Apparent diffusion coefficient scalars correlate with near-infrared spectroscopy markers of cerebrovascular autoregulation in neonates cooled for perinatal hypoxic-ischemic injury.

BACKGROUND AND PURPOSE: Neurologic morbidity remains high in neonates with perinatal hypoxic-ischemic injury despite therapeutic hypothermia. DTI provides qualitative and quantitative information about the microstructure of the brain, and a near-infrared spectroscopy index can assess cerebrovascular autoregulation. We hypothesized that lower ADC values would correlate with worse autoregulatory function. MATERIALS AND METHODS: Thirty-one neonates with hypoxic-ischemic injury were enrolled. ADC scalars were measured in 27 neonates (age range, 4-15 days) in the anterior and posterior centrum semiovale, basal ganglia, thalamus, posterior limb of the internal capsule, pons, and middle cerebellar peduncle on MRI obtained after completion of therapeutic hypothermia. The blood pressure range of each neonate with the most robust autoregulation was identified by using a near-infrared spectroscopy index. Autoregulatory function was measured by blood pressure deviation below the range with optimal autoregulation. RESULTS: In neonates who had MRI on day of life ≥10, lower ADC scalars in the posterior centrum semiovale (r = -0.87, P = .003, n = 9) and the posterior limb of the internal capsule (r = -0.68, P = .04, n = 9) correlated with blood pressure deviation below the range with optimal autoregulation during hypothermia. Lower ADC scalars in the basal ganglia correlated with worse autoregulation during rewarming (r = -0.71, P = .05, n = 8). CONCLUSIONS: Blood pressure deviation from the optimal autoregulatory range may be an early biomarker of injury in the posterior centrum semiovale, posterior limb of the internal capsule, and basal ganglia. Optimizing blood pressure to support autoregulation may decrease the risk of brain injury in cooled neonates with hypoxic-ischemic injury.

Ambivalent childbearing motivations: predicting condom use by urban, African-American, female youth.

STUDY OBJECTIVE: To describe a model of how interactions between positive and negative childbearing motivations affect the use of condoms for contraceptive purposes and test hypotheses based on that model. DESIGN: Psychological and behavioral data were collected during a study that sampled randomly selected census block groups. SETTING: Respondents were household residents of Baltimore City, Maryland, between 2004 and 2007. PARTICIPANTS: English-speaking, sexually active African-American women between the ages of 15 and 24 who had completed a reliable and valid measure of both positive and negative childbearing motivations. MAIN OUTCOME MEASURES: Regularity of condom use during the past 90 days and contraceptive method at last sex. RESULTS: The results of regression analyses with the total sample confirm that antinatal childbearing motivations predicted more regular condom use and that ambivalent, pronatal, and indifferent childbearing motivations acting together each predicted less regular condom use. The results with a subgroup using condom and not hormonal contraception confirmed that ambivalent childbearing motivation alone predicted less regular condom use. CONCLUSIONS: Our findings demonstrate how positive and negative childbearing motivations interact to create a dynamic effect on contraceptive behavior that transcends the effect of either positive or negative motivation acting alone. We conclude that the dynamics of these motivational interactions have important implications for further research on contraceptive decision-making, for augmenting the understanding of caretakers and providers, and for the formation of new policies that focus on the prevention of unplanned pregnancy among youth.

Partial posterior hyaloidectomy for macular disorders.

PURPOSE: To evaluate the effect of partial posterior hyaloidectomy (PPH) in preventing iatrogenic retinal breaks related to the induction of a posterior vitreous detachment (IPVD). METHODS: Fifty-nine patients who necessitated IPVD for an epiretinal membrane or macular hole were included in this prospective, interventional case series. Extensive removal of vitreous gel, close to the retina, was conducted before IPVD under 23 G (gauge)-vitrectomy system. The PPH involved the limited extent of IPVD and limited removal of the outermost vitreous cortex to an area slightly beyond the margin of the temporal major vascular arcade. The incidence of retinal breaks related to the surgery was compared with 57 eyes that had undergone conventional 23-G total vitrectomy accompanied by extensive IPVD using χ(2)-test. RESULTS: Patients were followed-up for a mean of 14.3 months (6-30 months) after the surgery. The incidence of peripheral retinal breaks after the PPH was 3.4% (2/59 eyes), which was significantly lower than that in the eyes that underwent conventional 23 G vitrectomy (15.8%, 9/57 eyes, P=0.023) for the same disorders that required an IPVD. No patient complained of postoperative floaters, postoperatively. CONCLUSIONS: PPH would be an efficient procedure to prevent iatrogenic peripheral retinal breaks related to an IPVD.

