The effect of sociodemographic characteristics, academic factors, and individual health behaviors on psychological well-being among college students.

Objective: This study aimed to measure the potential relationships between sociodemographic characteristics, academic factors, body mass index (BMI), financial challenges, individual health behaviors, impact of COVID-19, and psychological well-being (PWB) among students. Participants: Undergraduate college students. Methods: Data from the National College Health Assessment III (American College Health Association [ACHA]) were used (n = 1,439). Differences in absolute values among PWB groups were analyzed using analysis of variance (ANOVA). To measure the influence of all factors combined on PWB, multiple regression analyses were performed. Results: Significant differences were observed in age, GPA, financial challenges, and individual health behaviors by PWB groups (p < .05). Being older, being female, having a higher GPA, being a full-time student, having a higher intake of vegetables, taking less time to fall asleep, and having lower stress levels were significantly positively associated with higher PWB scores (p < .05). Conclusions: Multiple considerations related to the academic environment and individual behaviors seem to influence PWB among college students.

5-year follow-up of the randomised Diabetes Remission Clinical Trial (DiRECT) of continued support for weight loss maintenance in the UK: an extension study.

BACKGROUND: In DiRECT, a randomised controlled effectiveness trial, weight management intervention after 2 years resulted in mean weight loss of 7·6 kg, with 36% of participants in remission of type 2 diabetes. Of 36 in the intervention group who maintained over 10 kg weight loss at 2 years, 29 (81%) were in remission. Continued low-intensity dietary support was then offered up to 5 years from baseline to intervention participants, aiming to maintain weight loss and gain clinical benefits. This extension study was designed to provide observed outcomes at 5 years. METHODS: The DiRECT trial took place in primary care practices in the UK. Participants were individuals aged 20-65 years who had less than 6 years' duration of type 2 diabetes, a BMI greater than 27 kg/m2, and were not on insulin. The intervention consisted of withdrawal of antidiabetic and antihypertensive drugs, total diet replacement (825-853 kcal per day formula diet for 12-20 weeks), stepped food reintroduction (2-8 weeks), and then structured support for weight-loss maintenance. After sharing the 2-year results with all participants, UK National Health Service data were collected annually until year 5 from remaining intervention participants who received low-intensity dietary support, intervention withdrawals, and the original randomly allocated groups. The primary outcome was remission of type 2 diabetes; having established in the DiRECT trial that sustained weight loss was the dominant driver of remission, this was assumed for the Extension study. The trial is registered with the ISRCTN registry, number 03267836. FINDINGS: Between July 25, 2014, and Aug 5, 2016, 149 participants were randomly assigned to the intervention group and 149 were assigned to the control group in the original DiRECT study. After 2 years, all intervention participants still in the trial (101 [68%] of 149) were approached to receive low-intensity support for a further 3 years. 95 (94%) of 101 were able to continue and consented and were allocated to the DiRECT extension group. 54 participants were allocated to the non-extension group, where intervention was withdrawn. At 5 years, DiRECT extension participants (n=85) lost an average of 6·1 kg, with 11 (13%) of 85 in remission. Compared with the non-extension group, DiRECT extension participants had more visits with HbA1c <48 mmol/mol (<6·5%; 36% vs 17%, p=0·0004), without glucose-lowering medication (62% vs 30%, p<0·0001), and in remission (34% vs 12%, p<0·0001). Original control participants (n=149) had mean weight loss 4·6 kg (n=82), and 5 (5%) of 93 were in remission. Compared with control participants, original intervention participants had more visits with weight more than 5% below baseline (61% vs 29%, p<0·0001), HbA1c below 48 mmol/mol (29% vs 15%, p=0·0002), without antidiabetic medication (51% vs 16%, p<0·0001), and in remission (27% vs 4%, p<0·0001). Of those in remission at year 2, 26% remained in remission at 5 years. Serious adverse events in the original intervention group (4·8 events per 100 patient-years) were under half those in the control group (10·2 per 100 patient-years, p=0·0080). INTERPRETATION: The extended DiRECT intervention was associated with greater aggregated and absolute weight loss, and suggested improved health status over 5 years. FUNDING: Diabetes UK.

