth to singleton infants from March 2004 through December 2009. Obesity was classified as obese I (30.0-34.9), obese II (35.0-39.9), and obese III (≥40.0). Logistic regression was used to calculate the adjusted odds ratios and 95% confidence interval, representing the association between pre-pregnancy BMI and each of the 26 specific birth defects (and an 'any birth defect' composite). Models were adjusted for maternal age, race/ethnicity, education, smoking, marital status, and nativity., Results: The livebirth prevalence of any birth defect increased with increasing BMI, from 3.9% among underweight women to 5.3% among obese III women (P < 0.001). Results show a direct dose-response relationship between maternal pre-pregnancy BMI and 10 defects under study (cleft palate without cleft lip, diaphragmatic hernia, hydrocephalus without spina bifida, hypoplastic left heart syndrome, pulmonary valve atresia and stenosis, pyloric stenosis, rectal and large intestinal atresia/stenosis, transposition of great arteries, tetralogy of Fallot, and ventricular septal defects) and the 'any birth defect' category. Conversely, gastroschisis exhibited a statistically significant inverse relationship with pre-pregnancy BMI., Conclusions: This study provides evidence of the increasing risk of birth defect-affected pregnancy with increasing pre-pregnancy obesity. Reducing pre-pregnancy obesity, even among obese women, may reduce the occurrence of birth defects., (© 2013 John Wiley & Sons Ltd.)

Background: Critical congenital heart disease (CCHD) was recently added to the U.S. Recommended Uniform Screening Panel for newborns. States considering screening requirements may want more information about the potential impact of screening. This study examined potentially avoidable mortality among infants with late detected CCHD and assessed whether late detection was associated with increased hospital resource use during infancy., Methods: This was a state-wide, population-based, observational study of infants with CCHD (n = 3603) born 1998 to 2007 identified by the Florida Birth Defects Registry. We examined 12 CCHD conditions that are targets of newborn screening. Late detection was defined as CCHD diagnosis after the birth hospitalization. Deaths potentially avoidable through screening were defined as those that occurred outside a hospital following birth hospitalization discharge and those that occurred within 3 days of an emergency readmission., Results: For 23% (n = 825) of infants, CCHD was not detected during the birth hospitalization. Death occurred among 20% (n = 568/2,778) of infants with timely detected CCHD and 8% (n = 66/825) of infants with late detected CCHD, unadjusted for clinical characteristics. Potentially preventable deaths occurred in 1.8% (n = 15/825) of infants with late detected CCHD (0.4% of all infants with CCHD). In multivariable models adjusted for selected characteristics, late CCHD detection was significantly associated with 52% more admissions, 18% more hospitalized days, and 35% higher inpatient costs during infancy., Conclusion: Increased CCHD detection at birth hospitals through screening may lead to decreased hospital costs and avoid some deaths during infancy. Additional studies conducted after screening implementation are needed to confirm these findings., (Copyright © 2013 Wiley Periodicals, Inc.)

Objectives: Critical congenital heart disease (CCHD) was recently added to the US Recommended Uniform Screening Panel for newborns. This study assessed whether maternal/household and infant characteristics were associated with late CCHD detection., Methods: This was a statewide, population-based, retrospective, observational study of infants with CCHD born between 1998 and 2007 identified by using the Florida Birth Defects Registry. We examined 12 CCHD conditions that are primary and secondary targets of newborn CCHD screening using pulse oximetry. We used Poisson regression models to analyze associations between selected characteristics (eg, CCHD type, birth hospital nursery level [highest level available in the hospital]) and late CCHD detection (defined as diagnosis after the birth hospitalization)., Results: Of 3603 infants with CCHD and linked hospitalizations, CCHD was not detected during the birth hospitalization for 22.9% (n = 825) of infants. The likelihood of late detection varied by CCHD condition. Infants born in a birth hospital with a level I nursery only (adjusted prevalence ratio: 1.9 [95% confidence interval: 1.6-2.2]) or level II nursery (adjusted prevalence ratio: 1.5 [95% confidence interval: 1.3-1.7]) were significantly more likely to have late-detected CCHD compared with infants born in a birth hospital with a level III (highest) nursery., Conclusions: After controlling for the selected characteristics, hospital nursery level seems to have an independent association with late CCHD detection. Thus, perhaps universal newborn screening for CCHD could be particularly beneficial in level I and II nurseries and may reduce differences in the frequency of late diagnosis between birth hospital facilities.