Recruitment approaches to identifying newly diagnosed HIV infection among African American men who have sex with men.

To determine effectiveness of alternate venue testing (AVT), social network strategy (SNS) and provider referral (PR) for identifying previously undiagnosed HIV-infected 18-64-year-old African American men who have sex with men (AA MSM) by a health department. For AVT, staff used a mobile clinic to conduct HIV testing. For PR, staff solicited contact information from HIV-infected AA MSM, located contacts and offered HIV testing. For SNS, HIV-positive AA MSM recruited network associates for HIV testing. Two hundred and eighteen self-identified AA MSM were tested through AVT (25.2% HIV positivity) of whom 20 were newly identified HIV-positive. Fourteen HIV-positive men participated in SNS; 22 AA MSM contacts were recruited through SNS, eight (36.4%) were HIV positive and none were new positives. Two HIV-infected men participated in the PR strategy, yielding two AA MSM sex partners (one previously positive). The results suggest the need for health departments to consider using several complimentary strategies for identifying previously undiagnosed HIV infections in AA MSM in urban environments such as Baltimore.

Characteristics of epiretinal membranes according to the presence or absence of posterior vitreous detachment.

PURPOSE: The purpose of this study is to investigate the morphological features of epiretinal membrane (ERM) in the presence or absence of a posterior vitreous detachment (PVD). DESIGN: Retrospective observational comparative case series. METHODS: This study involved 34 patients in whom the vitreoretinal relationship was confirmed during vitrectomy for treatment of ERM. We analyzed demography, direction of macular folds in fundus photographs, and foveal contours assessed by optical coherence tomography (OCT) in two groups of patients, the posterior vitreous attachment (PVA) group and the PVD group. RESULTS: Mean age of the 14 patients in the PVA group was 58.2 ± 8.2 years, and that of 20 patients in the PVD group was 66.7 ± 6.7 years (P=0.0023). Funduscopic examination revealed radiating folds in 57.1% of patients in the PVA group and 10% of patients in the PVD group, and a flat-shaped foveal contour was observed on OCT in 71.5% of patients in the PVA group and 25.0% of patients in the PVD group. Significant differences were observed between the PVA group and the PVD group in both direction of the macular folds (P<0.01) and foveal contours (P=0.028). CONCLUSION: Patients with ERM and PVA were usually younger than 60 years. Radiating macular folds and flat foveal contour in patients with ERM are highly sensitive and specific findings indicative of PVA.

Polypoidal choroidal vasculopathy and late geographic hyperfluorescence on indocyanine green angiography.

BACKGROUND/AIMS: To report the clinical significance of late geographic hyperfluorescence (LGH) on indocyanine green angiography (ICGA) in cases of polypoidal choroidal vasculopathy (PCV). METHODS: The medical records of 43 eyes with PCV, all of which had undergone at least 12 months of follow-up, 40 eyes with exudative age-related macular degeneration (AMD) and 20 eyes of age-matched normal subjects were retrospectively analysed. The incidence of LGH, defined as a well-demarcated geographic hyperfluorescent lesion on late phase ICGA, was compared in each respective group. The natural course of the LGH and its changes after photodynamic therapy (PDT) were analysed. RESULTS: LGH was noted in all of the eyes with PCV, whereas LGH was noted in three eyes (7.5%) of the eyes with exudative AMD and was not noted in any of the normal subjects (p<0.01). Of the 27 eyes (62.8%) with PCV, LGH was matched to the total area of the branching vascular network and polyps. The extent of LGH was enlarged over time in approximately one-half of the cases. As compared with the eyes demonstrating persistent LGH after PDT, the eyes with fading or disappearing LGH evidenced a lower recurrence of active PCV (p<0.05). CONCLUSION: LGH is a highly sensitive and specific ICGA finding for the diagnosis of PCV. Increased surveillance should be implemented in eyes in which LGH persists after PDT.

Clinical manifestations and treatment of retinoblastoma in Korea.

BACKGROUND/AIMS: To analyse the clinical manifestations and results of treatment for patients with retinoblastoma in Korea. METHODS: The medical records of 70 children (92 eyes) diagnosed as having retinoblastoma and treated between 2000 and 2006 were retrospectively analysed. Data on gender, age at diagnosis, laterality, presenting sign, classification of tumour, treatment modality and prognosis were collected. RESULTS: The most common presenting sign was leucocoria (80%). 31.4% developed bilateral retinoblastoma. Using the International Classification of Retinoblastoma, 7.5% were group A, 23.8% were group B, 6.3% were group C, 38.8% were group D, and 23.8% were group E. 26.1% of eyes were treated with chemoreduction and/or focal therapy, namely, they achieved globe preservation, and all other eyes were enucleated. The globe preservation was achieved in 100% of group A, 77.8% of group B, 66.7% of group C, and 26.7% of group D. CONCLUSIONS: In Korea, most children with retinoblastoma showed an advanced stage of tumour at the time of diagnosis and although they were treated with an updated therapeutic approach according to the newly introduced classification, the rate of globe preservation did not reach that of developed countries. Increased surveillance should be performed.

