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Objective:Using newly harmonised individual-level data on health and socio-economic environments in Latin American cities (from the Salud Urbana en América Latina (SALURBAL) study), we assessed the association between obesity and education levels and explored potential effect modification of this association by city-level socio-economic development.Design:This cross-sectional study used survey data collected between 2002 and 2017. Absolute and relative educational inequalities in obesity (BMI ≥ 30 kg/m2, derived from measured weight and height) were calculated first. Then, a two-level mixed-effects logistic regression was run to test for effect modification of the education–obesity association by city-level socio-economic development. All analyses were stratified by sex.Setting:One hundred seventy-six Latin American cities within eight countries (Brazil, Chile, Colombia, Costa Rica, El Salvador, Guatemala, Mexico and Peru).Participants:53 186 adults aged >18 years old.Results:Among women, 25 % were living with obesity and obesity was negatively associated with educational level (higher education–lower obesity) and this pattern was consistent across city-level socio-economic development. Among men, 18 % were living with obesity and there was a positive association between education and obesity (higher education–higher obesity) for men living in cities with lower levels of development, whereas for those living in cities with higher levels of development, the pattern was inverted and university education was protective of obesity.Conclusions:Among women, education was protective of obesity regardless, whereas among men, it was only protective in cities with higher levels of development. These divergent results suggest the need for sex- and city-specific interventions to reduce obesity prevalence and inequalities.

During the 60 years since the first scientific reports about a relation between aflatoxin exposure and adverse health consequences, both in animals and humans, there has been a remarkable number of basic, clinical and population science studies characterising the impact of this mycotoxin on diseases such as liver cancer. Many of these human investigations to date have focused on populations residing in Asia and Africa due to the high incidence of liver cancer and high exposures to aflatoxin. These studies formed the basis for the International Agency for Research on Cancer to classify the aflatoxins as Group 1 known human carcinogens. In addition, aflatoxin contamination levels have been used in international commodity trade to set the price of various staples such as maize and groundnuts. While there have been many case-control and prospective cohort studies of liver cancer risk over the years there have been remarkably few investigations focused on liver cancer in Latin America. Our interdisciplinary and multiple institutional collaborative has been developing a long-term strategy to characterise the role of aflatoxin and other mycotoxins as health risk factors in Guatemala and neighbouring countries. This paper summarises a number of the investigations to date and provides a roadmap of our strategies for the near term to discern the emergent aetiology of liver cancer in this region. With these data in hand public health-based prevention strategies could be strategically implemented and conducted to lower the impact of these mycotoxins on human health.

Clinicians began describing chronic postviral conditions such as “post-influenzal hysteria” as early as the 1890s.[1][1] But their accounts were often vague and plagued by questionable generalizations. It was the massive expansion of public health systems around the time of the 1918 flu pandemic

Objective:Food environments may be contributing to the rapid increase in obesity occurring in most Latin American (LA) countries. The present study reviews literature from LA that (i) describes the food environment and policies targeting the food environment (FEP); and (ii) analytic studies that investigate associations between the FEP and dietary behaviours, overweight/obesity and obesity related chronic diseases. We focus on six dimensions of the FEP: food retail, provision, labelling, marketing, price and composition.Design:Systematic literature review. Three databases (Web of Science, SciELO, LILACS) were searched, from 1 January 1999 up to July 2017. Two authors independently selected the studies. A narrative synthesis was used to summarize, integrate and interpret findings.Setting:Studies conducted in LA countries.Participants:The search yielded 2695 articles of which eighty-four met inclusion criteria.Results:Most studies were descriptive and came from Brazil (61 %), followed by Mexico (18 %) and Guatemala (6 %). Studies were focused primarily on retail/provision (n 27), marketing (n 16) and labelling (n 15). Consistent associations between availability of fruit and vegetable markets and higher consumption of fruits and vegetables were found in cross-sectional studies. Health claims in food packaging were prevalent and mostly misleading. There was widespread use of marketing strategies for unhealthy foods aimed at children. Food prices were lower for processed relative to fresh foods. Some studies documented high sodium in industrially processed foods.Conclusions:Gaps in knowledge remain regarding policy evaluations, longitudinal food retail studies, impacts of food price on diet and effects of digital marketing on diet/health.

Background There are no data on the prevalence of non-alcoholic fatty liver disease (NAFLD) in general population samples in Guatemala or in other Central American countries. The prevalence and distribution of NAFLD and its associated risk factors were evaluated in a population-based sample of adults in Guatemala. Methods Cross-sectional study of 411 men and women 40 years of age or older residing in urban and rural areas of Guatemala. Metabolic outcomes included obesity, central obesity, hypercholesterolemia, diabetes, and metabolic syndrome (MetS). Liver disease outcomes included elevated liver enzymes, elevated Fatty Liver Index (FLI), and elevated FIB-4 score. Results The overall prevalence of obesity, central obesity, diabetes, and MetS were 30.9, 74.3, 21.6, and 64.2%, respectively. The fully-adjusted prevalence ratios (95% CI) for obesity, central obesity, diabetes, and MetS comparing women to men were 2.83 (1.86–4.30), 1.72 (1.46–2.02), 1.18 (1.03–1.34), and 1.87 (1.53–2.29), respectively. The overall prevalence of elevated liver enzymes (ALT or AST), elevated FLI, and elevated FIB-4 scores were 38.4, 60.1, and 4.1%, respectively. The fully-adjusted prevalence ratios (95% CI) for elevated liver enzymes (either ALT or AST) and elevated FLI score comparing women to men were 2.99 (1.84–4.86) and 1.47 (1.18–1.84), respectively. Conclusions The prevalence of metabolic abnormalities and liver outcomes in this general population study was very high. The prevalence of metabolic and liver abnormalities was particularly high among women, an observation that could explain the atypical 1:1 male to female ratio of liver cancer in Guatemala.

Background: Severe injury to the knee joint often results in accelerated posttraumatic osteoarthritis (PTOA). In an ovine knee injury model, altered kinematics and degradation of the cartilage have been observed at 20 and 40 weeks after partial anterior cruciate ligament (ACL) transection (p-ACL Tx) surgery. However, changes to the integrity of the remaining intact intra-articular ligaments (posterolateral [PL] band and posterior cruciate ligament [PCL]) as well as the subchondral bone after anteromedial (AM) band Tx remain to be characterized. Purpose: (1) To investigate histological alterations to the remaining intact intra-articular ligaments, the synovium, and the infrapatellar fat pad (IPFP) and (2) to quantify subchondral bone changes at the contact surfaces of the proximal tibia at 20 and 40 weeks after AM band Tx. Study Design: Descriptive laboratory study. Methods: Mature female Suffolk cross sheep were allocated into 3 groups: nonoperative controls (n = 6), 20 weeks after partial ACL transection (p-ACL Tx; n = 5), and 40 weeks after p-ACL Tx (n = 6). Ligament, synovium, and IPFP sections were stained and graded. Tibial subchondral bone microarchitecture was assessed using high-resolution peripheral quantitative computed tomography. Results: p-ACL Tx of the AM band led to significant change in histological scores of the PL band and the PCL at 20 weeks after p-ACL Tx ( P = .031 and P = .033, respectively) and 40 weeks after p-ACL Tx ( P = .011 and P = .029) as compared with nonoperative controls. Alterations in inflammatory cells and collagen fiber orientation contributed to the greatest extent of the combined histological score in the PL band and PCL. p-ACL Tx did not lead to chronic activation of the synovium or IPFP. Trabecular bone mineral density was strongly inversely correlated with combined gross morphological damage in the top and middle layers of the subchondral bone in the lateral tibial plateau for animals at 40 weeks after p-ACL Tx. Conclusion: p-ACL Tx influences the integrity (biology and structure) of remaining intact intra-articular ligaments and bone microarchitecture in a partial knee injury ovine model. Clinical Relevance: p-ACL Tx leads to alterations in structural integrity of the remaining intact ligaments and degenerative changes in the trabecular bone mineral density, which may be detrimental to the injured athlete’s knee joint in the long term.

