Philip J. Schluter

Smoking during pregnancy: how reliable are maternal self reports in New Zealand?

OBJECTIVE: To determine the reliability of self reports of smoking during pregnancy. METHODS: Residual sera from early and late antenatal blood samples were tested for cotinine for all pregnancies over a six month period. Over an overlapping 12 month period, a postal questionnaire on smoking was also sent to all new mothers (n = 4857) when their baby was 4-8 weeks old. Smoking status from obstetric booking notes was also obtained. RESULTS: The cotinine-validated smoking prevalence was 31.3% for the first trimester and 27.7% for the third trimester. Questionnaire self reported prevalences were 19.2% and 15.7% for the first and third trimesters respectively, and 18.9% for obstetric booking. Of cotinine-validated smokers, 22% denied smoking-self deceivers. Of mothers who replied to the questionnaire, a half appeared to systematically under report the amount they smoked. CONCLUSIONS: Nearly a quarter of smoking pregnant women did not report smoking. Moreover, of those who did, the amount smoked was often under reported. This tendency to under report may rise as pressures to stop smoking increase. Accurate measures of smoking prevalence in pregnant women will require objective testing.

Cyanobacterial lipopolysaccharides and human health – a review

Cyanobacterial lipopolysaccharide/s (LPS) are frequently cited in the cyanobacteria literature as toxins responsible for a variety of heath effects in humans, from skin rashes to gastrointestinal, respiratory and allergic reactions. The attribution of toxic properties to cyanobacterial LPS dates from the 1970s, when it was thought that lipid A, the toxic moiety of LPS, was structurally and functionally conserved across all Gram-negative bacteria. However, more recent research has shown that this is not the case, and lipid A structures are now known to be very different, expressing properties ranging from LPS agonists, through weak endotoxicity to LPS antagonists. Although cyanobacterial LPS is widely cited as a putative toxin, most of the small number of formal research reports describe cyanobacterial LPS as weakly toxic compared to LPS from the Enterobacteriaceae.We systematically reviewed the literature on cyanobacterial LPS, and also examined the much lager body of literature relating to heterotrophic bacterial LPS and the atypical lipid A structures of some photosynthetic bacteria. While the literature on the biological activity of heterotrophic bacterial LPS is overwhelmingly large and therefore difficult to review for the purposes of exclusion, we were unable to find a convincing body of evidence to suggest that heterotrophic bacterial LPS, in the absence of other virulence factors, is responsible for acute gastrointestinal, dermatological or allergic reactions via natural exposure routes in humans.There is a danger that initial speculation about cyanobacterial LPS may evolve into orthodoxy without basis in research findings. No cyanobacterial lipid A structures have been described and published to date, so a recommendation is made that cyanobacteriologists should not continue to attribute such a diverse range of clinical symptoms to cyanobacterial LPS without research confirmation.

Bone mineral density in Australian children, adolescents and adults with cystic fibrosis: a controlled cross sectional study

Background: Low bone mineral density (BMD) is recognised in individuals with cystic fibrosis (CF) although the pathogenesis remains unclear. The aims of this study were to compare BMD over a broad continuum of Australian individuals with CF with healthy controls and to examine the relationship between BMD and clinical parameters including physical activity, nutrition, and vitamin D levels. Methods: BMD of the lumbar spine (LS), total body (TB), femoral neck (FN), cortical wrist (R33%), and distal wrist (RUD) was examined in 153 individuals with CF aged 5.3–55.8 years (84 males) and in 149 local controls aged 5.6–48.3 years (66 males) using dual energy x ray absorptiometry. Anthropometric variables, body cell mass, markers of disease severity, corticosteroid usage, measures of physical activity, dietary calcium and caloric intake and serum vitamin D were assessed and related to BMD. Results: Compared with controls, mean BMD was not significantly different in children aged 5–10 years with CF. Adolescents (females 11–18 years, males 11–20 years) had reduced TB and R33% BMD when adjusted for age, sex, and height (difference in BMD (g/cm2) adjusted means between control and CF: TB = 0.04 (95% CI 0.01 to 0.07); R33% = 0.03 (95% CI 0.01 to 0.06)). BMD was reduced at all sites except R33% in adults (difference in BMD (g/cm2) adjusted means between control and CF: TB = 0.05 (95% CI 0.02 to 0.09); LS = 0.08 (95% CI 0.03 to 0.14); FN = 0.09 (95% CI 0.03 to 0.15); RUD = 0.03 (95% CI 0.01 to 0.05)). In children/adolescents BMD was weakly associated with nutritional status and disease severity. Conclusions: BMD was normal in a well nourished group of prepubertal children with CF. A BMD deficit appears to evolve during adolescence and becomes more marked in adults. Individuals with CF should optimise nutrition, partake in physical activity, and maximise lung health in order to optimise BMD. Further longitudinal studies are required to understand the evolution of reduced BMD in young people and adults with CF.