Improving morbidity and mortality in hip fragility fractures.

PURPOSE OF REVIEW: Hip fragility fractures (HFF) carry high morbidity and mortality for patients and will increase in frequency and in proportion to the average patient age. Provision of effective, timely care for these patients can decrease their morbidity and mortality and reduce the large burden they place on the healthcare system. RECENT FINDINGS: There are associative relationships between prefracture frailty, postoperative delirium and increased morbidity and mortality. The use of a multidisciplinary approach to HFF care has shown improved outcomes in care with focus on modifiable factors including admission to specialty care floor, use of peripheral nerve blocks preoperatively and Anesthesia and Physical Therapy involvement in the care team. Peripheral nerve blocks including pericapsular nerve group (PENG) blocks have shown benefit in lowering morbidity and mortality. SUMMARY: HFF are associated with >40% chance of continued pain and inability to return to prefracture functional status at 1 year as well as >30% mortality at 2 years. In this opinion piece, we will discuss how a multidisciplinary approach that includes Anesthesia as well as utilization of peripheral nerve blocks can help to lessen postoperative issues and improve recovery.

Aetiology of Type 2 diabetes in people with a 'normal' body mass index: testing the personal fat threshold hypothesis.

Weight loss in overweight or obese individuals with Type 2 diabetes (T2D) can normalize hepatic fat metabolism, decrease fatty acid oversupply to ß cells and restore normoglycaemia. One in six people has BMI <27 kg/m2 at diagnosis, and their T2D is assumed to have different aetiology. The Personal Fat Threshold hypothesis postulated differing individual thresholds for lipid overspill and adverse effects on ß-cell function. To test this hypothesis, people with Type 2 diabetes and body mass index <27kg/m2 (n = 20) underwent repeated 5% weight loss cycles. Metabolic assessments were carried out at stable weight after each cycle and after 12 months. To determine how closely metabolic features returned to normal, 20 matched normoglycemic controls were studied once. Between baseline and 12 months: BMI fell (mean ± SD), 24.8 ± 0.4 to 22.5 ± 0.4 kg/m2 (P<0.0001) (controls: 21.5 ± 0.5); total body fat, 32.1 ± 1.5 to 27.6 ± 1.8% (P<0.0001) (24.6 ± 1.5). Liver fat content and fat export fell to normal as did fasting plasma insulin. Post-meal insulin secretion increased but remained subnormal. Sustained diabetes remission (HbA1c < 48 mmol/mol off all glucose-lowering agents) was achieved by 70% (14/20) by initial weight loss of 6.5 (5.5-10.2)%. Correction of concealed excess intra-hepatic fat reduced hepatic fat export, with recovery of ß-cell function, glycaemic improvement in all and return to a non-diabetic metabolic state in the majority of this group with BMI <27 kg/m2 as previously demonstrated for overweight or obese groups. The data confirm the Personal Fat Threshold hypothesis: aetiology of Type 2 diabetes does not depend on BMI. This pathophysiological insight has major implications for management.

Parasternal intercostal plane block catheters for cardiac surgery: a retrospective, propensity weighted, cohort study.

Aim: Anesthesia for cardiac surgery has evolved toward fast-track recovery strategies incorporating non opioid analgesics and regional anesthesia. Materials & methods: This retrospective cohort study compared opioid consumption, pain scores and length of stay in patients who underwent cardiac surgery via median sternotomy and did or did not receive preoperative parasternal intercostal plane block catheters with postoperative ropivacaine infusions. Results: Postoperative opioid consumption and postoperative pain scores did not differ. Blocks were associated with decreased intraoperative opioids and reduced length of stay in the intensive care unit and hospital. Conclusion: Parasternal intercostal plane block catheters were not associated with decreased postoperative opioid consumption or pain scores, but were associated with reduced intraoperative opioids and length of stay.