International audience; Rho-associated kinase (ROCK) activation was shown to contribute to microvascular closure, retinal hypoxia, and to retinal pigment epithelium (RPE) barrier disruption in a rat model of diabetic retinopathy. Fasudil, a clinically approved ROCK inhibitor, improved retinal perfusion and reduced edema in this model, indicating that ROCK inhibition could be a promising new therapeutic approach for the treatment of diabetic retinopathy. However, due to its short intravitreal half-life, fasudil is not suitable for long-term treatment. In this study, we evaluated a very potent ROCK1/2 inhibitor (BIRKI) in a depot formulation administered as a single intravitreal injection providing a slow release for at least four weeks. Following BIRKI intravitreal injection in old Goto-Kakizaki (GK) type 2 diabetic rats, we observed a significant reduction in ROCK1 activity in the retinal pigment epithelium/choroid complex after 8 days and relocation of ROCK1 to the cytoplasm and nucleus in retinal pigment epithelium cells after 28 days. The chronic ROCK inhibition by the BIRKI depot formulation restored retinal pigment epithelial cell morphology and distribution, favored retinal capillaries dilation, and reduced hypoxia and inner blood barrier leakage observed in the diabetic retina. No functional or morphological negative effects were observed, indicating suitable tolerability of BIRKI after intravitreous injection. In conclusion, our data suggest that sustained ROCK inhibition, provided by BIRKI slow-release formulation, could be a valuable treatment option for diabetic retinopathy, especially with regard to the improvement of retinal vascular infusion and protection of the outer retinal barrier.

ObjectiveIn Guatemala, cirrhosis is among the 10 leading causes of death, and mortality rates have increased lately. The reasons for this heavy burden of disease are not clear as the prevalence of prominent risk factors, such as hepatitis B virus, hepatitis C virus and heavy alcohol consumption, appears to be low. Aflatoxin B1 (AFB1) exposure, however, appears to be high, and thus could be associated with the high burden of cirrhosis. Whether AFB1 increases the risk of cirrhosis in the absence of viral infection, however, is not clear.DesignCirrhosis cases (n=100) from two major referral hospitals in Guatemala City were compared with controls (n=200) from a cross-sectional study. Logistic regression was used to estimate the ORs and 95% CIs of cirrhosis and quintiles of AFB1 in crude and adjusted models. A sex-stratified analysis was also conducted.ResultsThe median AFB1 level was significantly higher among the cases (11.4 pg/mg) than controls (5.11 pg/mg). In logistic regression analyses, higher levels of AFB1 was associated with cirrhosis (quintile 5 vs quintile 1, OR: 11.55; 95% CI 4.05 to 32.89). No attenuation was observed with adjustment by sex, ethnicity, hepatitis B virus status, and heavy alcohol consumption. A significantly increasing trend in association was observed in both models (p trend 1 association was more prominent among men.ConclusionsThe current study found a significant positive association between AFB1 exposure and cirrhosis. Mitigation of AFB1 exposure and a better understanding of additional risk factors may be important to reduce the burden of cirrhosis in Guatemala.

Nutrition in pregnancy and early childhood affects later blood pressure and precursors of atherosclerosis, but its influence on arterial stiffness is unexplored. This study determines whether exposure to improved nutrition during early life influences Augmentation index (AI) and pulse wave velocity (PWV) in mid-adulthood. We included 1221 adults (37-54y) who participated in a cluster-randomized nutritional supplementation trial of a protein-energy beverage (Atole), conducted between 1969-1977 in Guatemala. The comparison group received Fresco, a low-calorie protein-free beverage. In 2015-17, we measured anthropometry (weight, height, and waist-to-height ratio); AI and PWV (using carotid-femoral tonometry); blood pressure; fasting plasma glucose and serum lipids; and sociodemographic characteristics. Based on patterns of exposure, we characterized participants as fully, partially or unexposed to the intervention from conception to their second birthday (the 'first 1000 days'). We fit pooled and sex-specific models using intention-to-treat, difference-in-difference regression analysis to test whether exposure to the supplement in the first 1000 days was associated with AI and PWV in adulthood adjusting for basal and current sociodemographic variables and current life-style and cardio-metabolic risk factors. Prevalence of obesity in men and women was 39.6% and 19.6%, and prevalence of hypertension was 44.0% and 36.0%, respectively. Women had higher AI (34.4±9.6%) compared to men (23.0± 9.8%), but had similar PWV (7.60±1.13 m/s and 7.60±1.31, respectively). AI did not differ significantly across intervention groups. PWV was lower in individuals with full exposure to the supplement during the first 1000 days (-0.39m/s, 95% CI -0.87, 0.09; p = 0.1) compared to unexposed individuals. This difference was similar after adjusting for cardio-metabolic risk factors (-0.45m/s; 95%C-0.93, 0.01; p = 0.06). Exposure to improved nutrition during the first 1000 days was marginally associated with lower PWV, but not with AI.

SUMMARY We present a technique of fixation of trimalleolar fractures with additional fracture of the anterior tibial tubercle ("quadrimalleolar") or anterior fibular rim ("quadrimalleolar equivalent"). Twenty-four patients with a mean age of 60 years were treated with open reduction and internal fixation of all 4 malleoli. There were 17 quadrimalleolar and 6 quadrimalleolar equivalent fractures. One patient had both anterior tibial and fibular avulsion fracture in addition to a trimalleolar ankle fracture. Surgical approaches and internal fixation were tailored individually. Twenty patients were operated in the prone position with direct fixation of the posterior malleolus and 4 patients in the supine position with anterior to posterior screw fixation of the posterior malleolus. After fixation of al 4 malleoli, only 1 patient (4%) required a syndesmotic screw for residual syndesmotic instability on intraoperative testing. There were no infections and no wound healing problems. All patients went on to solid union. Nineteen patients (79%) were followed for a mean of 77 months (range, 15-156 months). The Foot Function Index averaged 15 (range, 50 to 0), the Olerud and Molander Score averaged 79 (range, 45-100), and the American Orthopaedic Foot and Ankle Society Ankle and Hindfoot Scale averaged 87 (range, 39-100). Fixation of the anterior and posterior tibial fragments increases syndesmotic stability by providing a bone-to-bone fixation. Anatomic reduction of the anterior and posterior tibial rim restores the physiological shape of the tibial incisura and therefore facilitates fibular reduction.