Uterine preservation or hysterectomy at sacrospinous colpopexy for uterovaginal prolapse

This study retrospectively compared 34 women who had a sacrospinous hysteropexy and 36 who had a vaginal hysterectomy and sacrospinous fixation for symptomatic uterine prolapse. All women underwent independent review and examination, with a mean follow-up of 36 months in the hysterectomy group and 26 months in the hysteropexy group. The subjective success rate was 86% in the hysterectomy group and 78% in the hysteropexy group (P = 0.70). The objective success rate was 72% and 74%, respectively (P = 1.00). The patient-determined satisfaction rate was 86% in the hysterectomy group and 85% in the hysteropexy group (P = 1.00). The operating time in the hysterectomy group was 91 minutes, compared to 59 minutes in the hysteropexy group (P<0.01). The mean intraoperative blood loss in the hysterectomy group was 402 ml, compared to 198 ml in the hysteropexy group (P<0.01). The sacrospinous hysteropexy is effective in the treatment of uterine prolapse. Vaginal hysterectomy may not be necessary in the surgical treatment of uterine prolapse.

Recreational and occupational field exposure to freshwater cyanobacteria – a review of anecdotal and case reports, epidemiological studies and the challenges for epidemiologic assessment

Cyanobacteria are common inhabitants of freshwater lakes and reservoirs throughout the world. Under favourable conditions, certain cyanobacteria can dominate the phytoplankton within a waterbody and form nuisance blooms. Case reports and anecdotal references dating from 1949 describe a range of illnesses associated with recreational exposure to cyanobacteria: hay fever-like symptoms, pruritic skin rashes and gastro-intestinal symptoms are most frequently reported. Some papers give convincing descriptions of allergic reactions while others describe more serious acute illnesses, with symptoms such as severe headache, pneumonia, fever, myalgia, vertigo and blistering in the mouth. A coroner in the United States found that a teenage boy died as a result of accidentally ingesting a neurotoxic cyanotoxin from a golf course pond. This death is the first recorded human fatality attributed to recreational exposure to cyanobacteria, although uncertainties surround the forensic identification of the suspected cyanotoxin in this case.We systematically reviewed the literature on recreational exposure to freshwater cyanobacteria. Epidemiological data are limited, with six studies conducted since 1990. Statistically significant increases in symptoms were reported in individuals exposed to cyanobacteria compared to unexposed counterparts in two Australian cohort studies, though minor morbidity appeared to be the main finding. The four other small studies (three from the UK, one Australian) did not report any significant association. However, the potential for serious injury or death remains, as freshwater cyanobacteria under bloom conditions are capable of producing potent toxins that cause specific and severe dysfunction to hepatic or central nervous systems. The exposure route for these toxins is oral, from ingestion of recreational water, and possibly by inhalation.A range of freshwater microbial agents may cause acute conditions that present with features that resemble illnesses attributed to contact with cyanobacteria and, conversely, acute illness resulting from exposure to cyanobacteria or cyanotoxins in recreational waters could be misdiagnosed. Accurately assessing exposure to cyanobacteria in recreational waters is difficult and unreliable at present, as specific biomarkers are unavailable. However, diagnosis of cyanobacteria-related illness should be considered for individuals presenting with acute illness following freshwater contact if a description is given of a waterbody visibly affected by planktonic mass development.

Prolotherapy injections, saline injections, and exercises for chronic low-back pain: a randomized trial

