Acute diabetic neuropathy following improved glycaemic control: a case series and review.

SUMMARY: We present three cases of acute diabetic neuropathy and highlight a potentially underappreciated link between tightening of glycaemic control and acute neuropathies in patients with diabetes. Case 1: A 56-year-old male with poorly controlled type 2 diabetes (T2DM) was commenced on basal-bolus insulin. He presented 6 weeks later with a diffuse painful sensory neuropathy and postural hypotension. He was diagnosed with treatment-induced neuropathy (TIN, insulin neuritis) and obtained symptomatic relief from pregabalin. Case 2: A 67-year-old male with T2DM and chronic hyperglycaemia presented with left lower limb pain, weakness and weight loss shortly after achieving target glycaemia with oral anti-hyperglycaemics. Neurological examination and neuro-electrophysiological studies suggested diabetic lumbosacral radiculo-plexus neuropathy (DLPRN, diabetic amyotrophy). Pain and weakness resolved over time. Case 3: A 58-year-old male was admitted with blurred vision diplopia and complete ptosis of the right eye, with intact pupillary reflexes, shortly after intensification of glucose-lowering treatment with an SGLT2 inhibitor as adjunct to metformin. He was diagnosed with a pupil-sparing third nerve palsy secondary to diabetic mononeuritis which improved over time. While all three acute neuropathies have been previously well described, all are rare and require a high index of clinical suspicion as they are essentially a diagnosis of exclusion. Interestingly, all three of our cases are linked by the development of acute neuropathy following a significant improvement in glycaemic control. This phenomenon is well described in TIN, but not previously highlighted in other acute neuropathies. LEARNING POINTS: A link between acute tightening of glycaemic control and acute neuropathies has not been well described in literature. Clinicians caring for patients with diabetes who develop otherwise unexplained neurologic symptoms following a tightening of glycaemic control should consider the possibility of an acute diabetic neuropathy. Early recognition of these neuropathies can obviate the need for detailed and expensive investigations and allow for early institution of appropriate pain-relieving medications.

How many sputum samples should be examined during follow-up of tuberculosis patients in Myanmar: two or one?

Setting: Ten selected microscopy centres in Sagaing Region, Myanmar, functioning under an external quality assurance system with no reported major errors. Objective: To assess the pattern of serial sputum results (NN, both smear-negative; NP, first smear-negative and second smear-positive; PN, first smear-positive and second smear-negative; and PP, both smear-positive) among follow-up sputum microscopy examinations of tuberculosis (TB) patients (end of intensive phase, mid-continuation phase and end of treatment) conducted from 1 November 2017 to 15 April 2018. Design: Cross-sectional study using secondary data (laboratory registers). Results: Of 2001 examinations, 94 (4.7%) were smear-positive: 66 PP (3.3%), 12 PN (0.6%) and 16 NP (0.8%); 75% of NP results were scanty. The proportion of NP results was 0.8% (95%CI 0.5-1.3), i.e., 125 smears (95%CI 77-200) were required to detect one additional smear-positive result in the second sample. Of the 16 NP results (15 patients), 14 were tested using Xpert® MTB/RIF and none had rifampicin resistance. During the continuation phase of treatment, 13 became smear-negative, one remained smear-positive and one had unknown follow-up smear status. Conclusion: The benefit of the second sputum sample for monitoring anti-tuberculosis treatment was negligible. Given the favourable resource implications (reduced laboratory workload and costs), we recommend changing the policy from two sputum smears to one during follow-up sputum examinations of TB patients.