Tandem high-dose chemotherapy and autologous stem cell rescue in children with bilateral advanced retinoblastoma.

Although external-beam radiation therapy (EBRT) has been an effective treatment modality in patients with bilateral advanced retinoblastoma, it significantly increases the risk of second malignancies and facial deformities. This study aimed to evaluate the efficacy of tandem high-dose chemotherapy and autologous stem cell rescue (HDCT/ASCR) for treatment, instead of EBRT, in children with bilateral advanced retinoblastoma. Fourteen patients with bilateral retinoblastoma received chemotherapy, and local therapy was provided whenever possible. When at least one functional eye could not be saved by chemoreduction and local therapy, tandem HDCT/ASCR was provided to avoid EBRT. As a result, nine patients received tandem HDCT/ASCR. The toxicities were tolerable and there was no TRM. All nine patients who received tandem HDCT/ASCR had at least one functional eye without EBRT, and in two patients, both eyes were saved. No second malignancy has developed to date. HDCT/ASCR might be an effective treatment for bilateral advanced retinoblastoma, especially in cases in which at least one functional eye could not be preserved with chemoreduction and local therapy alone, and where EBRT was unavoidable. Long-term follow-up and further studies are needed to evaluate the efficacy and toxicity of HDCT/ASCR as an alternative treatment to EBRT.

Percutaneous endoscopic cervical discectomy for discogenic cervical headache due to soft disc herniation.

A discogenic cervical headache is a subtype of cervicogenic headache (CEH) that arises from a degenerative cervical disc abnormality. The purpose of this study was to evaluate the clinical outcome of percutaneous endoscopic cervical discectomy (PECD) for patients with chronic cervical headache due to soft cervical disc herniation. Seventeen patients underwent PECD for intractable headache. The inclusion criteria were soft disc herniation without segmental instability, proven by both local anesthesia and provocative discography for headache unresponsive to conservative treatment. The mean follow-up period was 37.6 months. Fifteen of the 17 patients (88.2%) showed successful outcomes based on the Macnab criteria. Pain scores on a visual analog scale (VAS) improved from a preoperative mean of 8.35 +/- 0.79 to 2.12 +/- 1.17, postoperatively (P < 0.01). The mean disc height decreased from 6.81 +/- 1.08 to 5.98 +/- 1.07 mm (P < 0.01). There was no newly developed segmental instability or spontaneous fusion on follow-up radiography. In conclusion, PECD appears to be effective for chronic severe discogenic cervical headache under strict inclusion criteria.

Factors predicting excellent outcome of percutaneous cervical discectomy: analysis of 111 consecutive cases.

Percutaneous cervical discectomy (PCD) has been developed as an effective treatment option for soft cervical disc herniation. However, no prognostic study of this procedure has yet been made. The purpose of this study was to evaluate the surgical outcome of PCD and to determine the factors predicting excellent outcome. A retrospective review was performed of 111 consecutive patients who underwent PCD with a mean follow-up period of 49.4 months (range, 29-64 months). Under local anesthesia, a percutaneous anterior approach was followed by discectomy with microforceps and endoscopic Ho:YAG laser. The surgical outcomes of the 111 patients based on the Macnab criteria were excellent in 52 patients (46.9%), good in 37 (33.3%), fair in 9 (8.1%), and poor in 13 (11.7%), thereby indicating a symptomatic improvement in 88.3% of the patients. In this study, the two major factors predicting an excellent long-term outcome were the symptom of radiating arm pain (P = 0.02) and the location of lateral disc herniation (P < 0.02). Proper patient selection remains critical for the success of this minimally invasive procedure.

Access to medical care and service utilization among injection drug users with HIV/AIDS.

Access to care and optimal service utilization among 287 low income African American former and current drug injectors was examined. Results indicated suboptimal outpatient care, and no evidence of alternative use of hospital services. Participation in drug treatment and case management were associated with greater access to care and use of outpatient services, even after controlling for current drug use, gender, and insurance. AIDS and physical functioning limitation were associated with emergency room (ER) use and hospitalization. Participation in drug treatment and case management and an AIDS diagnosis were associated with optimal outpatient service use. Daily alcohol use was associated with ER as the usual facility for care. Integration of substance abuse treatment, case management, and medical services delivery may contribute to improved HIV care for this population.