The alkaline hydrogen peroxide (AHP) pretreatment of cashew apple bagasse (CAB) was evaluated based on the conversion of the resultant cellulose into glucose. The effects of the concentration of hydrogen peroxide at pH 11.5, the biomass loading and the pretreatment duration performed at 35°C and 250 rpm were evaluated after the subsequent enzymatic saccharification of the pretreated biomass using a commercial cellulase enzyme. The CAB used in this study contained 20.56 ± 2.19% cellulose, 10.17 ± 0.89% hemicellulose and 35.26 ± 0.90% lignin. The pretreatment resulted in a reduced lignin content in the residual solids. Increasing the H2O2 concentration (0-4.3% v/v) resulted in a higher rate of enzymatic hydrolysis. Lower biomass loadings gave higher glucose yields. In addition, no measurable furfural and hydroxymethyl furfural were produced in the liquid fraction during the pretreatment. The results show that alkaline hydrogen peroxide is effective for the pretreatment of CAB., (Crown Copyright © 2013. Published by Elsevier Ltd. All rights reserved.)

Background: The relationship between hyperglycemia and prostate cancer remains controversial. According to current hypotheses, elevated serum glucose levels may lead to disease development or disease prevention. Our study examined the potential correlation between pre-operative glycemic levels of patients with prostate cancer and the grade of tumor aggressiveness., Method: We studied the case files of patients with a diagnosis of prostate cancer who had received putatively curative cancer surgery at the Urology Department of the Servidores do Estado Federal Hospital (RJ/Brazil). We transcribed information related to glycemia - collected up to 3 months before the surgery - and the histopathological grade of tumor aggressiveness (Gleason score) of the surgically removed prostates., Results: We analyzed 42 people who met the inclusion criteria. Based on Gleason scores, among the normoglycemic patients, we detected low, moderate, and highly aggressive neoplasias in 13%, 53%, and 36% of the cases, respectively. For the hyperglycemic group, these rates were 30%, 60%, and 10%, respectively. Normoglycemic patients had primary Gleason grade 3 in 40% of the cases and grade 4 in 60% of the cases. For the hyperglycemic patients, these rates were 90% and 10%, respectively (P < 0.05 vs. grade 3 group)., Conclusion: Both Gleason score and primary Gleason grade were lower in hyperglycemic patients with prostate cancer than in normoglycemic patients, suggesting a "protective action" of hyperglycemic states., Competing Interests: There were no conflicts of interest.

Unlabelled: What's known on the subject? and What does the study add? Photovaporization of the prostate (PVP) is now challenging TURP as the standard treatment for lower LUTS caused by BPH. The learning curve for PVP is short and the main advantages of this method over TURP are a shorter period of hospitalization, a shorter period of postoperative vesical catheterization, lower levels of retrograde ejaculation, rare development of dilutional hyponatraemia syndrome, the lack of a need for postoperative vesical irrigation as a result of extremely low indices of postoperative haematuria, and the lack of a need to suspend anticoagulant medication for the surgery. Traditionally, comparisons of the effectiveness of TURP vs PVP have involved parameters such as peak flow urinary rate and post-void residual urine volume measurements, and have employed questionnaires such as the IPSS and the International Index of Erectile Function instruments. However, studies evaluating detailed urodynamic parameters remain scarce and non-comparative The present study compared postoperative, medium-term urodynamic parameters among patients receiving TURP and high-power PVP. We consider the present study to be distinctive because it involved a double-blind, detailed functional analysis of the vesical emptying stage over the course of 2 years, and did not simply comprise an evaluation of clinical parameters and uroflowmetrics. We saw a reduction of infravesical obstruction, as shown by the significant reduction of ≥20 cm H(2)O in the mean micturition pressure for the groups studied, as well as a significant reduction in bladder outlet obstruction index. Thus, the present data show that high-power PVP can achieve and maintain the same results as TURP over a period of 24 months regarding an aspect that is particularly important for maintaining vesical health (i.e. detrusor pressure during the evacuation of the bladder). Such urodynamic data describing the functional outcome of PVP are currently missing from the literature., Objective: To assess the impact of GreenLight HPS™ 120-W (American Medical System Incorporation, Minnetonka, MN, USA) laser photovaporization of the prostate (PVP) compared to transurethral resection of the prostate (TURP) on urodynamic results, voiding function and sexual function., Patients and Methods: In total, 20 men with intermediate/severe lower urinary tract symptoms as a result of benign prostatic hyperplasia (BPH) were randomly selected and equally divided into two groups: TURP and PVP. Urodynamic evaluation was performed and International Prostate Symptom Score (IPSS), International Index of Erectile Function-5 and International Consultation on Incontinence Questionnaire - Short Form questionnaires were completed. The results were assessed at 2 years., Results: Mean IPSS scores were reduced in both groups, although they did not differ between the TURP and PVP groups. There was no significant change in International Index of Erectile Function-5 scores. Half of the patients in the PVP group developed urge urinary incontinence with spontaneous resolution. The urodynamic parameters analyzed showed an improvement for both groups, although the values in the TURP group values were not significantly different from those in the PVP group., Conclusions: Bladder storage symptoms may represent a major concern, although they are of limited duration in patients undergoing PVP. High-power PVP can achieve and maintain the same results as TURP over a period of 24 months., (© 2012 BJU INTERNATIONAL.)