Contexte : Dix centres de microscopie sélectionnés de la région de Sagaing, Myanmar, fonctionnant avec un système d'assurance de qualité externe sans erreurs majeures rapportées.Objectif : Evaluer les profils de séries de résultats de crachats (NN, deux frottis négatifs ; NP, premier frottis négatif et deuxième frottis positif ; PN, premier frottis positif et deuxième frottis négatif ; et PP, deux frottis positifs) parmi les examens de suivi de microscopie de crachats de patients TB (à la fin de la phase intensive, au milieu de la phase de continuation et à la fin du traitement) réalisés du 1e novembre 2017 au 15 avril 2018.Schéma : Etude transversale grâce à des données secondaires (registres de laboratoire).Résultats : Sur 2001 examens, 94 (4,7%) ont eu un frottis positif : 66 (3,3%) PP ; 12 (0,6%) PN ; 16 (0,8%) NP ; 75% des NP avaient de rares bacilles. La proportion de NP a été de 0,8% (IC95% 0,5­1,3), impliquant qu'il a fallu 125 frottis (IC95% 77­200) pour détecter un frottis positif supplémentaire dans un deuxième échantillon. Sur les 16 NP (15 patients), 14 ont été testés par Xpert® MTB/RIF et aucun n'a eu de résistance à la rifampicine. Lors de la continuation du traitement, 13 sont devenus à frottis négatif, un patient est resté à frottis positif et un autre a eu un frottis de suivi « indéterminé ¼.Conclusion : Le bénéfice du deuxième échantillon de crachats pour le suivi du traitement antituberculeux a été négligeable. Devant les implications favorables en termes de ressources (charge de travail et coûts réduits pour le laboratoire), nous recommandons de modifier la politique de deux frottis de crachats à un seul lors du suivi de patients TB par examens des crachats.

Marco de Referencia: Diez centros de microscopia escogidos en la región de Sagaing de Birmania, que funcionan con un sistema externo de garantía de la calidad y no notifican errores importantes.Objetivos: Evaluar el perfil de los resultados seriados del esputo (NN, ambas baciloscopias negativas; NP, primera baciloscopia negativa y segunda positiva; PN, primera baciloscopia positiva y segunda negativa; y PP, ambas baciloscopias positivas) en las baciloscopias de esputo de seguimiento de los pacientes con tuberculosis (TB) (al final de la fase intensiva, en medio de la fase de continuación y al final del tratamiento), realizadas del 1° de noviembre del 2017 al 15 de abril del 2018.Métodom: Fue este un estudio transversal que utilizó datos secundarios (los registros de laboratorio).Resultados: De las 2001 baciloscopias realizadas, 94 (4,7%) fueron positivas, a saber: 66 (3,3%) PP; 12 (0,6%) PN; 16 (0,8%) NP; 75% de los resultados NP se notificaron como 'escasos bacilos'. La proporción de resultados NP fue 0,8% (IC95% 0,5­1,3), lo cual indica que se precisaron 125 baciloscopias a fin de detectar una baciloscopia positiva adicional en la segunda muestra (IC95% 77­200). De los 16 casos NP (15 pacientes), 14 se examinaron mediante la prueba Xpert® MTB/RIF y ninguno exhibió resistencia a rifampicina. Durante la fase de continuación del tratamiento, en 13 casos la baciloscopia se hizo negativa, uno permaneció positivo y en otro caso el resultado de la baciloscopia de seguimiento era 'desconocido'.Conclusión: La utilidad de una segunda muestra de esputo en la supervisión del tratamiento antituberculoso fue insignificante. Teniendo en cuenta sus repercusiones económicas favorables (disminución de la carga de trabajo y los costos de laboratorio), se recomienda cambiar la norma de practicar dos muestras de esputo por una sola muestra, durante las baciloscopias de seguimiento de los pacientes con TB.

Factors influencing elevated serum apolipoprotein B48 in diabetic and control participants.

Factors influencing the concentration of apolipoprotein B48 (apo B48) at fasting and post-prandial time frames are still being elucidated. This study assesses some possible contributing factors including the presence of type 2 diabetes and gender using an established enzyme-linked immunosorbent assay (ELISA) method. Apo B48 and triglyceride (TG) levels were measured before and for two, four and six hours post-prandially in 49 poorly controlled participants with type 2 diabetes and in 60 apparently healthy participants (controls). Apo B48 levels in the control participants increased post-prandially, peaking at four hours (14.81 ± 7.72 µg/mL) with similar responses demonstrated in TG concentrations. Post-prandial apo B48 levels were significantly higher in male control participants as demonstrated by apo B48 area under the curve (AUC); similar responses were also confirmed in triglyceride AUC. Post-prandial apo B48 concentrations in control participants correlated with HOMA-IR (P < 0.05). Apo B48 continued to increase throughout the six hours in participants with type 2 diabetes (17.73 ± 13.46 µg/mL), when levels were significantly greater than in the control participants (13.04 ± 7.67 µg/mL) (P < 0.05) despite a decrease in accompanying TG levels in participants with type 2 diabetes. Using an ELISA method, this study demonstrated that gender, insulin resistance (as evidenced by HOMA-IR) and diabetes status influence serum apo B48 levels. These effects were only apparent post-prandially.