Background Previous studies have suggested an association between Helicobacter pylori (H pylori) and nonalcoholic fatty liver disease (NAFLD). The aim of the current study was to examine the association in Guatemala, a region with elevated prevalences of both H pylori and NAFLD. Associations between H pylori and other metabolic conditions were also examined, as were associations between H hepaticus and H bilis and the metabolic conditions. Materials & methods The analysis included 424 participants from a cross-sectional study in Guatemala. H pylori seropositivity was defined as positivity for ≥ 4 antigens. Seropositivities for H bilis and H hepaticus were defined as positivity for ≥ 2 antigens. NAFLD was estimated using the Fatty Liver Index and the Hepatic Steatosis Index. Other conditions examined were obesity, central obesity, hypercholesterolemia, low HDL, diabetes and metabolic syndrome (MetSyn). Prevalence odds ratios (POR) and 95% confidence intervals (CIs) were estimated. Results No overall associations between H pylori, H hepaticus, or H bilis and NAFLD or related metabolic conditions were found. Seropositivity for H pylori antigens CagA and VacA and H hepaticus antigen HH0713 was each significantly associated with NAFLD, however. In addition, associations were observed between the H pylori antigens HyuA, HP1564, and UreA and specified metabolic conditions. Conclusions While no overall associations between H pylori or Helicobacter species with NAFLD or related conditions were observed, some selected Helicobacter spp. antigens were associated with NAFLD. Further research is warranted to examine whether H. species are associated with any metabolic condition.

Background: There has been increased interest in the hypothesis that undernutrition in early life predisposes to cardiometabolic disease risk in adulthood. The Institute of Nutrition of Central America and Panama Longitudinal Study is able to address one critical aspect of this field, specifically whether improvements in nutrition can prevent this increased risk. Objective: To describe the main findings on obesity and body composition across 5 waves of field work (1988-1989, 1991-1994, 1998-1999, 2002-2004, and 2015-2017) and on cardiometabolic health across 3 waves (1998-1999, 2002-2004, and 2015-2017). Results: Body weight and body fat increased considerably in adulthood, especially among women with sedentary occupations. Adiposity and weight in adulthood were strongly predicted by weight gain after the first 1000 days of life. On the other hand, exposure to improved nutrition in early life reduced diabetes risk by approximately 50% but increased the risk of overweight and obesity. Conclusions: Future research will aid in clarifying the underlying mechanisms that drive the opposite associations among diabetes and obesity with early-life nutrition.

The industry uses nutrition and health claims, premium offers, and promotional characters as marketing strategies (MS). The inclusion of these MS on ultra-processed products may influence child and adolescent purchase behavior. This study determined the proportion of foods carrying claims and marketing strategies, also the proportion of products with critical nutrients declaration, and nutritional profile differences between products that carry or not claims and MS on the front-of-package (FoP) of ultra-processed food products sold in Costa Rica. Data were obtained from 2423 photographs of seven food groups consumed as snacks that were sold in one of the most widespread and popular hypermarket chains in Costa Rica in 2015. Ten percent of products lacked a nutrition facts panel. Sodium was the least reported critical nutrient. Energy and critical nutrients were significantly highest in products that did not include any nutrition or health claim and in products that included at least one MS. Forty-four percent and 10% of all products displayed at least one nutrition or at least one health claim, respectively, and 23% displayed at least one MS. In conclusion, regulations are needed to restrict claims and marketing on ultra-processed food packages to generate healthier food environments and contribute to the prevention of childhood and adolescent obesity in Costa Rica.

Objective:To analyse disparities of malnutrition in all its forms by socio-economic indicators in children aged Design:We defined wasting/underweight, stunting/short stature, overweight and obesity following the WHO criteria for children aged Setting:Guatemalan 2014–2015 National Maternal and Child Health Survey.Participants:Children aged n 11 962), adolescent girls aged 15–19 years (n 1086) and WRA aged 20–49 years (n 11 354).Results:Stunting/short stature prevalence among children, adolescents and WRA was 2·8, 2·1 and 2·0 times higher in the poorest compared with the richest; 2·9, 2·9 and 2·1 times higher in the lower educational level than in the highest; and 1·7, 1·7 and 1·6 times higher in the indigenous than in the non-indigenous population. In contrast, overweight/obesity prevalence among children, adolescents and WRA was 1·6, 2·1 and 1·8 times higher in the richest compared with the poorest; 1·6, 1·3 and 1·3 times higher in the higher educational level than in the lowest; and 1·3, 1·7 and 1·3 times higher in the non-indigenous than in the indigenous population.Conclusions:Stunting/short stature is more prevalent among low-income, low-education and indigenous populations in all age groups. In contrast, overweight/obesity is more prevalent in high-income, high-education and non-indigenous populations in all age groups. These outcomes demonstrate socio-economic and ethnic disparities for malnutrition in all its forms.

Anterior cruciate ligament (ACL) tears are common sports-related knee injuries that increase the risk of developing post-traumatic osteoarthritis. ACL tears are rarely an isolated injury but are often associated with traumatic bone marrow lesions (BMLs). While early loss of bone mass following the ACL injury has been previously described, to date, microarchitectural information has not been reported due to the limited resolution of clinical imaging systems. In this study, we provide the first evidence of detailed bone mass and microarchitectural changes in the first 10 months following an acute ACL tear, and localized to traumatic BMLs. Fifteen participants with an acute unilateral ACL tear were assessed at four-time points using dual-energy X-ray absorptiometry and high-resolution peripheral quantitative computed tomography, and traumatic BMLs were identified with magnetic resonance imaging. Loss of bone mass was localized to the injured knee (-4.6% to -15.8%, depending on bone and depth) and was accelerated immediately following the injury before suggesting a recovery phase. This loss of bone was accelerated even greater in traumatic BMLs (-18.2% to -20.6%, depending on bone). Bone loss was accompanied by microstructural degeneration of trabecular bone. For example, in the lateral femur of the injured knee, the subchondral bone plate decreased in thickness (-9.0%). This study confirmed loss of bone mass in the months following ACL tears and described the underlying bone microstructural changes. The presented bone changes were accelerated in regions of traumatic BMLs. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2325-2336, 2019.

Anterior cruciate ligament (ACL) tears increase the risk of developing knee osteoarthritis. This risk increases further with concurrent meniscus injury. The role of bone changes during knee osteoarthritis development are not well-understood, but may be important to its etiology.To explore the effects of ACL tears on bone mineral density (BMD) and bone microarchitecture at five years post-op and their relationship to meniscal pathology, using high-resolution peripheral quantitative computed tomography (HR-pQCT).Twenty-eight participants with unilateral ACL reconstructions five years prior and no evidence of clinical or radiographic osteoarthritis were recruited. All participants represented one of three meniscus statuses: meniscus intact, meniscus repair, or meniscectomy. BMD and bone microarchitecture of the subchondral bone plate and adjacent trabecular bone were assessed using HR-pQCT, and percent-differences between the injured and contralateral knee were determined.Subchondral bone plate thickness in the lateral femoral condyle was higher in the reconstructed knee (9.0%, p = 0.002), driven by the meniscus repair and meniscectomy groups (15.2% to 15.4%, p 0.05). Trabecular BMD was lower in the reconstructed knee in the medial femoral condyle (-4.8% to -7.6%, p 0.05), driven by all meniscus statuses. In the lateral compartments, few differences in trabecular bone were found. However, accounting for meniscus status, the meniscus intact group had lower trabecular BMD throughout both femur and tibia.Five years post-op, reconstructed knees demonstrated detectable differences in BMD and bone microarchitecture, despite having normal radiographs. Meniscus damage affected primarily the lateral compartment, warranting further investigation to determine if these changes relate to osteoarthritis development.