Tropical rock lobster (Panulirus ornatus) uses chemoreception via the antennular lateral flagellum to identify conspecific ecdysis.

The tropical rock lobster, Panulirus ornatus, is a commercially important aquaculture species exhibiting complex social interactions in laboratory culture, including cannibalism of moulting conspecifics. Cannibalism of soft-shelled post-moult stage individuals is a major limitation during the juvenile stage of culture. Not limited to P. ornatus, cannibalism is widespread across farmed decapods, limiting stocking densities in crab, freshwater crayfish, and prawn species. To understand the mechanisms driving this behaviour and reduce its prevalence, we have investigated the role of chemoreception via the aesthetasc-bearing region of the lateral antennular flagellum, in the recognition of conspecific moulting cues. Differential expression analysis of several tissues in P. ornatus shows an upregulation of 70 ionotropic receptor isoforms, including co-receptors (IR25a and IR93a) and divergent receptors (IR4, IR7, and IR21a) in the aesthetasc-bearing region of the antennules. Deafferentation of the aesthetascs via deionised water exposure prevents juveniles from responding to conspecific moulting cues in a two-current choice flume, suggesting chemoreception, possibly olfaction, plays a role in identifying moulting juveniles. This is the first step in understanding the mechanisms via which cannibalism is triggered in juvenile P. ornatus culture. Further work in this area will help discover means to limit cannibalism in laboratory and commercial culture.

Creation of a Novel Child Simulator and Curriculum to Optimize Administration of Seizure Rescue Medication.

INTRODUCTION: Although most cases of pediatric convulsive status epilepticus start in the prehospital setting, many patients do not receive treatment. The use of prehospital seizure rescue medications by caregivers is crucial, but studies suggest a lack of proper training on medication use. METHODS: We created a novel proof of principle mannequin and simulation for training proper administration of rectal diazepam, with a scoring paradigm to standardize and assess the educational process. RESULTS: Twenty-three health care providers (nurses and nurse practitioners, residents/fellows, and attending physicians) and 5 patient guardians/parents were included in the study. The rectal diazepam simulator displayed a high degree of physical and emotional realism (mean ≥ 4/5 on Likert scale survey) that effectively decreased time to treatment (-12.3 seconds; SD, 16.3) and improved the accuracy of medication delivery in a simulation setting (-4.2 points; SD, 3.1). The scoring technique had appropriate interrater reliability (≥86% on all but 2 prompts) and was a feasible instrument to assess the effectiveness of the educational intervention. CONCLUSIONS: A unique procedure-focused child simulator and rescue medication score offer an innovative and effective means to train caregivers on the use of lifesaving seizure rescue medications.

Development of a two-current choice flume behavioural bioassay for juvenile Panulirus ornatus response to moulting cues.

Characterising crustacean behaviour in response to conspecific chemical cues contributes to our evolving knowledge of the drivers of their social behaviour. There is particular interest in understanding the chemical and behavioural mechanisms contributing to cannibalism at ecdysis, as this behaviour substantially limits culture productivity of several commercially important crustaceans. Before investigating the role of chemoreception in cannibalism of moulting crustaceans, we must investigate its role in detecting moulting conspecifics. Here we use a two-current choice flume to observe juvenile tropical rock lobster (Panulirus ornatus) behavioural response to conspecific moulting cues and identifying attracted and avoidant behaviours correlating to moult stage and social relationship. Observed cue preferences show inter-moult juveniles are attracted to the moulting cues of lobsters to which they are socially naïve. In contrast, post-moult and inter-moult juveniles avoid the moulting cues of individuals whom they are socially familiar with. Average speed and total distance travelled by lobsters increases in response to conspecific moulting cues. This study demonstrates the suitability of a two-current choice flume for behavioural assays in P. ornatus and characterises clear behavioural patterns in juveniles exposed to conspecific moulting cues. This provides important framework for understanding the role of chemical communication in eliciting cannibalism.