Barriers to exercise in obese patients with type 2 diabetes.

BACKGROUND: Although regular exercise is a critical component of the management of type 2 diabetes, many patients do not meet their exercise targets. Lack of exercise is associated with obesity and adverse cardiovascular outcomes. AIM: We aimed to assess exercise habits in obese Irish patients with type 2 diabetes to determine if patients are adhering to exercise guidelines and to identify perceived barriers to exercise in this group. DESIGN: A cross-sectional study of obese patients with type 2 diabetes attending routine outpatient diabetes clinics at our institution, a public teaching hospital located on the outskirts of Dublin City. METHODS: A total of 145 obese patients with type 2 diabetes were administered a questionnaire to evaluate exercise habits and perceived barriers to exercise. Anthropometric details were measured. RESULTS: About 47.6% (n = 69) of patients exercised for <150 minutes per week (40% of males, 62% of females; P = 0.019) and these patients had a higher body mass index than those meeting targets (35 vs. 33.5 kg/m(2); P = 0.02). Perceived barriers to exercise were varied, with lack of time and physical discomfort being the most common. Reported barriers to exercise varied with age, gender and marital status. CONCLUSION: This study highlights the challenges facing clinicians in improving exercise levels in patients, and the need to identify the specific barriers to exercise in the individual to improve health outcomes.

Serum prolactin concentration at presentation of non-functioning pituitary macroadenomas.

OBJECTIVE: Serum PRL levels at presentation may be useful in distinguishing between disconnection hyperprolactinemia in non-secretory pituitary adenomas and prolactinomas in order to guide appropriate therapy; however, there is a debate regarding the discriminatory PRL thresholds. We aimed to examine PRL concentrations at presentation in a cohort of histologically proven non-functioning pituitary adenomas (NFPA). DESIGN AND METHODS: Retrospective case note analysis was performed. Clinical, biochemical, histopathological and radiological data were recorded and analyzed. Complete data were available for 250 subjects with NFPA. RESULTS: Of the study population, 44.8% were hyperprolactinemic at presentation, 55.3% of whom were female. Of those with hyperprolactinemia, 73.2% had PRL<1000 mIU/l on presentation, 24.1% had PRL between 1000 and 1999 mIU/l. Only 2.7% (no.=3 females, 1.2% whole cohort) had PRL>2000 mIU/l (94.3 ng/ml), 2 of whom were pregnant. No male subject and no subjects with an intrasellar macroadenoma had serum PRL>1000 mIU/l (47.2 ng/ml). Overall, serum PRL was not higher among 43 subjects taking medications known to raise PRL. CONCLUSIONS: Our data support recent evidence that the serum PRL concentration is rarely >1000 mIU/l in males, or >2000 mIU/l in females, with non-functioning macroadenomas and that, once other contributing factors to the hyperprolactinemia have been excluded, a trial of dopamine agonist therapy for such lesions is indicated.

Leucocytosis in women with polycystic ovary syndrome (PCOS) is incompletely explained by obesity and insulin resistance.