Children of injection drug users: impact of parental HIV status, AIDS, and depression.

We investigated the association between parental factors (including infection with human immunodeficiency virus [HIV], acquired immunodeficiency syndrome [AIDS] diagnosis, parental medical illness, and depression) and children's behavioral and emotional problems among children of injection drug users (IDUs). IDUs were recruited through community outreach. The sample included 73 parents of 73 children, aged 4 to 12 years. Parental depression (odds ratio [OR] = 4.61) and medical illness (OR = 4.70) were found to be significantly associated with internalizing (depressive and anxiety-related symptoms), but not with externalizing (aggressive and disruptive behaviors) symptoms in the children of IDUs. The clinical implications are that children of IDUs are known to be at high risk for psychiatric symptoms and disorders; these data suggest that children of depressed and/or medically ill IDU parents may be at even higher risk of internalizing symptoms (depression and anxiety symptoms) than children of IDUs who do not suffer from these conditions.

Irreversible inactivation of protein kinase C by glutathione.

The tripeptide glutathione (GSH) is the predominant low molecular weight thiol reductant in mammalian cells. In this report, we show that at concentrations at which GSH is typically present in the intracellular milieu, GSH and the oxidized GSH derivatives GSH disulfide (GSSG) and glutathione sulfonate each irreversibly inactivate up to 100% of the activity of purified Ca2+- and phosphatidylserine (PS)-dependent protein kinase C (PKC) isozymes in a concentration-dependent manner by a novel nonredox mechanism that requires neither glutathiolation of PKC nor the reduction, formation, or isomerization of disulfide bridges within PKC. Our evidence for a nonredox mechanism of PKC inactivation can be summarized as follows. GSSG antagonized the Ca2+- and PS-dependent activity of purified rat brain PKC with the same efficacy (IC50 = 3 mM) whether or not the reductant dithiothreitol was present. Glutathione sulfonate, which is distinguished from GSSG and GSH by its inability to undergo disulfide/thiol exchange reactions, was as effective as GSSG in antagonizing Ca2+- and PS-dependent PKC catalysis. The irreversibility of the inactivation mechanism was indicated by the stability of the inactivated form of PKC to dilution and extensive dialysis. The inactivation mechanism did not involve the nonspecific phenomena of denaturation and aggregation of PKC because it obeyed pseudo-first order kinetics and because the hinge region of PKC-alpha remained a preferential target of tryptic attack following GSH inactivation. The selectivity of GSH in the inactivation of PKC was also indicated by the lack of effect of the tripeptides Tyr-Gly-Gly and Gly-Ala-Gly on the activity of PKC. Furthermore, GSH antagonism of the Ser/Thr kinase casein kinase 2 was by comparison weak (<25%). Inactivation of PKC-alpha was not accompanied by covalent modification of the isozyme by GSH or other irreversible binding interactions between PKC-alpha and the tripeptide, but it was associated with an increase in the susceptibility of PKC-alpha to trypsinolysis. Treatment of cultured rat fibroblast and human breast cancer cell lines with N-acetylcysteine resulted in a substantial loss of Ca2+- and PS- dependent PKC activity in the cells within 30 min. These results suggest that GSH exerts negative regulation over cellular PKC isozymes that may be lost when oxidative stress depletes the cellular GSH pool.

Evaluation of pooled fibrin sealant for ear surgery.

HYPOTHESIS: This study investigated the bonding strength and tissue toxicity of a commercially prepared dual-virally-inactivated pooled-blood fibrin tissue adhesive (ViGuard-FS; Melville Biologics, Inc., NY, U.S.A.) and compared it with an autologous fibrin tissue adhesive made by the precipitation of fibrinogen using ethanol and freezing (AFTA-E). METHODS: The bonding strength of FS was optimized by varying the concentrations of fibrinogen and human or bovine thrombin using three different surface media: inorganic (silastic), animal skin, and human dura mater. Furthermore, tissue reactions and duration of fibrin clots were studied by injecting FS into the auricles of rats. RESULTS: This study showed that optimized FS with human thrombin was superior in bonding strength to AFTA-E on all three surface media, and that FS does not produce any toxic tissue responses when injected into rat auricles. Minimal traces of the adhesive clot could be observed in a few auricles at 35 days after application. CONCLUSIONS: Because it is made from pooled-donor blood that has been treated with virus elimination procedures, FS is superior to autologous fibrin tissue adhesive in which fibrinogen is precipitated by the ethanol/freezing method. FS has not shown any undesirable tissue reactions when injected into live rat auricles. We believe that these results provide a rationale for further clinical development of ViGuard-FS as a tissue adhesive for otologic surgery.