Comparison of lateral quadratus lumborum and lumbar plexus blocks for postoperative analgesia following total hip arthroplasty: a randomized clinical trial.

INTRODUCTION: Effective analgesia after total hip arthroplasty must minimize pain and optimize early ambulation. Lumbar plexus blocks (LPBs) provide analgesia but may cause motor weakness. Quadratus lumborum blocks (QLBs) may provide analgesia with preserved motor strength. METHODS: This trial randomized subjects scheduled for elective hip arthroplasty to receive an LPB or lateral QLB for postoperative analgesia. The primary outcome was opioid consumption at 12-hour postoperative. Non-inferiority of lateral QLBs compared with LPBs was conducted using a one-sided two-sample t-test. Secondary outcomes included pain scores, cumulative opioid consumption, quadriceps strength, time to ambulation, and distance ambulated. Differences in pain scores and opioid consumption over time between groups were evaluated using a linear mixed model. RESULTS: The trial consented and randomized 111 subjects and 103 completed the study: LPB (n=50) and lateral QLB (n=53). Mean (95% CI) cumulative opioid consumption (mg) at 12-hour postoperative was not found to be non-inferior in the lateral QLB (15.9 (12.7 to 19.2)) vs the LPB (12.7 (10.2 to 15.1)) group (p=0.625). Pain scores in postoperative anesthetic care unit (PACU) and 24-hour postoperative did not differ. The maximum distance ambulated did not differ, but lateral QLB patients were 2.4 times more likely to ambulate in the first 12 hours (p=0.024) and had significantly greater quadriceps strength in PACU (p<0.001). DISCUSSION: Although we were unable to demonstrate non-inferiority for opioid consumption at 12-hour postoperative, strength and mobilization were improved in lateral QLB subjects. TRIAL REGISTRATION NUMBER: NCT04402437.

Active Rehabilitation in a Patient During and After Venovenous Extracorporeal Membrane Oxygenation With a Diagnosis of COVID-19: A Case Report.

PURPOSE: The coronavirus disease-2019 (COVID-19) pandemic has resulted in an influx of critically ill patients requiring mechanical ventilation, some receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO). The benefits of early mobility while undergoing ECMO have been previously documented. However, the COVID-19 pandemic has presented physical therapists with novel challenges, balancing the risk of a widespread shortage of personal protective equipment (PPE) with the benefits of early mobility for patients on ECMO. The purpose of this case study is to report the successful rehabilitation of a critically ill patient with COVID-19 undergoing VV ECMO. METHODS: This is a case description of a 38-year-old man who presented to the hospital with COVID-19 and subsequent intubation and cannulation for VV ECMO. Physical therapy was initiated while the patient remained critically ill on VV ECMO. Focused coordination and education were employed to limit PPE usage by limiting the number of essential staff/therapists that entered the room as well as changing the frequency of therapy sessions dependent on how the patient was progressing functionally. RESULTS: On VV ECMO day 11, he was able to sit up and perform a sit-to-stand. ECMO decannulation occurred on hospital day 14 with extubation on hospital day 18. The patient progressed functionally while quarantined in the room until he was discharged home with supplemental oxygen after spending 29 days in the hospital. CONCLUSION: This case study demonstrates the clinical decision-making used to provide physical therapy services for a critically ill patient with COVID-19. High-level team coordination resulted in limiting the use of PPE as well as reducing staff exposure frequency during rehabilitation. Despite his severe critical illness, the patient was successfully discharged home within 30 days.

Low Oxygen Stress During Early Development Influences Regulation of Hypoxia-Response Genes in Farmed Atlantic Salmon (Salmo salar).