OBJECTIVES: Low-grade chronic inflammation predicts cardiovascular outcomes and is observed in women with polycystic ovary syndrome (PCOS). Whether this is entirely a cause or consequence of insulin resistance (IR) is unknown. METHODS: Seventy pairs of women with and without PCOS, matched for age, body mass index (BMI) and IR (HOMA, QUICKI and Avignon index), were generated from a larger cohort of 103 women with and 104 BMI-matched women without PCOS. Women with PCOS were studied in the follicular phase of the menstrual cycle. White cell count (WCC), high-sensitivity CRP (hsCRP) and a series of 12 cytokines and growth factors were measured. These inflammatory markers were also compared between women with PCOS and 10 normal women studied in the follicular, peri-ovulatory and luteal stages. RESULTS: When all subjects were compared, WCC (6.75 × 10(9) vs 5.60 × 10(9 ) g/l, P < 0.005), hsCRP (4.04 vs 2.90 mg/l, P < 0.05) and IL-6 (1.11 vs 0.72 pg/ml, P < 0.05) were greater in women with PCOS. Pair-matching for IR eliminated between-group differences in hsCRP and cytokines but did not alter the difference in WCC (6.60 × 10(9) vs 5.60 × 10(9 ) g/l, P < 0.005). WCC was greater in PCOS compared to normal women at all stages of the menstrual cycle. CONCLUSIONS: Low-grade inflammation occurs in PCOS. Increased hsCRP and cytokines are associated with IR, but increased WCC is observed even when IR is accounted for. The explanation for this and its clinical significance is unknown.

Well-known but rare pathogen in neonates: Listeria monocytogenes.

Listeria monocytogenes is a very important life-threatening bacteria in certain risk groups such as neonates, pregnant women, elderly people, transplant recipients and others with impaired cell-mediated immunity. However, its infections are very rare in healthy children. Reports of listeriosis in newborn period are limited. We report a case of neonatal listeriosis with erythematous rash, intractable convulsions, severe early neonatal sepsis, disseminated intravascular coagulation, multiple organ dysfunction syndrome and death. Although an empirical antibiotic therapy including ampicillin (semisentetic penicillin) and aminoglycoside combination is effective by the means of a probable Listeria infection, the progression of the very early-onset disease may be fatal, despite vigorous treatment efforts as in our case.

Do-it-yourself grommets.

In the absence of a healthcare budget enabling the import of ready-made aural grommets, Myanmar ENT surgeons have devised an ingenious 'home-grown' solution. We describe how grommets are made from raw materials bought from the local market.

Imaging of blebs after phacotrabeculectomy with Ologen collagen matrix implants.

OBJECTIVE: To analyse blebs of phacotrabeculectomies performed with Ologen collagen implants (ProTop & MediKing, Taipei, Taiwan) and to compare these with blebs of mitomycin C (MMC)­augmented phacotrabeculectomies. METHODS: 33 participants underwent phacotrabeculectomy with Ologen implants, and 33 controls underwent phacotrabeculectomy with MMC. Blebs were analysed for height and area using anterior segment optical coherence tomography (ASOCT) at 30, 60 and 90 days after surgery and were also graded clinically with the Moorfields bleb grading system (MBGS) 60 days after surgery. RESULTS: With ASOCT, there was no difference in mean bleb height at 30 and 60 days, but at 90 days, bleb height was lower in the Ologen group (Ologen vs MMC, 0.74±0.20 vs 1.00±0.28 mm, p<0.001). There was no difference in mean bleb area at 30, 60 or 90 days. Mean reduction in intraocular pressure at 90 days was greater in the MMC group (Ologen vs MMC, 2.18±4.93 vs 8.00 ±7.60 mm Hg, p<0.001). At 90 days, the Ologen implants were visible in ASOCT images in 13 (39.4%) of 33 participants. With the Moorfields bleb grading system at 60 days, there was no difference in maximal bleb area score between the groups, but bleb height score was lower (Ologen vs MMC, 1.53±0.51 vs 1.81±0.59, p=0.05) and central bleb vascularity score was higher in the Ologen group (3.88±0.55 vs 2.91±0.59, p<0.001). CONCLUSIONS: Within 3 months of surgery, mean bleb height was lower in the Ologen blebs compared with the MMC blebs. The Ologen implants had not degraded in a third of eyes.

Lipoprotein subclass patterns in women with polycystic ovary syndrome (PCOS) compared with equally insulin-resistant women without PCOS.