Objective: We linked data from two independent birth defects surveillance systems with different case-finding methods in an overlapping geographic area to assess Florida's suveillance of birth defects (e.g., neural tube defects, orofacial clefts, gastroschisis/omphalocele, and chromosomal defects), focusing on sensitivity and completeness of ascertainment measures., Methods: Live-born infants identified from each system born during 2003-2006 in a nine-county catchment area with specific birth defects were linked to birth certificates. Using the enhanced surveillance system as a gold standard, we calculated the sensitivity of the Florida Birth Defects Registry (FBDR) for identifying infants. Next, we used capture-recapture models to estimate the completeness of case ascertainment and the prevalence of each birth defect in the catchment area. We used multivariable logistic regression models with backward elimination to estimate adjusted odds ratios and 95% confidence intervals for factors significantly associated with the FBDR's failure to capture infants ultimately identified by enhanced surveillance., Results: The FBDR's sensitivity was 89.3%, and the overall completeness of ascertainment was estimated as 86.6%. Defect-specific sensitivity and completeness of ascertainment varied significantly by defect. The combined defect-specific sensitivity for all malformations under study was 86.6%; completeness of ascertainment ranged from 45.6% for anencephaly to 88.6% for Down syndrome, 87.9% for spina bifida without anencephaly, and 87.0% for orofacial clefts., Conclusions: For the defects under study, the FBDR captured nearly nine of every 10 infants born with selected birth defects. However, the FBDR's ability to identify specific defects was both more limited and defect dependent with widely varying defect-specific sensitivities.

Pseudomeningocoele is a recognised complication of spinal surgery. It could be either asymptomatic or symptomatic. We present a 63-year-old male who developed a delayed pseudomeningocoele and symptomatic transdural herniation and strangulation of the cauda equinae following resection of a Myxopapillary ependymoma. He underwent successful operative re-exploration, un-tethering of the cauda equinae and re-closure of the dural defect with resolution of his symptoms. We discuss the clinical features, operative technical factors involved and the essential importance of neuroimaging with critical analysis of the imaging findings and correlation of the clinical symptoms, when such a diagnosis is being considered.

Since 1998, the Florida Department of Health (FDOH) has operated the Florida Birth Defects Registry (FBDR), a statewide, population-based, passive surveillance system. Cases are identified by collecting information from extant data sources including the statewide hospital inpatient and ambulatory discharge data sets. Additional data sources include administrative, clinical, and service-related information from the FDOH's Children's Medical Services program for children with special health care needs. Like many state birth defects programs, the FBDR faces diminishing funding and resources that may restrict the registry to hospital discharge data. We conducted an evaluation to quantify the potential under-ascertainment to the FBDR resulting from loss of specific data sources, and to determine if there would be a disproportionate loss of cases by sociodemographic and perinatal characteristics. Analyses involved a series of retrospective reconstructions of the FBDR for 1998-2007 to assess the number of cases that would have been ascertained and reported based on the hypothetical loss of 1 or more of the FBDR source data sets. The reconstructed number of cases identified for each defect category was then compared to the current FBDR (constructed using all 5 source data sets) to determine the proportion of cases that would have been missed if the data sources in question were eliminated. These scenarios were constructed overall and by selected characteristics to identify potential disparities in the proportion of cases missed. The inpatient hospital discharge data set was the primary data source for identification of birth defects in the FBDR. Elimination of this single data source would cause the FBDR to miss nearly three fourths of infants diagnosed with 1 or more of the birth defects under study. Our evaluation revealed that an FBDR constructed on hospital discharge data alone would disproportionately miss more cases born to subgroups of women, including non-Hispanic blacks, Hispanics, and those born outside the US. Despite funding and resource constraints, the FBDR continues efforts to identify data sources that may contribute to completeness of case ascertainment in an effort to serve the needs of the Florida maternal and child health population.

Background: Completeness of case ascertainment is a concern for all birth defects registries and generally requires a multisource approach. Using infant death certificates as one case ascertainment source may identify cases of birth defects that would have otherwise been missed. We sought to examine the utility of adding infant death certificates to the Florida Birth Defect Registry's (FBDR) case ascertainment methods and to determine what factors are associated with the registry's failure to capture infants that die from birth defects., Methods: FBDR cases from 1999 to 2006 were matched to a statewide linked birth-infant death file. Descriptive statistics were used to assess the FBDR's ability to capture infants with a birth defect-related cause of death (COD) and identify conditions most commonly missed. Factors associated with the FBDR's failure to capture an infant who died from a birth defect during the first year of life were identified with logistic regression models., Results: There were 2558 (21.1%) infant deaths with birth defects listed as the underlying or an associated COD, of which the FBDR captured 73.3%. Most often missed defects included malformation of the coronary vessels, lung hypoplasia/dysplasia, anencephaly, and unspecified congenital malformations. Logistic regression identified gestational age/birth weight, age at death, autopsy decision, plurality, adequacy of prenatal care, and maternal nativity as factors associated with the FBDR's failure to capture an infant with a birth defect-related COD., Conclusions: Although the overall potential contribution of infant death certificates to the FBDR is small, this source contributes to the prevalence of specific defects., (Copyright © 2010 Wiley-Liss, Inc.)