Survival and growth of developing salmonids are negatively affected by low oxygen levels within gravel nests in natural streams, and hypoxic stress is often experienced by farmed Atlantic salmon (Salmo salar) within hatcheries. Exposure to hypoxia during early development may have long-lasting effects by altering epigenetic marks and gene expression in oxygen regulatory pathways. Here, we examine the transcriptomic response to low dissolved oxygen (DO) in post-hatch salmon reared continuously in 30%, 60% or 100% DO from fertilization until start of feeding. RNA sequencing revealed multiple differentially expressed genes, including oxygen transporting hemoglobin embryonic α subunit (hbae) and EGLN3 family hypoxia-inducible factor 3 (egln3) which regulates the stability of hypoxia inducible factor 1α (HIF-1α). Both hbae and egln3 displayed expression levels inversely correlated to oxygen concentration, and DNA methylation patterns within the egln3 promoter were negatively associated with the transcript levels. These results suggest that epigenetic processes are influenced by low oxygen levels during early development in Atlantic salmon to upregulate hypoxia-response genes.

Early Mobilization in the ICU: A Collaborative, Integrated Approach.

To develop and implement a protocol to increase patient mobility in three adult ICUs using an interdisciplinary approach and existing resources. DESIGN: The Iowa Model of Evidence-Based Practice was used for synthesis of literature and intervention planning. A retrospective pre- and post-intervention data collection design was used to compare outcomes of interest. SETTING: Three adult ICUs (64 total beds) in an urban, academic hospital. Physician, nursing, respiratory therapy, physical therapy, and occupational therapy representatives participated in planning and development. All adult ICU patients were included. INTERVENTIONS: Development and implementation of an inclusive early mobility protocol in three adult ICUs. Focus on interdisciplinary collaboration to restructure workflow, focusing on optimization and coordination of standard tasks. Multimodal education occurred in an interdisciplinary setting and on-site champions facilitated implementation. MEASUREMENTS AND MAIN RESULTS: Time from admission to ambulation, overall frequency of ambulation, and frequency of ambulation by age group were assessed across three time periods: no awareness (Time 1), awareness without protocol (Time 2), and protocolization (Time 3). Decrease in hours from admission to ambulation were seen in the cardiovascular ICU (62.3 vs 56.1; p = 0.10) and surgical ICU (64.9 vs 58.6; p = 0.022). Significant increase demonstrated in the proportion of patients who ambulated while in the ICU (24.6% vs 33.0%; p < 0.001). All age groups had increase in frequency of ambulation. The largest gains in patients over 65 years old (T1 = 19.7%, T2 = 26.6%, T3 = 30.9%; p < 0.001). No change found in ICU length of stay, hospital length of stay, or ventilator days. CONCLUSIONS: This single-center evidenced-based practice project demonstrated increased mobility for ICU patients without addition of staff resources following implementation of an early mobility protocol using an interdisciplinary approach. Successful implementation led to creation of mobility protocol toolkit for use across all ICUs in the broader health system.

Low-carbohydrate interventions for adolescent obesity: Nutritional adequacy and guidance for clinical practice.

Low-carbohydrate dietary patterns are re-emerging as a popular method of weight reduction. However, their nutritional adequacy to meet the needs of growing adolescents should be considered. This study aimed to design theoretical low-carbohydrate meal plans for clinical use in the management of adolescent obesity and assess nutritional adequacy. Meal plans were created for three levels of carbohydrate restriction (≤30, ≤50 and ≤120 g/day) without energy, protein or total fat restriction. Nutrient analysis was conducted using the FoodWorks Australia Ltd software (databases: AUSNUT 2013, AusBrands 2017, AusFoods 2017, NUTTAB 2010, New Zealand FOODfiles 2016), and compared with Australian Nutrient Reference Values for male and female adolescents aged 14 to 18 years. All low-carbohydrate meal plans met the Recommended Dietary Intake, Adequate Intake or Estimated Average Requirements for most micronutrients at an energy intake of 6.3 to 7.2 MJ/day (1510-1730 kcal/day). The proportion of energy from saturated fat exceeded recommendations across all models (11.3%-17.1%). Dietary manipulation was required to minimize saturated fat and reach micronutrient adequacy, particularly for calcium in males and females, and iron for females. In practice, this may be challenging considering individual lifestyle and preferences. Therefore, the use of low-carbohydrate diets with adolescents should be monitored by a trained professional to ensure nutritional adequacy.