Anterior cruciate ligament (ACL) tears are a common sports-related knee injury that increases the risk of developing post-traumatic osteoarthritis (OA). During OA progression bone microarchitecture changes in the affected knee, however, little is known about bone microarchitecture in knees with early stage OA. The purpose of this study is to investigate in a cohort of females predisposed to develop OA how bone microarchitecture in ACL reconstructed knees differs from uninjured contralateral knees as well as healthy control knees and how this relates to early changes in OA. Bone microarchitecture was directly assessed in ACL reconstructed knees of injured female participants (n=15) with a median age of 25.4years (age range: 22.5-28.5) and compared to their uninjured contralateral knees, as well as to a healthy age-matched female control sample (n=14) with a median age of 25.2years (age range: 22.2-27.1). ACL reconstructed knees had lower trabecular bone mineral density (compared to contralateral: -7.7% to -10.4%, p

Summary Objective Anterior cruciate ligament (ACL) tears increase early onset osteoarthritis (OA) risk leading to cartilage and bone degradation. While the contribution of bone in OA development is unclear, evidence suggests that bone changes accompany cartilage degradation. This study aims to assess if regions with differences in subchondral bone plate thickness have differences in cartilage thickness when comparing ACL reconstructed (ACLR) knees of women ≥5 years post-injury to contralateral and controls with uninjured knees. Design Magnetic resonance imaging (MRI) assessed cartilage and high resolution peripheral quantitative computed tomography (HR-pQCT) assessed subchondral bone in both knees. Multimodal 3D image registration aligned anatomy. Maps of the spatial distribution of thickness on the articular surfaces were generated to compare women with ACL reconstructions to contralateral and controls with uninjured knees. Results ACLR knees had a thicker subchondral bone plate in the posterior and central lateral femur compared to contralateral knees (10.4% and 4.2% thicker, P = 0.032 and 0.032, W = 108 and 107, respectively) and in the posterior lateral femur compared to control knees (17.1% thicker, P = 0.014, W = 177). Cartilage differences were not detected ( P > 0.05) in these regions. Conclusions This study demonstrates that subchondral bone plate thickness differences are prominent following knee injury, as measured by HR-pQCT, but no statistically significant differences in cartilage morphology, measured by MRI, were found between ACLR knees compared to contralateral and control knees. These data provide novel insight into post-traumatic knee injuries that may be signs of early OA pathogenesis.

Background: As the prevalence of obesity increases in developingcountries, the double burden of malnutrition (DBM) has becomea public health problem, particularly in countries such as Guatemalawith a high concentration of indigenous communities where theprevalence of stunting remains high.Objective: The aim was to describe and analyze the prevalence ofDBM over time (1998–2008) in indigenous and nonindigenousGuatemalan populations.Design: We used 3 National Maternal and Child Health Surveysconducted in Guatemala between 1998 and 2008 that include an-thropometric data from children aged 0–60 mo and women of re-productive age (15–49 y). We assessed the prevalence of childhoodstunting and both child and adult female overweight and obesitybetween 1998 and 2008. For the year 2008, we assessed the prev-alence of DBM at the household (a stunted child and an overweightmother) and individual (stunting/short stature and overweight oranemia and overweight in the same individual) levels and comparedthe expected and observed prevalence rates to test if the coexistenceof the DBM conditions corresponded to expected values.Results: Between 1998 and 2008, the prevalence of childhoodstunting decreased in both indigenous and nonindigenous popula-tions, whereas overweight and obesity in women increased faster inindigenous populations than in nonindigenous populations (0.91%compared with 0.38%/y; P-trend , 0.01). In 2008, the prevalenceof stunted children was 28.8 percentage points higher and of over-weight women 4.6 percentage points lower in indigenous comparedwith nonindigenous populations (63.7% compared with 34.9% and46.7% compared with 51.3%, respectively). DBM at the householdand individual levels was higher in indigenous populations and washigher in geographic areas in which most of the population wasindigenous, where there was also a greater prevalence of stuntingand DBM at the individual level, both in women and children.Conclusions: In Guatemala, DBM is more prevalent in indigenousthan in nonindigenous populations at the household and individuallevels. To enhance effectiveness, current strategies of national policiesand programs should consider DBM and focus on indigenous popula-tions. Am J Clin Nutr doi: 10.3945/ajcn.114.083857.Keywords double burden, Guatemala, malnutrition, indigenous, obe-sity, stunting, anemiaINTRODUCTIONApproximately half (42%) of the Guatemalan population isself-identified as indigenous, and .75% of indigenous in-dividuals live in poverty (1). The double burden of malnutrition(DBM)

BACKGROUND In Mexico, stunting and anemia have declined but are still high in some regions and subpopulations, whereas overweight and obesity have increased at alarming rates in all age and socioeconomic groups. OBJECTIVE The objective was to describe the coexistence of stunting, anemia, and overweight and obesity at the national, household, and individual levels. DESIGN We estimated national prevalences of and trends for stunting, anemia, and overweight and obesity in children aged

In Alzheimer's disease, substantial evidence indicates the causative role of soluble amyloid β (Aβ) aggregates. Although a variety of Aβ assemblies have been described, the debate about their individual relevance is still ongoing. One critical issue hampering this debate is the use of different methods for the characterization of endogenous and synthetic peptide and their intrinsic limitations for distinguishing Aβ aggregates. Here, we used different protocols for the establishment of prefibrillar Aβ assemblies with varying morphologies and sizes and compared them in a head-to-head fashion. Aggregation was characterized via the monomeric peptide over time until spheroidal, protofibrillar, or fibrillar Aβ aggregates were predominant. It could be shown that a change in the ionic environment induced a structural rearrangement, which consequently confounds the delineation of a measured neurotoxicity toward a distinct Aβ assembly. Here, neuronal binding and hippocampal neurotransmission were found to be suitable to account for the synaptotoxicity to different Aβ assemblies, based on the stability of the applied Aβ aggregates in these settings. In contrast to monomeric or fibrillar Aβ, different prefibrillar Aβ aggregates targeted neurons and impaired hippocampal neurotransmission with nanomolar potency, albeit by different modalities. Spheroidal Aβ aggregates inhibited NMDAR-dependent long-term potentiation, as opposed to protofibrillar Aβ aggregates, which inhibited AMPAR-dominated basal neurotransmission. In addition, a provoked structural conversion of spheroidal to protofibrillar Aβ assemblies resulted in a time-dependent suppression of basal neurotransmission, indicative of a mechanistic switch in synaptic impairment. Thus, we emphasize the importance of addressing the metastability of prefacto characterized Aβ aggregates in assigning a biological effect.

Liver cancer is an emerging global health issue, with rising incidence in both the United States and the economically developing world. Although Guatemala experiences the highest rates of this disease in the Western hemisphere and a unique 1:1 distribution in men and women, few studies have focused on this population. Thus, we determined the prevalence and correlates of aflatoxin B1 (AFB1) exposure and hepatitis virus infection in Guatemalan adults. Healthy men and women aged ≥40 years (n = 461), residing in five departments of Guatemala, were enrolled in a cross-sectional study from May-October of 2016. Serum AFB1-albumin adducts were quantified using isotope dilution mass spectrometry. Multivariate linear regression was used to assess relationships between AFB1-albumin adduct levels and demographic factors. Biomarkers of hepatitis B virus and hepatitis C virus infection were assessed by immunoassay and analyzed by Fisher's exact test. AFB1-albumin adducts were detected in 100% of participants, with a median of 8.4 pg/mg albumin (range, 0.2-814.8). Exposure was significantly higher (p