The superior hypogastric plexus (SHP) is the part of the autonomic nervous system, which is responsible for the sympathetic innervation of pelvic organs and extrapelvic genitals in humans of both sexes. The SHP also functions as the anatomic pathway for the major part of visceral sensitive fibers originating from pelvic viscera. In this study, the morphology of the SHP was analyzed through anatomical dissections performed both in human adult and fetal cadavers. A computerized morphometrical investigation of the SHP was also performed and the resulting quantitative data statistically assessed. The comparison between fetal and adult SHP revealed that in the male group there was a developmental increase of six times (in height) and of about five times (in width); while in the female group, there was a developmental increase of 3.5 times both in height and width values. In addition, the distance from the superior border of the SHP to the bifurcation of the common iliac arteries presented a developmental increase of about six times in the male group, and about four times in the female group. We propose an original morphological classification with six types, based upon the anatomical arrangement of the nervous fibers in this autonomic plexus.

Lennox-Gastaut Syndrome is a severe childhood epilepsy syndrome characterised by the diagnostic triad of a slow spike and wave pattern on electroencephalogram, multiple seizure types and developmental delay. Idiopathic intracranial hypertension is a syndrome characterised by raised cerebrospinal fluid pressure in the absence of an intracranial mass lesion or ventricular dilatation and often headache. We present the first reported case of Lennox-Gastaut Syndrome associated with symptomatic idiopathic intracranial hypertension in a 15 year old male, requiring cerebrospinal fluid diversion by means of ventriculoperitoneal shunting., (Copyright 2010. Published by Elsevier Ltd.)

The value of any public health surveillance program is derived from the ways in which data are managed and used to improve the public's health. Although birth defects surveillance programs vary in their case volume, budgets, staff, and objectives, the capacity to operate efficiently and maximize resources remains critical to long-term survival. The development of a fully-integrated relational database management system (DBMS) can enrich a surveillance program's data and improve efficiency. To build upon the Florida Birth Defects Registry--a statewide registry relying solely on linkage of administrative datasets and unconfirmed diagnosis codes-the Florida Department of Health provided funding to the University of South Florida to develop and pilot an enhanced surveillance system in targeted areas with a more comprehensive approach to case identification and diagnosis confirmation. To manage operational and administrative complexities, a DBMS was developed, capable of managing transmission of project data from multiple sources, tracking abstractor time during record reviews, offering tools for defect coding and case classification, and providing reports to DBMS users. Since its inception, the DBMS has been used as part of our surveillance projects to guide the receipt of over 200 case lists and review of 12,924 fetuses and infants (with associated maternal records) suspected of having selected birth defects in over 90 birthing and transfer facilities in Florida. The DBMS has provided both anticipated and unexpected benefits. Automation of the processes for managing incoming case lists has reduced clerical workload considerably, while improving accuracy of working lists for field abstraction. Data quality has improved through more effective use of internal edits and comparisons with values for other data elements, while simultaneously increasing abstractor efficiency in completion of case abstraction. We anticipate continual enhancement to the DBMS in the future. While we have focused on enhancing the capacity of our DBMS for birth defects surveillance, many of the tools and approaches we have developed translate directly to other public health and clinical registries.

Systemic lupus erythematosus (SLE) is a clinically heterogeneous disease translating the different genetic and environmental factors involved. Polymorphisms at several loci, including the major histocompatibility complex (MHC), have been associated worldwide with SLE, although inconsistencies exist among these studies mainly due to genetic heterogeneity between populations and sample characteristics. The aim of the present study was to investigate in Portuguese SLE the association of HLA-DRB1 alleles with clinical patterns of the disease and severity. Two hundred eighteen Portuguese patients with SLE--42% of whom had kidney involvement--were studied for HLA-DRB1. Clinical and laboratory manifestations were correlated with HLA allele frequencies. HLA-DRB1 * 03 allele frequency was significantly higher in SLE patients--as a whole and as either with or without renal involvement--compared to controls, while HLA-DRB1 * 09 and DRB1 * 13 allele frequencies were decreased. Regarding the relationship with the presence or absence of specific clinical manifestations, it was only found that HLA-DRB1 * 08 allele frequency was increased in patients with neurological involvement. No association with the presence or absence of anti-dsDNA, anti-sm or antiphospholipid antibodies, or antiphospholipid syndrome, was observed. These results were reproducible when analysis was repeated only with patients with more than 5 years of evolution. As in other populations HLA-DRB1 * 03 is a susceptibility allele in Portuguese SLE patients, while HLA-DRB1 * 09 and DRB1 * 13 alleles may be protective alleles, not only for the disease, but for the development of nephritis. No correlations with the different clinical manifestations were found, except with the neurological system.