Low-Carbohydrate Diets in the Management of Obesity and Type 2 Diabetes: A Review from Clinicians Using the Approach in Practice.

Low-carbohydrate diets are increasingly used to help patients with obesity and type 2 diabetes. We sought to provide an overview of the evidence for this treatment approach, considering the epidemiology and pathophysiology of obesity and diabetes in terms of carbohydrate excess. We describe the mechanistic basis for the clinical benefits associated with nutritional ketosis and identify areas of practice where the evidence base could be improved. We summarize the key principles which inform our approach to treating patients with low-carbohydrate diets. The scientific controversy relating to these diets is real but is consistent with the known challenges of any dietary interventions and also the limitations of nutritional epidemiology. Secondly, notwithstanding any controversy, international guidelines now recognize the validity and endorse the use of these diets as a therapeutic nutritional approach, in appropriate patients. Thirdly, we have found that early de-prescription of diabetes medications is essential, in particular insulin, sulphonylureas, and sodium-glucose cotransporter (SGLT2) inhibitors. Fourthly, we encourage patients to eat ad libitum to satiety, rather than calorie counting per se. Furthermore, we monitor cardiovascular risk factors frequently, as with all patients with obesity or diabetes, but we do not necessarily consider an increase in low-density lipoprotein (LDL)-cholesterol as an absolute indication to stop these diets, as this is usually related to large LDL particles, which are not associated with increased cardiovascular risk. In the absence of large randomized controlled trials with cardiovascular and other hard endpoints, adopting a low-carbohydrate diet is a legitimate and potentially effective treatment option for patients with diabetes or obesity.

The Crisis of Deficiency in Emergency Coverage for Hand and Facial Trauma: Exploring the Discrepancy Between Availability of Elective and Emergency Surgical Coverage.

INTRODUCTION: Injuries are one of the most common reasons for emergency department visits, with approximately 40.2 million injury-related visits occurring in 2011. Facial, hand, and wrist injuries make up a large portion of these visits. Despite the high demand for specialists to attend to these injury-related emergency department visits, recent studies have suggested a discrepancy between elective surgical coverage and trauma care in general. The goal of this study was to determine if there was a difference between access to elective surgical procedures in comparison with on-call emergency care for facial and hand/wrist conditions in New York State. METHODS: Hospitals throughout New York State, excluding New York City, were selected from the Department of Health Web site, hospitals.nyhealth.gov. A phone survey was administered between May 2012 and October 2013, to quantify the availability of elective and emergent procedures for facial and hand/wrist conditions. We compared the availability of emergency facial and hand/wrist surgical care based on hospital characteristics such as bed size and access to a surgical intensive care unit. RESULTS: We selected 113 hospitals, and 52 hospitals participated for a response rate of 46%. A total of 88% of hospitals offered elective hand procedures, but only 27% had consistent coverage for emergency hand trauma. Furthermore, only 29 % of hospitals had a facial specialist consistently available whereas the availability for elective facial procedures was 79%. CONCLUSION: Our study results show a discrepancy between the availability of surgeons for elective procedures and on-call emergency care for facial and hand/wrist condition.

Post-operative pain control for burn reconstructive surgery in a resource-restricted country with subcutaneous infusion of local anesthetics through a soaker catheter to the surgical site: Preliminary results.