OBJECTIVES: Women with polycystic ovary syndrome (PCOS) are more insulin resistant and display an atherogenic lipid profile compared with normal women of similar body mass index (BMI). Insulin resistance (IR) at least partially underlies the dyslipidemia of PCOS, but it is unclear whether PCOS status per se confers additional risk. RESEARCH DESIGN AND METHODS: Using a case-control design, we compared plasma lipids and lipoprotein subclasses (using polyacrylamide gel tube electrophoresis) in 70 women with PCOS (National Institutes of Health criteria) and 70 normal women pair matched for age, BMI, and IR (homeostasis model assessment-IR, quantitative insulin sensitivity check index, and the Avignon Index). Subjects were identified as having a (less atherogenic) type A pattern consisting predominantly of large low-density lipoprotein (LDL) subfractions or a (more atherogenic) non-A pattern consisting predominantly of small-dense LDL subfractions. RESULTS: Total, high-density lipoprotein, or LDL cholesterol, or triacylglycerol did not differ between the groups, but very low-density lipoprotein levels (P<0.05) were greater in women with PCOS, whereas a non-A LDL profile was seen in 12.9% compared with 2.9% of controls (P<0.05, chi2). Multiple regression analysis revealed homeostasis model assessment-IR and waist circumference to be independent predictors of very low-density lipoprotein together explaining 40.2% of the overall variance. Logistic regression revealed PCOS status to be the only independent determinant of a non-A LDL pattern (odds ratio 5.48 (95% confidence interval 1.082-27.77; P<0.05). CONCLUSIONS: Compared with women matched for BMI and IR, women with PCOS have potentially important differences in lipid profile with greater very low-density lipoprotein levels and increased rates of a more atherogenic non-A LDL pattern.

High-molecular-weight adiponectin is selectively reduced in women with polycystic ovary syndrome independent of body mass index and severity of insulin resistance.

CONTEXT: High-molecular-weight (HMW) adiponectin contributes to insulin resistance (IR), which is closely associated with the pathophysiology of polycystic ovary syndrome (PCOS). Abnormalities in adipocyte function have been identified in PCOS and potentially contribute to lower adiponectin concentrations. OBJECTIVE: Our objective was to determine which variables in plasma and adipose tissue influence HMW adiponectin in a well characterized cohort of women with PCOS. DESIGN: This was a cross-sectional study. SETTINGS AND PARTICIPANTS: A teaching hospital. Women with PCOS (n = 98) and body mass index (BMI)-matched controls (n = 103) (including 68 age-, BMI-, and IR-matched pairs). INTERVENTIONS: A standard 75-g oral glucose tolerance test was performed for each participant. Subcutaneous adipose tissue samples were taken by needle biopsy for a subset of PCOS women (n = 9) and controls (n = 8). MAIN OUTCOME MEASURES: Serum levels of HMW adiponectin and their relation to indices of insulin sensitivity, body composition, and circulating androgens as well as adipose tissue expression levels of ADIPOQ, TNFalpha, PPARgamma, and AR were assessed. RESULTS: HMW adiponectin was significantly lower in women with PCOS compared with both BMI- and BMI- and IR-matched controls (P = 0.009 and P = 0.027, respectively). Although BMI and IR were the main predictors of HMW adiponectin, an interaction between waist to hip ratio and plasma testosterone contributed to its variance (P = 0.026). Adipose tissue gene expression analysis demonstrated that AR and TNFalpha (P = 0.008 and P = 0.035, respectively) but not ADIPOQ mRNA levels were increased in PCOS compared with controls. CONCLUSIONS: HMW adiponectin is selectively reduced in women with PCOS, independent of BMI and IR. Gene expression analysis suggests that posttranscriptional/translational modification contributes to reduced HMW adiponectin in PCOS.

Efficient transmicrocatheter delivery of functional fibroblasts with a bioengineered collagen gel-platinum microcoil complex: toward the development of endovascular cell therapy for cerebral aneurysms.