Abstract 13 Background: The proportion of liver cancer (LC) that is linked to metabolic risk factors has been increasing in many countries. Guatemala has the highest reported incidence of LC in the Americas, 1 but the prevalence of metabolic risk factors is not clear. We undertook this work to examine the prevalence of metabolic risk factors for LC in Guatemala by sex and residence. Methods: We conducted a cross-sectional study of 461 adults older than 40 years who resided in rural and urban areas. Risk factors were defined by using physical exam and laboratory data, including anthropometry, blood pressure, fasting plasma glucose, serum liver enzymes, and lipids. Fatty liver disease (FLD) was defined as a fatty liver index score of > 60 and liver fibrosis (LF) as defined by a FIB-4 score of > 2.67. 2 , 3 Results: Among participants, 66% resided in rural areas and 57% were women. Mean ages of men and women were 58.0 ± 11.3 and 53.4 ± 9.8 years, respectively. Compared with men, women had higher prevalence of obesity (15% v 41%; P ≤ .001), metabolic syndrome (46% v 74%; P < .001), and FLD (67% v 52%; P < .001), but not LF (6% v 4%; P = .238). Compared with men and women from rural areas, those from urban areas had higher prevalence of diabetes (10% v 27%; P = .002; and 14% v 32%; P < .001) FLD (42% v 67%; P < .001; and 59% v 79%; P < .001), and metabolic syndrome (37% v 58%; P = .005; and 69% v 81%; P = .032), respectively. There was no difference in prevalence of LF by area among either men (6% v 6%; P = .86) or women (3% v 4%; P = .75). Conclusion: This study highlights a high prevalence of metabolic risk factors for LC in Guatemala, especially among women in urban areas. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Alvaro Rivera-Andrade No relationship to disclose Maria Fernanda Kroker-Lobos No relationship to disclose Mariana Lazo No relationship to disclose Neal Freedman No relationship to disclose John Groopman No relationship to disclose Eliseo Guallar No relationship to disclose Carlos Mendoza-Montano No relationship to disclose Katherine McGlynn No relationship to disclose Josh Smith Research Funding: Abbott Nutrition Manuel Ramirez-Zea No relationship to disclose

The loss of a child during pregnancy can be a traumatic event associated with long-lasting grief and psychological distress. This study examined the efficacy of an internet-based cognitive behavioral therapy program for mothers after pregnancy loss. In a randomized controlled trial with a waiting list control group, 83 participants who had lost a child during pregnancy were randomly allocated either to 5 weeks of internet therapy or to a 5-week waiting condition. Within a manualized cognitive behavioral treatment program, participants wrote ten essays on loss-specific topics. Posttraumatic stress, grief, and general psychopathology, especially depression, were assessed pretreatment, posttreatment, and at 3-month follow-up. Intention-to-treat analyses and completer analyses were performed. Relative to controls, participants in the treatment group showed significant improvements in posttraumatic stress, grief, depression, and overall mental health, but not in anxiety or somatization. Medium to large effect sizes were observed, and the improvement was maintained at 3-month follow-up. This internet-based cognitive behavioral therapy program represents an effective treatment approach with stable effects for women after pregnancy loss. Implementation of the program can thus help to improve the health care provision for mothers in this traumatic loss situation.

Due to the advances in neonatal intensive care medicine, prenatal ultrasound-guided diagnostic measures and paediatric surgical options, conditions have been established to achieve long-term survival in newborns with severe diseases. In addition, this means that the "non-paediatric" physician can be increasingly confronted with patients who would not have survived childhood some decades ago. Therefore, the article summarises concisely selected diseases of premature infants and newborns, e. g., congenital abdominal wall defects, and outlines possible long-term consequences based on the surgical interventions and their basic diseases, respectively, which need to be adequately cared for in the case of a surgical disease of the former patient of paediatric surgery. The overview cannot be considered as a complete revision course; however, it might constitute a basic outline for thought-provoking impulses for personal professional skills and expertise in managing such patients in later age from a surgical perspective.

The summary of product characteristics of the grass allergy immunotherapy tablet (AIT) (Phleum pratense grass pollen allergen extract) states that clinical effect may be observed in the first pollen season of treatment, if treatment is initiated ≥2 months (8 weeks) before the start of the grass pollen season. However, because patients with grass allergy may first present to physicians during the season, immediate treatment initiation (ie, in-season initiation) may increase treatment compliance and reduce the risk for disease progression compared with asking patients to return before the next pollen season to initiate treatment. This "in-season approach" may offer more patients the potentially beneficial treatment option of specific immunotherapy. However, to date, the immunomodulatory effects and tolerability of in-season treatment initiation is unknown.The aim of this study was to assess the immunologic effects and tolerability of in-season initiation of treatment with the grass AIT.This multicenter, randomized, double-blind, placebo-controlled trial was carried out in Germany and Austria. Adults with grass pollen allergy (positive skin-prick test and specific grass-pollen immunoglobulin [Ig] E) and grass pollen-induced moderate to severe persistent rhinoconjunctivitis were enrolled. Patients were randomly assigned to receive once-daily grass AIT or placebo, starting during the 2008 grass pollen season and continuing for 8 to 10 weeks. The primary end point was change from baseline in IgE-blocking factor (serum components competing with IgE for allergen binding). Secondary end points included changes from baseline in specific IgE and IgG(4) and measures of tolerability (assessed mainly by adverse events [AEs]). Blood samples for immunologic assessment were obtained by the investigators at baseline and after treatment. All AEs observed by the investigator and/or reported by the patient were recorded throughout the trial and follow-up.A total of 276 patients were enrolled and formed the full analysis set (mean age, 35 years; 55% men, 45% women; 99% white; mean weight, 76 kg; history of asthma, 41%; mean duration of grass allergy, 15.1 years). No major differences in medical history were found between the grass AIT group (n = 219) and the placebo group (n = 57). The change from baseline in mean concentration of IgE-blocking factor was significantly greater with grass AIT compared with placebo (+0.14 vs +0.05; P0.0001). The changes from baseline in specific IgE and specific IgG(4) concentrations were significantly greater with AIT compared with placebo (IgE, +0.59 vs +0.21 log kU/L; IgG(4), +0.18 vs +0.04 log relative units; both, P0.0001). At least 1 AE was reported in 58% of patients in the AIT group and in 40% of patients in the placebo group. Most AEs considered related to AIT were mild or moderate events in the mouth, throat, and/or ears (eg, oral pruritus). Four serious AEs were reported in the AIT group (sinusitis, road traffic accident, salmonellosis, meniscus lesion), but all were considered unlikely to be related to treatment. Three percent of the grass AIT group and 2% of the placebo group were withdrawn from the trial due to an AE.In-season initiation of grass AIT was associated with an immunomodulatory response in terms of induction of IgE-blocking factor, specific IgE, and specific IgG(4). In-season initiation of grass AIT was generally well tolerated in this group of adults with moderate to severe grass pollen-induced rhinoconjunctivitis. These findings are consistent with those related to the preseasonal initiation of AIT therapy.

Background The number of children that SCUBA dive is increasing. Airway narrowing while SCUBA diving can cause dangerous complications like pulmonary barotrauma and arterial gas embolism. Statistics show that children are at an increased risk. Since data are scarce, the goal of this study was to gain new knowledge about acute lung function changes in children while SCUBA diving. Material and methods 41 children aged 8 - 14 years underwent lung function testing (spirometry and residual volume measurement) before and after a single age-adapted SCUBA dive in a swimming pool. Results A significant reduction of the dynamic expiratory lung function parameters FEV (1) (p 10 % (12 % - 21 %) was found in 5 children (12.2 %). Conclusion The majority of the children (87.8 %) did not show any relevant lung function changes. Five children had a considerable reduction of FEV (1). Signs indicate the importance of bronchial hyperreactivity (BHR) as a key factor. Children with asthma or BHR should not SCUBA dive. A detailed medical examination is recommended (including an unspecific bronchial provocation test) before starting to dive.