OBJECTIVE: Post-operative pain can significantly affect a patient's ability to recover following surgery. In this study we introduced the concept of post-operative pain evaluation of burn patients as well as a technique for placement and use of subcutaneous catheters for continuous infusion of local anesthetic to provide analgesia following skin harvest from the lateral thigh in a hospital in resource-restricted country--Ukraine. METHODS: A total of 109 patients were enrolled in this study. In the control group 64 patients received the standard post-operative pain regimen of metamizole 1 g and/or ketorolac 3%- 30 mg at the discretion of the nursing staff. In the interventional group, 45 patients received the catheter infusion of local anesthetic by elastomeric pump which was placed intraoperatively; it continuously delivers a regulated flow 4-5 ml/h of procaine 0.5% for 48 h to a patient's surgical donor site with the standard pain regimen available for breakthrough pain. All patients were assessed post-operatively and in the peri-dressing change period by the nursing staff. Blood pressure, heart rate, and pain scores were documented based on the Wong-Baker Faces Pain Rating Scale. All data were analyzed using SAS version 9.3. The Student's t test and Fisher's exact test were used to assess differences between groups for continuous variables. The Mann-Whitney U Test was used to examine differences in pain scores between groups. A p value of <0.05 was considered significant. RESULTS: The median pain score immediately following surgery was 5.0 in the control group, which was significantly greater (p=0.03) than median pain score of 4.0 for the patients receiving continuous infusion of procaine. However, there is no statistically significant difference in the median pain score (3.0 and 3.0) after the initial dressing change (p=0.73). CONCLUSIONS: Our Ukrainian colleagues now have a method of objective pain assessment and a new technique in pain management. With assessment linked to intervention, improvement in post-operative pain can be expected.

Risk factors for retained placenta.

OBJECTIVE: Retained placenta complicates 2-3% of vaginal deliveries and is a known cause of postpartum hemorrhage. Treatment includes manual or operative placental extraction, potentially increasing risks of hemorrhage, infections, and prolonged hospital stays. We sought to evaluate risk factors for retained placenta, defined as more than 30 minutes between the delivery of the fetus and placenta, in a large US obstetrical cohort. STUDY DESIGN: We included singleton, vaginal deliveries ≥24 weeks (n = 91,291) from the Consortium of Safe Labor from 12 US institutions (2002-2008). Multivariable logistic regression analyses estimated the adjusted odds ratios (OR) and 95% confidence intervals (CI) for potential risk factors for retained placenta stratified by parity, adjusting for relevant confounding factors. Characteristics such as stillbirth, maternal age, race, and admission body mass index were examined. RESULTS: Retained placenta complicated 1047 vaginal deliveries (1.12%). Regardless of parity, significant predictors of retained placenta included stillbirth (nulliparous adjusted OR, 5.67; 95% CI, 3.10-10.37; multiparous adjusted OR, 4.56; 95% CI, 2.08-9.94), maternal age ≥30 years, delivery at 24 0/7 to 27 6/7 compared with 34 weeks or later and delivery in a teaching hospital. In nulliparous women, additional risk factors were identified: longer first- or second-stage labor duration, whereas non-Hispanic black compared with non-Hispanic white race was found to be protective. Body mass index was not associated with an increased risk. CONCLUSION: Multiple risk factors for retained placenta were identified, particularly the strong association with stillbirth. It is plausible that there could be something intrinsic about stillbirth that causes a retained placenta, or perhaps there are shared pathways of certain etiologies of stillbirth and a risk of retained placenta.

The PPARß/δ agonist GW0742 modulates signaling pathways associated with cardiac myocyte growth via a non-genomic redox mechanism.