BACKGROUND AND PURPOSE: Endoaneurysmal implantation of fibroblasts may promote healing of aneurysms and reduce recanalization after therapeutic embolization. The purpose of our study was to develop a device for delivery of fibroblasts with use of current microcoil technology. MATERIALS AND METHODS: Cell carrier devices and cell-free devices were fabricated by associating collagen gels (with or without fibroblasts) with platinum microcoils. During the propagation of control cell carrier devices for 1 week in culture, cell-mediated gel contraction (CMGC) occurred. Modified cell carrier devices created by glutaraldehyde cross-linking, ascorbate coculture, or extended CMGC were also characterized in vitro. Devices were deployed through microcatheters (533 microm lumen, 160 cm length). Gel retention, cell retention, cell death, and the ability to support local cell migration were analyzed in vitro. RESULTS: Cell viability was reduced by glutaraldehyde cross-linking but not by microcatheter transit. During microcatheter transit, cell carrier devices liberated minimal particulate matter and cellular DNA. Liberated particulate matter was reduced by glutaraldehyde cross-linking (P < .05) and extended CMGC (P < .04). Only cell carrier devices treated with glutaraldehyde cross-linking did not exhibit cell migration after microcatheter transit. Passage of cell-free devices through microcatheters sheared off most of their collagen gel. CONCLUSION: Collagen gel-platinum microcoil complexes can mediate efficient transmicrocatheter delivery of viable, migration-capable fibroblasts. CMGC is a necessary component of the process of gel stabilization that enables successful microcatheter transit. Although extended CMGC and glutaraldehyde cross-linking enhance gel stabilization, glutaraldehyde cross-linking decreases cell viability and migratory potential.

Genomic structure of mouse PIR-A6, an activating member of the paired immunoglobulin-like receptor gene family.

The gene for one of the activating members of the paired Ig-like receptor family, Pira6, was isolated from a genomic library and sequenced. The first of 9 exons in the approximately 8.2 kb Pira6 gene encodes the 5' untranslated region, the translation initiation site, and approximately half of the signal sequence. The second exon encodes the rest of the signal sequence, exons 3-8 each encode a single Ig-like extracellular domain, and exon 9 encodes the transmembrane region, cytoplasmic tail and 3' UTR with four polyadenylation signals and six mRNA instability sequences. A soluble form of PIR-A6 may be generated by alternative splicing. The exonic sequences account for approximately 42% of the Pira6 gene and approximately 34% for the single inhibitory Pirb gene, thus defining Pira and Pirb as genes with relatively short intronic sequences. Extensive sequence homology was found between Pira6 and Pirb from approximately 2 kb upstream of the ATG initiation site to the beginning of intron 8. The Pir genes appear to be distributed in three regions of the proximal end of chromosome 7 based on the present data and an analysis of currently available mouse genomic sequence databases. One region contains a single Pir gene which is almost identical to Pira6, and the other two contain multiple Pir genes in opposite transcriptional orientations. Potential binding sites for hemopoiesis-specific and ubiquitous transcription factors were identified upstream of the Pira6 transcription start sites that reside within the initiator consensus sequence motif. These results provide important clues to the coordinate regulation observed for PIR-A and PIR-B expression during hematopoiesis.

New type of matrix support for bone marrow cell cultures: in vitro culture and in vivo transplantation experiments.

A new type of bone marrow cell culture system was developed by using a highly porous substrate matrix, i.e., porous polyvinyl formal (PVF) resin. Murine bone marrow (BM) cells were cultured without the use of exogenous growth factors in a three-dimensional matrix support made of collagen coated porous PVF resin. To examine the optimal conditions for highest stromal cell density, short-term and long-term in vitro culture experiments using PVF were performed. In the short-term culture experiments, it was found that cubes of PVF (10 x 10 x 2 mm and 130 microm in pore size) coated with type I collagen with a seeding density of 2x10(7) BM cells offered the most appropriate culture conditions. In the long-term cultures, BM cells in PVF maintained their viability for up to 6 weeks. In another series of re-inoculation experiments, freshly isolated BM cells were inoculated onto the already developed stromal layer. In this study, a higher cell density of the stromal layer was obtained in the PVF culture compared with those in the control dish culture. Based upon the results of in vitro experiments, in vivo transplantation studies were also performed. Histologic examinations of the subcutaneously transplanted PVF with stroma revealed host derived hematopoiesis inside the PVF matrix. Moreover, survival of approximately 15% of the transplanted BM cells that were cultured in PVF were confirmed in X-ray irradiated recipients. From these results, it is suggested that PVF resin is a promising three-dimensional substrate for BM cell culture and that it can maintain hematopoietic stem cells or progenitor cells after transplantation.