The necessity of haemangioma treatment in infants has been controversially discussed for years. One reason is the favoured clinical observation of a potential spontaneous involution without any therapeutic approach or medical treatment, thus avoiding their specific risks. On the other hand, there are several reports on serious cases with -rapidly growing haemangiomas including severe consequences. There are potential complications such as loss of visus in cases of periorbital manifestation. A basic problem is the lack of a unique systematic classification, on the basis of which -diagnostic measures, therapeutic indications and modes could be compared. Such a classification would be much more competent including a sufficient comparison of treatment results. The basic aim in management is to achieve control of the haemangioma growth and induction of its sub-sequent involution back to only a cosmetic detraction. Each threatening functional loss can be classified as an urgent indication for treatment. There is a need to consider the treatment options and their values; in particular, cryotherapy or laser therapy in localised manifestations are mostly -favoured because of the convincing evidence from available data. In the case of a more disseminated haemangioma manifestation, the initiation of propranol medication is possible, a novel drug for this indication. However, there are no follow-up data on the mid-term or long-term outcome available at this time. Further studies on the subject are therefore required.

The management of congenital abdominal wall defects is one of the main characteristics of quality for a department of paediatric surgery. The results of treatment in the early years were the reason for a continuous improvement of procedures, operation strategies and the kinds of -material that had been used. During the last years there has been a great discussion about the presumed increase in the incidence of gastroschisis and the preterm delivery of such cases. On the basis of our own first results (2006-2009) and details from the literature, we survey these two topics.

In acute depression a high prevalence of deficits in learning and memory performance has been reported. Still, it is unclear whether these cognitive deficits are present after remission of clinical symptoms of depression. The present study compared 20 inpatients recently remitted from severe major depressive disorder (MDD) with 20 healthy matched control participants on two sequence learning tasks: a modified serial reaction-time task (SRT) for implicit learning, which is sensitive to subcortical and frontal impairments, and a serial generation task (SGT) for explicit learning. As compared with performance in healthy controls, implicit and explicit learning were not impaired in recently remitted inpatients with depression. Intentional acquisition of new information was related to the severity of depressive symptoms as patients with higher scores on Beck's Depression Inventory (BDI) showed poorer explicit learning. In contrast to findings in acute depression, our results suggest a normal degree of learning in remitted depression; these findings are consistent with unimpaired fronto-striatal functioning. However, although not statistically significant, patients remitted from melancholic MDD revealed poorer implicit learning performance compared with patients remitted from non--melancholic MDD. Longitudinal studies in patients with melancholic vs. non-melancholic MDD are needed to investigate the course of cognitive functioning during the recovery from MDD.

Summary Background Patients with chronic obstructive pulmonary disease (COPD) have few options for treatment. The efficacy and safety of the phosphodiesterase-4 inhibitor roflumilast have been investigated in studies of patients with moderate-to-severe COPD, but not in those concomitantly treated with longacting inhaled bronchodilators. The effect of roflumilast on lung function in patients with COPD that is moderate to severe who are already being treated with salmeterol or tiotropium was investigated. Methods In two double-blind, multicentre studies done in an outpatient setting, after a 4-week run-in, patients older than 40 years with moderate-to-severe COPD were randomly assigned to oral roflumilast 500 μg or placebo once a day for 24 weeks, in addition to salmeterol (M2-127 study) or tiotropium (M2-128 study). The primary endpoint was change in prebronchodilator forced expiratory volume in 1 s (FEV 1 ). Analysis was by intention to treat. The studies are registered with ClinicalTrials.gov, number NCT00313209 for M2-127, and NCT00424268 for M2-128. Findings In the salmeterol plus roflumilast trial, 466 patients were assigned to and treated with roflumilast and 467 with placebo; in the tiotropium plus roflumilast trial, 371 patients were assigned to and treated with roflumilast and 372 with placebo. Compared with placebo, roflumilast consistently improved mean prebronchodilator FEV 1 by 49 mL (p 1 was noted in both groups. Furthermore, roflumilast had beneficial effects on other lung function measurements and on selected patient-reported outcomes in both groups. Nausea, diarrhoea, weight loss, and, to a lesser extent, headache were more frequent in patients in the roflumilast groups. These adverse events were associated with increased patient withdrawal. Interpretation Roflumilast improves lung function in patients with COPD treated with salmeterol or tiotropium, and could become an important treatment for these patients. Funding Nycomed.

The objective of this study was to compare psychiatric morbidity and the course of posttraumatic stress, depression, and anxiety in two groups with severe complications during pregnancy, women after termination of late pregnancy (TOP) due to fetal anomalies and women after preterm birth (PRE). As control group women after the delivery of a healthy child were assessed. A consecutive sample of women who experienced a) termination of late pregnancy in the 2nd or 3rd-trimester (N = 62), or b) preterm birth (N = 43), or c) birth of a healthy child (N = 65) was investigated 14 days (T1), 6 months (T2), and 14 months (T3) after the event. At T1, 22.4% of the women after TOP were diagnosed with a psychiatric disorder compared to 18.5% women after PRE, and 6.2% in the control group. The corresponding values at T3 were 16.7%, 7.1%, and 0%. Shortly after the event, a broad spectrum of diagnoses was found; however, 14 months later only affective and anxiety disorders were diagnosed. Posttraumatic stress and clinician-rated depressive symptoms were highest in women after TOP. The short-term emotional reactions to TOP in late pregnancy due to fetal anomaly appear to be more intense than those to preterm birth. Both events can lead to severe psychiatric morbidity with a lasting psychological impact.

BACKGROUND The safe and appropriate use of long-acting beta-agonists (LABAs) for the treatment of asthma has been widely debated. In two large clinical trials, investigators found a potential risk of serious asthma-related events associated with LABAs. This study was designed to evaluate the risk of administering the LABA salmeterol in combination with an inhaled glucocorticoid, fluticasone propionate. METHODS In this multicenter, randomized, double-blind trial, adolescent and adult patients (age, ≥12 years) with persistent asthma were assigned to receive either fluticasone with salmeterol or fluticasone alone for 26 weeks. All the patients had a history of a severe asthma exacerbation in the year before randomization but not during the previous month. Patients were excluded from the trial if they had a history of lifethreatening or unstable asthma. The primary safety end point was the first serious asthma-related event (death, endotracheal intubation, or hospitalization). Noninferiority of fluticasone–salmeterol to fluticasone alone was defined as an upper boundary of the 95% confidence interval for the risk of the primary safety end point of less than 2.0. The efficacy end point was the first severe asthma exacerbation. RESULTS Of 11,679 patients who were enrolled, 67 had 74 serious asthma-related events, with 36 events in 34 patients in the fluticasone–salmeterol group and 38 events in 33 patients in the fluticasone-only group. The hazard ratio for a serious asthmarelated event in the fluticasone–salmeterol group was 1.03 (95% confidence interval [CI], 0.64 to 1.66), and noninferiority was achieved (P = 0.003). There were no asthma-related deaths; 2 patients in the fluticasone-only group underwent asthmarelated intubation. The risk of a severe asthma exacerbation was 21% lower in the fluticasone–salmeterol group than in the fluticasone-only group (hazard ratio, 0.79; 95% CI, 0.70 to 0.89), with at least one severe asthma exacerbation occurring in 480 of 5834 patients (8%) in the fluticasone–salmeterol group, as compared with 597 of 5845 patients (10%) in the fluticasone-only group (P

In this experimental study we investigated the potential of near infrared (NIR) spectroscopy to support intra-operative assessment of the fat content of the liver, as needed in the context of liver transplantation. Rats with hepatic steatosis of different severities were subjected to the intra-operative assessment using a medical device to record NIR spectra. We observed that the changes in the optical properties of the liver, at 1210 nm using the second derivative, corresponded to the severity of hepatic steatosis as assessed by histology. Further studies have to be undertaken to validate the results, to add more parameters, and to further develop the technology for easy and safe use in the clinic.