The objective of this paper is to characterise the frequency of different surgical techniques for targeting the lateral ventricle in shunt surgery and the attitudes of Australasian neurosurgeons and advanced neurosurgical trainees to stereotactic adjuncts. Secondarily, we aim to learn from and collate the practical experiences of neurosurgeons for those attempting to improve their operative success. A survey of all practising and training members of the Neurosurgical Society of Australasia (NSA) was conducted. One hundred and eleven surveys were completed generating an overall response rate of 57%. Of those 108 performing shunt surgery, 10 (9%) preferred a frontal approach and 70 (65%) a posterior approach to the frontal horn. Twenty-seven neurosurgeons (25%) preferred the posterior approach to the atrium or body of the lateral ventricle. A wide range of burr hole sites and targeting landmarks were described and are discussed. There was no consistent pattern for neurosurgeons changing their preferred approach during their careers. Seventy-five per cent of respondents make adjustments to measurements for children by a wide range of methods. Frameless or frame-based stereotaxy is used at times by about half of all neurosurgeons. Posterior approaches to the lateral ventricle using freehand techniques are preferred among NSA members and their trainees but there are a wide variety of landmarks used. Many of these techniques have been developed over years of operative experience and could be modelled with planning software to assess their theoretical merits. There is no evidence of the uptake of generic accuracy guides but there is evidence of significant exposure to frameless stereotactic techniques that may grow in popularity as the technology improves.

Objectives: We assessed the safety and efficacy of early administration of abciximab prior to percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) patients., Background: Research suggests that platelet glycoprotein IIb/IIIa receptor inhibitors, e.g. abciximab, may improve myocardial perfusion. In particular, early administration in the emergency department, prior to PCI, may result in more effective reperfusion., Methods: Eighty AMI patients with planned PCI were randomized in a double-blind fashion to receive a 0.25 mg/kg abciximab bolus either "early" in the emergency department or "late" in the catheterization laboratory after angiographic assessment. In total, 74 patients underwent PCI after diagnostic angiography, all of which then received an abciximab infusion of 0.125 microg/kg/min for 12 hr., Results: Prior to PCI, no significant differences were observed between the two groups regarding the angiographic endpoints or ST-segment resolution. After PCI, thrombolysis in MI (TIMI) frame count (TFC) was significantly improved in patients treated early rather than in those treated late (23 +/- 10 vs. 41 +/- 35; P = 0.02). Consistent trends, also favoring early treatment, were observed for TIMI flow grade 3 (TFG 3), corrected TFC (CTFC), and TIMI myocardial perfusion grade 3 (TMPG 3). Nine deaths (4 early, 5 late) and six significant bleeds (4 early, 2 late) were observed at 30 days after randomization., Conclusions: Early administration of abciximab is both feasible and safe in patients planned for primary PCI, increasing coronary flow and myocardial reperfusion after PCI, as demonstrated by significantly decreased TFC scores and trends toward improvements in TFG, CTFC, and TMPG.

Objective: To determine the effectiveness of using the ICD-9-CM procedure code 54.71 for case ascertainment of gastroschisis., Methods: Using procedure code 54.71, we queried a statewide hospital discharge database to identify all cases coded as undergoing surgical repair of gastroschisis. Each retrieved case was verified as having gastroschisis by review of the hospital record. All gastroschisis cases were then matched to the Florida Birth Defect Registry (FBDR) dataset. This registry uses a passive system of multiple data sources and employs the ICD-9-CM diagnostic code 756.79 to identify gastroschisis and other abdominal wall defects., Results: Of 93 cases identified by using code 54.71, 92 were confirmed by record review to have gastroschisis. The FBDR identified 87 of the 92 cases (95%). The FBDR missed three of the remaining five cases because of linkage difficulties between inconsistent data elements in the respective data files. The other two cases were not identified by the FBDR because the source database (AHCA discharge) truncates the entry of ICD-9-CM diagnostic codes when more than 10 of them are listed in the medical record., Conclusions: Use of the surgical procedure code was demonstrated to be superior to the diagnostic code as a method for identification of gastroschisis cases. The same approach may be useful in the detection of malformations other than gastroschisis.