A lower jaw of Pondaungia cotteri from the Late Middle Eocene Pondaung Formation (Myanmar) confirms its anthropoid status.

Pondaungia cotteri is the largest primate known from the Late Middle Eocene Pondaung Formation, Myanmar. Its taxonomic status has been the subject of much debate because of the fragmentary nature of its remains. Initially described as an anthropoid, some authors recently have associated it with adapid primates. These debates have been fueled not only by the incompleteness of the fossils attributed to Pondaungia but also by the reticence of many authors to regard Asia as an important evolutionary theater for Eocene anthropoids. During the November 1998 Myanmar-French Pondaung Expedition, a right lower jaw was discovered that yields the most nearly complete dentition of Pondaungia cotteri ever found: it shows the complete horizontal ramus, alveoli for the second incisor and canine, three premolars, and three molars. The symphysis showed all characteristics of anthropoids but was unfused. The canine root is large, the first premolar is absent, and the second premolar is single-rooted, reduced, and oblique in the tooth row, as in anthropoids. The premolars show a reduced mesio-distal length compared with the tooth row, and their morphology is very similar to that of Amphipithecus mogaungensis. Therefore, the two Pondaung taxa appear to be closely related to each other, with Siamopithecus as their sister taxon.

Dyspnea differentiation index: A new method for the rapid separation of cardiac vs pulmonary dyspnea.

STUDY OBJECTIVE: To assess the utility of a new parameter in the differentiation of dyspnea of cardiac origin from dyspnea of pulmonary origin. METHODS: The peak expiratory flow (PEF) rate and the partial pressure of oxygen in arterial blood (PaO(2)) were measured in 71 patients with the chief complaint of dyspnea. The patients were treated in the hospital, and the final diagnosis (cardiac or pulmonary) of the cause of dyspnea was made at discharge. We defined a new measure, the dyspnea differentiation index (DDI), as (PEF x PaO(2))/1,000. We performed a receiver operating characteristic (ROC) curve analysis of the data to define the measure that best distinguished cardiac from pulmonary dyspnea. The curves also allowed us to establish an optimal cut-off point to distinguish between cardiac and pulmonary dyspnea. RESULTS: Patients with pulmonary dyspnea had a significantly lower mean PEF than patients with cardiac dyspnea (144 +/- 66 vs 267 +/- 97 L/min, respectively; p < 0.001). They also had a lower DDI than patients with cardiac dyspnea (8.4 +/- 4.0 vs 18.4 +/- 7.9 L-mm/min, respectively; p < 0.001). These two measures, PEF and DDI, also best distinguished pulmonary from cardiac dyspnea. PEF was able to diagnose the correct cause of dyspnea in 72% of patients, and DDI was correct in 79% of patients. This compares favorably to the performance of the emergency department physicians, who were able to predict the correct diagnosis in only 69% of patients. CONCLUSION: These results demonstrate that the PEF by itself is useful in differentiating between cardiac and pulmonary causes of dyspnea, but that the calculation of DDI is superior in this regard.

A new primate from the Middle Eocene of Myanmar and the Asian early origin of anthropoids.

A new genus and species of anthropoid primate, Bahinia pondaungensis gen. et sp. nov., is described from the Yashe Kyitchaung locality in the Late Middle Eocene Pondaung Formation (Myanmar). It is related to Eosimias, but it is represented by more complete remains, including upper dentition with associated lower jaw fragment. It is interpreted as a new representative of the family Eosimiidae, which corresponds to the sister group of the Amphipithecidae and of all other anthropoids. Eosimiidae are now recorded from three distinct Middle Eocene localities in Asia, giving support to the hypothesis of an Asian origin of anthropoids.