Low-income countries across the world are increasingly burdened with growing rates of cancer incidence and mortality. Opportunities for prevention in these populations may be realized most readily for cancer sites with known etiologies that are amenable to intervention. Liver cancer is the sixth-most commonly occurring cancer worldwide and is the second-most common contributor to global cancer mortality. Aflatoxin B1 (AFB1) is a known and potent human hepatocarcinogen, with exposure occurring via ingestion of grains - especially maize - contaminated with Aspergillus flavus. Previous work in regions with endemic levels of liver cancer has shown that reducing AFB1 exposure attenuated liver cancer mortality - even in the presence of other known etiological exposures, such as hepatitis B virus. Guatemala experiences high rates of liver cancer - which is uniquely distributed equally between men and women - and consumes maize as a dietary staple, making the assessment of AFB1 exposure a high priority for cancer prevention efforts in this country. Therefore, we measured circulating levels of the AFB1-albumin adduct, an established biomarker of AFB1 exposure, in adults residing in five geographically and ecologically dispersed departments of Guatemala (Guatemala, Suchitepéquez, Sololá, Escuintla, and Quiché). Healthy men and women aged 40 and older were recruited for the study. Pregnant women or individuals with implanted cardiac devices were excluded from participation. Subjects (n=436) gave informed consent and provided demographic information and a venipuncture blood sample during a clinic visit. Serum was separated from whole blood, digested with protease, subjected to solid-phase extraction, and analyzed with isotope dilution ultrahigh-performance liquid chromatography-triple quadrupole mass spectrometry. Serum albumin was measured by ELISA. AFB1-albumin adducts (pg AFB1-lysine adduct/mg albumin) were detectable in 100% of samples, with a mean ± SEM of 21.6 ± 2.5 and range of 0.2 - 814.8. These levels are similar to those observed in regions of China in the 1980s, prior to reductions in AFB1 exposure and liver cancer mortality. Stratification by demographic factors revealed significant differences in aflatoxin levels in urban (9.6 ± 1.3) versus rural (28.8 ± 3.9) subjects (p ≤ 0.001). Accordingly, AFB1-albumin adduct levels were lowest in the urban municipality of Escuintla (5.8 ± 1.1) and highest in rural Suchitepéquez (36.4 ± 4.8). Exposure was significantly different by sex, with men having higher levels compared to women (30.0 ± 5.4 vs. 15.3 ± 1.3, p = 0.01). These data show that AFB1 exposure in Guatemalan adults is similar to levels previously shown to increase liver cancer risk. Larger cohort and prospective studies are warranted to assess the relationship between liver cancer incidence and AFB1 exposure in this population. Citation Format: Joshua W. Smith, Patricia A. Egner, Mariana Lazo, Alvaro Rivera, Fernanda Kroker, Neal D. Freedman, Katherine A. McGlynn, Manuel Ramirez-Zea, Eliseo Guallar, John D. Groopman. Quantitative measurement of aflatoxin-serum albumin adducts reveals substantial exposure in Guatemala, a country with high rates of liver cancer mortality in men and women [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4247. doi:10.1158/1538-7445.AM2017-4247

Exposure of humans to particulate air pollution has been correlated with the incidence and aggravation of allergic airway diseases. In predisposed individuals, inhalation of environmental particles can lead to an exacerbation of immune responses. Previous studies demonstrated a beneficial effect of the compatible solute ectoine on lung inflammation in rats exposed to carbon nanoparticles (CNP) as a model of environmental particle exposure. In the current study we investigated the effect of such a treatment on airway inflammation in a mouse allergy model. Ectoine in nonsensitized animals significantly reduced the neutrophilic lung inflammation after CNP exposure. This effect was accompanied by a reduction of inflammatory factors in the bronchoalveolar lavage. Reduced IL-6 levels in the serum also indicate the effects of ectoine on systemic inflammation. In sensitized animals, an aggravation of the immune response was observed when animals were exposed to CNP prior to antigen provocation. The coadministration of ectoine together with the particles significantly reduced this exacerbation. The data indicate the role of neutrophilic lung inflammation in the exacerbation of allergic airway responses. Moreover, the data suggest to use ectoine as a preventive treatment to avoid the exacerbation of allergic airway responses induced by environmental air pollution.

Introduction: Stunting (ST) and anemia (AN) have declined but are still high in some regions and subpopulations and overweight and obesity (OW/OB) have increased at alarming rates; therefore, under...

Study objectives: To determine the recording capabilities of the POLY-MESAM (PM) unit (MAP; Martinsried, Germany), an American Sleep Disorders Association level III system, and to compare it with simultaneous 12-channel polysomnography in the sleep laboratory. Measurements and results: Fifty-three patients (49 men and 4 women) with obstructive sleeprelated breathing disorders of varying severity were included. The apnea-hypopnea indexes (AHIs) obtained using the two methods differed significantly from each other, although the correlation was close. The PM unit produced false-negative results in patients with mild to moderate obstructive sleep apnea (OSA). The sensitivity of the PM unit in detecting patients with an AHI > 10 was 92%, while the specificity was 96.3%. Conclusions: The correlation of AHIs obtained with polysomnography and with the PM unit is close. However, in some cases, the PM may underestimate OSA parameters. The PM unit produces false-negative results in patients with mild to moderate OSA. While inpatient polysomnography remains the “gold standard,” the PM unit may provide an inexpensive alternative in some special cases. (CHEST 2000; 117:1613‐1618)

Background Nasal continuous positive airway pressure ventilation therapy is the present gold standard in the treatment of obstructive sleep apnea. Depending on the definitions used, about 60% of the patients tolerate nCPAP therapy. The reason for this limited tolerance is a varying number of side effects. The aim of the present retrospective study was to analyze the incidence and intensity of otorhinolaryngological side effects of nCPAP therapy. Method Questionnaires inquiring about the frequency of using nCPAP and objective and subjective complaints were sent to 92 patients who were treated with nCPAP in our department within the last years. Six of 92 patients also used a heated humidifier. A telephone interview was added to complete the questionnaires as correctly as possible. Results Eighty questionnaires were sent back completely answered. The mean frequency of using nCPAP (+/- standard deviation) was 6.8 +/- 1.6 hours per night and 6.5 +/- 1.4 nights per week. The mean duration of nCPAP therapy was 28.0 +/- 21.0 months; the mean pressure used was 6.8 +/- 1.2 cm H2O. The following side effects were specified most frequently: disturbance of sleep during the night (71.3%), dry mouth (47.5%), dry nose (46.3%), pressure marks by the mask (41.3%), crusts within the nasal cavity (38.8%), and hearing loss (26.3%). Dryness within the nose and mouth was considered the most irritating side effects. Conclusions NCPAP therapy has a number of different side effects in the head and neck. These side effects are seen frequently. Prospective analysis must show whether there are correlations between the intensity and frequency of side effects and the duration of therapy, and whether technical improvements (quality of masks, noise reduction, humidifiers) are able to reduce the frequency of side effects.