Random amplified polymorphic DNA analysis was applied to DNAs extracted from Trichuris trichiura eggs recovered from human fecal samples. Four out of 6 primers tested displayed 18 distinct and well defined polymorphic patterns, ranging from 650 to 3200 base pairs. These results, upon retrieval and DNA sequencing of some of these bands from agarose gels, might help in establishing. T. trichiura specific genetic markers, not available yet, and an important step to design primers to be used in molecular diagnosis approaches.

Tissue pharmacokinetics of trovafloxacin, a new broad-spectrum fluoroquinolone antimicrobial agent, were measured by positron emission tomography (PET) with [18F]trovafloxacin in 16 healthy volunteers (12 men and 4 women). Each subject received a single oral dose of trovafloxacin (200 mg) daily beginning 5 to 8 days before the PET measurements. Approximately 2 h after the final oral dose, the subject was positioned in the gantry of the PET camera, and 1 h later 10 to 20 mCi of [18F]trovafloxacin was infused intravenously over 1 to 2 min. Serial PET images and blood samples were collected for 6 to 8 h, starting at the initiation of the infusion. Drug concentrations were expressed as the percentage of injected dose per gram, and absolute concentrations were estimated by assuming complete absorption of the final oral dose. In most tissues, there was rapid accumulation of the radiolabeled drug, with high levels achieved within 10 min after tracer infusion. Peak concentrations of more than five times the MIC at which 90% of the isolates are inhibited (MIC90) for most members of Enterobacteriaceae and anaerobes (>10-fold for most organisms) were achieved in virtually all tissues, and the concentrations remained above this level for more than 6 to 8 h. Particularly high peak concentrations (micrograms per gram; mean +/- standard error of the mean [SEM]) were achieved in the liver (35.06 +/- 5.89), pancreas (32.36 +/- 20. 18), kidney (27.20 +/- 10.68), lung (22.51 +/- 7.11), and spleen (21. 77 +/- 11.33). Plateau concentrations (measured at 2 to 8 h; micrograms per gram; mean +/- SEM) were 3.25 +/- 0.43 in the myocardium, 7.23 +/- 0.95 in the lung, 11.29 +/- 0.75 in the liver, 9.50 +/- 2.72 in the pancreas, 4.74 +/- 0.54 in the spleen, 1.32 +/- 0.09 in the bowel, 4.42 +/- 0.32 in the kidney, 1.51 +/- 0.15 in the bone, 2.46 +/- 0.17 in the muscle, 4.94 +/- 1.17 in the prostate, and 3.27 +/- 0.49 in the uterus. In the brain, the concentrations (peak, approximately 2.63 +/- 1.49 microg/g; plateau, approximately 0.91 +/- 0.15 microg/g) exceeded the MIC90s for such common causes of central nervous system infections as Streptococcus pneumoniae (MIC90, <0.2 microg/ml), Neisseria meningitidis (MIC90, <0.008 microg/ml), and Haemophilus influenzae (MIC90, <0.03 microg/ml). These PET results suggest that trovafloxacin will be useful in the treatment of a broad range of infections at diverse anatomic sites.

OBJECTIVE: To measure tissue pharmacokinetics of trovafloxacin (CP 99,219) in normal and infected animals by both direct tissue radioactivity measurements and positron emission tomography (PET). METHODS: Concentrations of [18F]trovafloxacin were measured in normal and infected rats (n=6/group), at 10, 30, 60, and 120 min after injection, by radioactivity measurements. In normal rabbits (n=4) and rabbits with Escherichia coli thigh infection (n=4), tissue concentrations of drug were measured over 2 h with PET. After acquiring the final images, the rabbits were killed and tissue concentrations measured with PET were compared to the results of direct tissue radioactivity measurements. RESULTS: In both species, there was rapid distribution of [18F] trovafloxacin in most peripheral organs. Peak concentrations of more than five times the MIC90 of most Enterobacteriaceae and anaerobes (>100-fold for most organisms) were achieved in all tissues and remained above this level for >2 h. Particularly high peak concentrations were achieved in the kidney (>75 micro g/g), liver (>100 micro g/g), blood (>40 micro g/g), and lung (>10 micro g/g). Even though the concentration of trovafloxacin in infected muscle was reduced (p<0.01), the peak concentration was still >4 micro g/g and tissue levels remained above 2 micro g/g for more than 2 h. Due to the lower concentrations that were achieved in the brain (peak approximately 5 micro g/g), it is expected that trovafloxacin will have limited central nervous system toxicity. CONCLUSION: PET with [18F]trovafloxacin is a useful technique for non-invasive measurements of tissue pharmacokinetics.