Peroxisome proliferator-activated receptors (PPARs) are ligand-activated transcription factors that belong to the nuclear hormone receptor superfamily and appear to have beneficial effects in the cardiovascular system. PPARß/δ has been shown previously to exert an inhibitory effect on cardiac myocyte hypertrophy in vivo and in vitro although the exact mechanism is not fully clear yet. The principal signaling pathways that have been involved in triggering cardiac hypertrophic response are mitogen-activated protein kinases (MAPKs) and PI3K/Akt cascades. In this study, we sought to evaluate the potential effects evoked by PPARß/δ activation on signaling pathways that are implicated in cardiac myocyte growth responses. The selective PPARß/δ agonist GW0742 attenuated ERK1/2 and Akt phosphorylation that was stimulated by growth promoting agonists (phenylephrine, insulin or IGF-1). This effect was not reversed by the specific PPARß/δ antagonist, GSK0660, but was inhibited by vanadate, a potent protein tyrosine phosphatase inhibitor. In addition, GW0742 prevented the oxidation and inactivation of PTEN supporting further the notion that its inhibitory action on the agonist-induced kinase phosphorylation is mediated by the modulation of phosphatase activity. Furthermore, GW0742 abolished the agonist-induced intracellular generation of reactive oxygen species, independently of PPARß/δ activation. Our data reveals a new non-genomic mechanism of GW0742, which ameliorates the generation of reactive oxygen species and attenuates ERK1/2 and PI3K/Akt signaling, with implications in the regulation of cardiac hypertrophic response.

Underreporting of viral encephalitis and viral meningitis, Ireland, 2005-2008.

Viral encephalitis (VE) and viral meningitis (VM) have been notifiable infectious diseases under surveillance in the Republic of Ireland since 1981. Laboratories have reported confirmed cases by detection of viral nucleic acid in cerebrospinal fluid since 2004. To determine the prevalence of these diseases in Ireland during 2005-2008, we analyzed 3 data sources: Hospital In-patient Enquiry data (from hospitalized following patients discharge) accessed through Health Intelligence Ireland, laboratory confirmations from the National Virus Reference Laboratory, and events from the Computerised Infectious Disease Reporting surveillance system. We found that the national surveillance system underestimates the incidence of these diseases in Ireland with a 10-fold higher VE hospitalization rate and 3-fold higher VM hospitalization rate than the reporting rate. Herpesviruses were responsible for most specified VE and enteroviruses for most specified VM from all 3 sources. Recommendations from this study have been implemented to improve the surveillance of these diseases in Ireland.

PPAR-alpha activation as a preconditioning-like intervention in rats in vivo confers myocardial protection against acute ischaemia-reperfusion injury: involvement of PI3K-Akt.

Peroxisome proliferator-activated receptors (PPAR) regulate the expression of genes involved in lipid metabolism, energy production, and inflammation. Their role in ischaemia-reperfusion (I/R) is less clear, although research indicates involvement of PPARs in some forms of preconditioning. This study aimed to explore the effects of PPAR-α activation on the I/R injury and potential cardioprotective downstream mechanisms involved. Langendorff-perfused hearts of rats pretreated with the selective PPAR-α agonist WY-14643 (WY, pirinixic acid; 3 mg·(kg body mass)·day(-1); 5 days) were subjected to 30 min ischaemia - 2 h reperfusion with or without the phosphatidylinositol 3-kinase (PI3K)-Akt inhibitor wortmannin for the evaluation of functional (left ventricular developed pressure, LVDP) recovery, infarct size (IS), and reperfusion-induced arrhythmias. A 2-fold increase in baseline PPAR-α mRNA levels (qPCR) in the WY-treated group and higher post-I/R PPAR-α levels compared with those in untreated controls were accompanied by similar changes in the expression of PPAR-α target genes PDK4 and mCPT-1, regulating glucose and fatty acid metabolism, and by enhanced Akt phosphorylation. Post-ischaemic LVDP restoration in WY-treated hearts reached 60% ± 9% of the pre-ischaemic values compared with 24% ± 3% in the control hearts (P < 0.05), coupled with reduced IS and incidence of ventricular fibrillation that was blunted by wortmannin. Results indicate that PPAR-α up-regulation may confer preconditioning-like protection via metabolic effects. Downstream mechanisms of PPAR-α-mediated cardioprotection may involve PI3K-Akt activation.