Inhaled combustion derived carbon nanoparticles (CNP) have been described to induce neutrophilic lung inflammation. The effects of these particles during an ongoing inflammation by interaction with the neutrophils themselves however are not well understood. In the current study we aimed to investigate the effects of CNP on neutrophilic life span and the impact of these effects on environmentally induced lung inflammation. For this purpose, ex vivo studies with blood neutrophils from volunteers but also from COPD patients investigating neutrophil apoptosis and signalling events were performed. Additionally, lung inflammation was induced by intratracheal application of particles in Fisher 344 rats in order to correlate neutrophil apoptosis rates with the strength of inflammatory parameters in lung lavages (BAL). As we earlier described a new group of compounds to interfere with CNP-induced signalling, we also investigated whether these substances (compatible solutes) have preventive effects on the anti-apoptotic signalling in neutrophils. Exposure of blood neutrophils from volunteers and COPD patients to CNP resulted in a significant reduction of the naturally occurring apoptosis rates. This effect was mediated by the activation of Akt and, subsequently, of Mcl-1. Interestingly, the prevention of the activation of these signalling events by the compatible solute ectoine resulted in a very effective restoration of the natural apoptosis rate. Similar effects were observed in vivo after single or repetitive instillation of particles with or without subsequent application of ectoine. Neutrophils isolated from BAL showed reduced apoptosis rates after particle treatment which was restored after the application of ectoine. Accordingly, CNP-triggered lung inflammation was reduced by the therapeutic application of ectoine. Monitoring the inflammatory kinetics in the presence or absence of ectoine indicated that ectoine accelerates the clearance of neutrophils from the lung by preventing the anti-apoptotic signalling in neutrophils. The data identify the reduction of natural apoptosis of neutrophilic granulocytes as a mechanism of the pro-inflammatory effect of carbonaceous nanoparticles. Moreover, as compatible solutes are well tolerated by humans, they may be used therapeutically for the treatment of chronic neutrophilic inflammation like in COPD.

Background: The loss of a child during pregnancy causes significant psychological distress for many women and their partners, and may lead to long-lasting psychiatric disorders. Internet-based interventions using exposure techniques and cognitive restructuring have proved effective for posttraumatic stress disorder (PTSD) and prolonged grief. This study compared the effects of an Internet-based intervention for parents after prenatal loss with a waiting list condition (WLC). Methods: The Impact of Event Scale - Revised assessed symptoms of PTSD; the Inventory of Complicated Grief and the Brief Symptom Inventory assessed depression, anxiety, and general mental health. The 228 participants (92% female) were randomly allocated to a treatment group (TG; n = 115) or a WLC group (n = 113). The TG received a 5-week cognitive behavioral intervention including (1) self-confrontation, (2) cognitive restructuring, and (3) social sharing. Results: The TG showed significantly reduced symptoms of posttraumatic stress, prolonged grief, depression, and anxiety relative to the WLC control group. Intention-to-treat analysis revealed treatment effects of between d = 0.84 and d = 1.02 for posttraumatic stress and prolonged grief from pre- to posttreatment time points. Further significant improvement in all symptoms of PTSD and prolonged grief was found from the posttreatment evaluation to the 12-month follow-up. The attrition rate of 14% was relatively low. Conclusions: The Internet-based intervention proved to be a feasible and cost-effective treatment, reducing symptoms of posttraumatic stress, grief, depression, anxiety, and general mental health after pregnancy loss. Low-threshold e-health interventions should be further evaluated and implemented routinely to improve psychological support after pregnancy loss.

Objective: To assess preference, satisfaction and critical errors with a novel, breath-actuated, multi-dose dry powder inhaler (DPI; Genuair®/Pressair™), versus a widely used, single-dose DPI (HandiHaler®) in patients with moderate-to-severe chronic obstructive pulmonary disease. Methods: In this randomised, open-label, multicentre, cross-over study, patients (aged ≥ 40 years) inhaled placebo once daily through both inhalers for 2 weeks in addition to current medication. The primary end point was percentage of patients who preferred Genuair to HandiHaler. Overall patient satisfaction (5-point scale: 1 = very dissatisfied; 5 = very satisfied), critical errors and willingness to continue using each inhaler (0 = not willing; 100 = definitely willing) were assessed. Results: Of 130 patients randomised, 105 were included in the intent-to-treat population (71.4% male; mean age 65.7 years). After 2 weeks, significantly more patients preferred Genuair than HandiHaler (79.1 vs 20.9%; p < 0.0001). Overall satisfaction scores (4.6 vs 3.8; p < 0.0001) and willingness to continue use scores (84.0 vs 62.5; p < 0.0001) were significantly higher with Genuair versus HandiHaler. Significantly fewer patients made ≥ 1 critical error with Genuair only compared with HandiHaler only (2.9 vs 19.0%; p < 0.0001). Conclusion: After 2 weeks' practice, patients preferred and were more willing to continue using Genuair than HandiHaler. Genuair was associated with higher patient satisfaction and fewer critical errors than HandiHaler Read More: http://informahealthcare.com/doi/abs/10.1517/17425247.2013.808186

The loss of a child during pregnancy results in significant psychological stress for many women, and may lead to long-lasting grief and psychological illnesses. However, only a small percentage of those affected seek or receive traditional forms of psychological treatment, and therefore novel treatment approaches and methods are required. This article introduces an Internet-based psychotherapy programme for patients after pregnancy loss. The five-week intervention comprises two components: structured writing disclosure and cognitive-behavioural therapy. Communication between the therapist and patient is text-based and asynchronous. The writing protocol consists of three treatment phases: self-confrontation, cognitive reappraisal and social sharing. A case report is presented to illustrate the course of the treatment and clinical considerations associated with delivering Internet-based interventions to patients after pregnancy loss.

Demographic estimations for the UK predict an increase in the number of major orthopaedic surgical procedures in elderly people. The two major indications for surgery are osteoporotic fractures and severe osteoarthritis of weight-bearing joints. Coexisting medical disease makes elderly patients a surgical high-risk group, and mortality and morbidity after emergency surgery remains high.

The traumatic loss of an unborn child by induced termination of pregnancy because of fetal malformation is a major life event that causes intense maternal grief. Increasing evidence supports the hypothesis that the same neural structures involved in the experience of physical pain are involved in the experience of social pain and loss.To investigate neural activation patterns related to acute grief, the authors conducted a functional MRI study of 12 post-termination women and 12 noninduced women who delivered a healthy child. Brain activation was measured while participants viewed pictures of happy baby, happy adult, and neutral adult faces.Relative to comparison women, post-termination women showed greater activation in the middle and posterior cingulate gyrus, the inferior frontal gyrus, the middle temporal gyrus, the thalamus, and the brainstem in response to viewing happy baby faces. Functional connectivity between the cingulate gyrus and the thalamus during the processing of happy baby faces was significantly stronger in post-termination women.Overall, acute grief after the loss of an unborn child was closely related to the activation of the physical pain network encompassing the cingulate gyrus, the inferior frontal gyrus, the thalamus, and the brainstem. To the authors' knowledge, the stronger functional thalamocingulate connectivity in post-termination women is the first in vivo demonstration of an involvement of the neural maternal attachment network in grief after the loss of an unborn child.