Objective: Thermal injury is associated with the development of encephalopathy. The mechanism(s) for the development of this condition have not been established. In the present study, the effects of thermal injury were determined on rat brain glucose utilization (Rg), using 2-[18F]fluoro-2-deoxy-D-glucose (18FDG)., Design: Four types of studies were performed. In one group of rats, the effect of thermal injury on total rat brain glucose utilization (Rg) was determined at 6 hours, 24 hours, and 3 weeks after injury. The brains of thermally injured rats were also assayed for hexokinase and glucose-6-phosphatase activities, since these enzyme activities are responsible for the phosphorylation and dephosphorylation of the 18FDG. We also measured total body oxygen consumption in the thermally injured rats. We wanted to compare the changes produced by thermal injury on rat brain glucose utilization (Rg) with the effects produced by compounds known to modify energy metabolism and/or rat brain glucose utilization (Rg). For that reason, in a second group of rats, an inflammatory state was produced by lipopolysaccharide injection, and rat brain glucose utilization (Rg) was determined. In the third group of rats, overall metabolism in rats was reduced by pentobarbital injection, followed by hypothermia, and rat brain glucose utilization (Rg) was determined. In the fourth group of rats, overall metabolism in rats was stimulated by 2,4-dinitrophenol injection, and rat brain glucose utilization (Rg) was determined., Materials and Methods: Glucose utilization (Rg) by the brains of these treated rats was determined using 18FDG. Oxygen consumption in vivo, as well as glucose-6-phosphatase and hexokinase activity in vitro, were measured by standard procedures., Measurements and Main Results: Glucose utilization (Rg) by rat brain was significantly reduced (p < 0.01) at 6 and 24 hours after injury, but returned to normal values 3 weeks after injury. These reductions were associated with decreases in rat brain hexokinase activity, increases in rat brain glucose-6-phosphatase activity, and decreased oxygen consumption by rats in vivo. Pentobarbital injection followed by hypothermia reduced rat brain glucose utilization (Rg) (p < 0.01), while 2,4-dinitrophenol treatment elevated rat brain glucose utilization (Rg) (p < 0.01). In contrast, LPS treatment had no effect on rat brain glucose utilization (Rg)., Conclusions: These data indicate that thermal injury decreases glucose utilization (Rg) in rat brain during the hypometabolic phase. This effect can be explained, at least in part, by alterations in hexokinase and glucose-6-phosphatase activities, as well as reductions in oxygen consumption. Thus, the changes in brain glucose utilization (Rg) appear to be associated with the ebb phase of the thermal injury. The present results observed in burned rats may provide evidence to explain the encephalopathy observed in burned patients.

The pharmacokinetics of fleroxacin, a new broad-spectrum fluoroquinolone, were measured by positron emission tomography (PET) with [18F]fleroxacin in five patients with acute bacterial exacerbations of chronic bronchitis and in five patients with symptomatic, complicated urinary tract infection. Two studies were performed with each patient, one within 24 h of the initiation and one within 24 h of the completion of a 7-day course of fleroxacin, 400 mg/day. For each study, the patient received an infusion of that day's therapeutic dose of fleroxacin (400 mg) supplemented with approximately 740 MBq of [18F]fleroxacin, and serial PET images and blood samples were collected for 6 to 8 h starting at the initiation of the infusion. Between studies, the drug was administered orally. In all infected tissues, there was rapid accumulation of radiolabeled drug, with stable levels achieved within 1 h after completion of the infusion. In kidneys, accumulation was greater in the presence of active infection (P < 0.01), while in lungs, accumulation was lower (P < 0.02). Infection of the lung or urinary tract had no effect on drug delivery to uninvolved tissues. Also, there was no difference between the results obtained at the beginning and the end of therapy. Overall, peak concentrations of drug many times the MIC at which 90% of the infecting organisms are inhibited (MIC90) were achieved in the kidneys (> 30 micrograms/g), prostate glands (> 11 micrograms/g), and lungs (> 14 micrograms/g). Plateau concentrations (2 to 8 h; given as mean micrograms per gram +/- standard error of the mean) of drug in kidneys (15.11 +/- 0.55), prostate glands (5.08 +/- 0.19), and lungs (5.75 +/- 0.22) were also well above the MIC90 for most relevant pathogens. All patients had a good therapeutic response to fleroxacin.

Positron emission tomography (PET) with [18F]fleroxacin was used to study the pharmacokinetics of fleroxacin, a new broad-spectrum fluoroquinolone, in 12 healthy volunteers (9 men and 3 women). The subjects were infused with a standard therapeutic dose of fleroxacin (400 mg) supplemented with approximately 20 mCi of [18F]fleroxacin. Serial PET images were made and blood samples were collected for 8 h, starting at the initiation of the infusion. The subjects were then treated with unlabeled drug for 3 days (400 mg/day). On the fifth day, infusion of radiolabeled drug, PET imaging, and blood collection were repeated. In most organs, there was rapid accumulation of radiolabeled drug, with stable levels achieved within 1 h after completion of the infusion. Especially high peak concentrations (in micrograms per gram) were achieved in the kidney (> 34), liver (> 25), lung (> 20), myocardium (> 19), and spleen (> 18). Peak concentrations of drug more than two times the MIC for 90% of Enterobacteriaceae strains tested (> 10-fold for most organisms) were achieved in all tissues except the brain and remained above this level for more than 6 to 8 h. The plateau concentrations in tissues (2 to 8 h, in micrograms per gram +/- standard error of the mean) of drug were as follows: brain, 0.83 +/- 0.032; myocardium, 4.53 +/- 0.24; lung, 5.80 +/- 0.48; liver, 7.31 +/- 0.33; spleen, 6.00 +/- 0.47; bowel, 3.53 +/- 0.74; kidney, 8.85 +/- 0.64; bone, 2.87 +/- 0.29; muscle, 4.60 +/- 0.33; prostate, 4.65 +/- 0.48; uterus, 3.87 +/- 0.39; breast, 2.68 +/- 0.11; and blood, 2.35 +/- 0.09. Concentrations of fleroxacin in tissue were similar in males and females, before and after pretreatment with unlabeled drug.

The distribution of fluconazole in tissue of human volunteers was determined by positron emission tomographic scanning over a 2-h period following the infusion of a tracer dose of 18F-fluconazole (5 to 7 mCi) plus 400 mg of unlabeled drug (the standard daily dose of fluconazole). Previous studies have validated this approach for animals. From serial positron emission tomographic imaging and blood sampling, pharmacokinetics of fluconazole in tissue were determined. There was significant distribution of the radiolabeled drug in all organs studied, with nearly constant levels achieved by 1 h. Plateau concentrations of fluconazole in key organs (micrograms per gram) included the following: whole brain, 4.92 +/- 0.17; heart, 6.98 +/- 0.20; lung, 7.81 +/- 0.46; liver, 12.94 +/- 0.24; spleen, 22.96 +/- 2.5; kidney, 11.23 +/- 0.61; prostate, 8.24 +/- 0.58; and blood, 3.76 +/- 0.30. Since levels of fluconazole of > 6 micrograms/g are needed to treat infection with most strains of Candida and levels of > 10 micrograms/g are needed for Cryptococcus neoformans, Coccidioides immitis, and Histoplasma capsulatum, the following predictions can be made. The current standard dose of 400 mg/day should be more than adequate in the treatment of urinary tract and hepatosplenic candidiasis but problematic in the treatment of candidal osteomyelitis, even with the higher levels that develop after multiple doses. Similarly, higher doses should be considered, particularly in immunocompromised patients, with infection with C. neoformans, H. capsulatum, and C. immitis that involves the central nervous and musculoskeletal systems.

Our previous study with radioiodinated 1-methyl-1-(2-hydroxyethyl)-4- phenylpiperazinium derivatives indicated that these compounds localize selectively in the rat myocardium. Based upon these results, 1-[11C]methyl-1-alkyl-4-phenylpiperazinium cations were synthesized and evaluated for their potential as myocardial imaging agents. Biodistribution studies were performed in rats and imaging studies in normal dogs. The results indicate high concentrations of 3-4% ID/g in the rat heart at 5 min, comparable to those obtained with the radioiodinated analogs. Sequential imaging of the canine heart showed a similar pattern of uptake. The level of activity reached at 20 min was maintained over the 1-h time period. These results suggest that the phenylpiperazinium agents may have potential application as myocardial imaging agents.

A new method of tracing the disposition of fleroxacin was tested in infected and noninfected animals in an effort to develop a technique that might be applicable in humans. [18F]fleroxacin was synthesized and shown to be identical physically, chemically, and in its antimicrobial activity to the commercially produced product. Tracer amounts of [18F]fleroxacin were coinjected with a pharmacologic dose of unlabeled drug (10 mg/kg) into normal mice, rats with focal thigh infection due to Escherichia coli, and normal and infected rabbits. The rats and mice were killed at fixed time intervals after injection, and the concentration of drug was determined by radioactive counting in a well-type counter; the rabbits were studied both by this method and by positron emission tomographic (PET) imaging. These studies validated the reliability of the new approach and suggested that it could be applied safely to humans. In all three animal species studied, delivery of [18F]fleroxacin to most tissues was rapid, with the notable exception of the brain. Accumulation of drug in infected thigh muscle was similar to that in normal muscle. The concentrations of drug reached in various tissues suggest that fleroxacin will be particularly useful in the treatment of gastrointestinal, urinary tract, hepatobiliary, and skeletal infections and that it shows promise for the treatment of lung and soft tissue infection. The minimal concentrations of drug delivered to the brain should decrease the occurrence of central nervous system toxicity with this particular fluoroquinolone.