Objectives. To assess the efficacy of a prolotherapy injection and exercise protocol in the treatment of chronic nonspecific low back pain. Design. Randomized controlled trial with two-by-two factorial design, triple-blinded for injection status, and single-blinded for exercise status. Setting. General practice. Participants. One hundred ten participants with nonspecific low-back pain of average 14 years duration were randomized to have repeated prolotherapy (20% glucose/0.2% lignocaine) or normal saline injections into tender lumbo-pelvic ligaments and randomized to perform either flexion/extension exercises or normal activity over 6 months. Main outcome measures Pain intensity (VAS) and disability scores (Roland-Morris) at 2.5, 4, 6, 12, and 24 months. Results. Follow-up was achieved in 96% at 12 months and 80% at 2 years. Ligament injections, with exercises and with normal activity, resulted in significant and sustained reductions in pain and disability throughout the trial, but no attributable effect was found for prolotherapy injections over saline injections or for exercises over normal activity. At 12 months, the proportions achieving more than 50% reduction in pain from baseline by injection group were glucose-lignocaine: 0.46 versus saline: 0.36. By activity group these proportions were exercise: 0.41 versus normal activity: 0.39. Corresponding proportions for >50% reduction in disability were glucose-lignocaine: 0.42 versus saline 0.36 and exercise: 0.36 versus normal activity: 0.38. There were no between group differences in any of the above measures. Conclusions. In chronic nonspecific low-back pain, significant and sustained reductions in pain and disability occur with ligament injections, irrespective of the solution injected or the concurrent use of exercises.

Impact of Premorbid Undernutrition on Outcome in Stroke Patients

Background and Purpose— To assess the prevalence of premorbid undernutrition and its impact on outcomes 1 month after stroke. Methods— The study recruited from consecutive stroke admissions during a 10-month period. Premorbid nutritional status (using the subjective global assessment [SGA]), premorbid functioning (modified Rankin scale [MRS]), and stroke severity (National Institutes of Health Stroke Scale [NIHSS] score) were assessed at admission. The associations between premorbid nutritional status, poor outcome (defined as MRS ≥3), and mortality were examined before and after adjustment for confounding variables, including age, gender, stroke risk factors, stroke severity, and admission serum albumin. Results— Thirty of 185 patients were assessed as having undernutrition at admission. Significant unadjusted associations were observed between undernutrition and poor outcome (odds ratio [OR], 3.4; 95% CI, 1.3 to 8.7; P =0.01), and mortality (OR, 3.1, 95% CI, 1.3 to 7.7; P =0.02) at 1 month. NIHSS, age, and premorbid MRS were also significantly associated with poor outcomes. After adjustment for these factors, the effect size of associations remained important but not significant (poor outcome: OR, 2.4; 95% CI, 0.7 to 9.0, P =0.18; mortality: OR, 3.2; 95% CI, 1.0 to 10.4, P =0.05). Conclusions— Premorbid undernutrition, as assessed using the SGA, appears to be an independent predictor of poor stroke outcome. Stroke prevention strategies should target undernutrition in the population at risk for stroke to improve outcomes.

Midline rectovaginal fascial plication for repair of rectocele and obstructed defecation.

OBJECTIVE: To estimate the efficacy of midline fascial plication of the posterior vaginal wall in women with rectoceles and obstructed defecation. METHODS: Prospective evaluation of 38 consecutive women with symptomatic rectoceles (stage II or greater) and obstructed defecation included pre- and postoperative standardized pelvic floor questions, pelvic organ prolapse quantification measurements, validated bowel function questionnaires, defecating proctogram, and patient satisfaction. Reviews were conducted by nonsurgical coauthors. RESULTS: The median follow-up was 12.5 months (range 2.5–26 months). The subjective success rates were 97% (95% confidence interval [CI] 0.83–1.00%) at 12 months and 89% (95% CI 0.55–0.98%) at 24 months. The objective success rates were 87% (95% CI 0.64–0.96%) at 12 months and 79% (95% CI 0.51–0.92%) at 24 months. The average points, Ap and Bp, were significantly reduced from −0.1 (range −2 to 3) and 1.1 (range −1 to 8), preoperatively, to −2.6 (range −3 to −1) and −2.5 (range −3 to 0), postoperatively, respectively (P < .001). Depth of rectocele also reduced postoperatively on defecating fluoroscopy (P < .001). The correction of the anatomical defect was associated with improved functional outcome, with 33 women (87%) no longer experiencing obstructed defecation, and there was a significant reduction in postoperative straining to defecate, hard stools, and dyspareunia (P = .001). The improved anatomical and functional outcomes were reflected in the fact that 97% of the women reported very high patient satisfaction. CONCLUSION: Midline fascial plication is effective in correcting anatomical and functional outcomes associated with symptomatic rectoceles and obstructed defecation. LEVEL OF EVIDENCE: III

Ranking and selecting motor vehicle accident sites by using a hierarchical Bayesian model

Identification, ranking and selecting hazardous traffic accident locations from a group under consideration is a fundamental goal for traffic safety researchers. Few methods exist that can quantitatively, accurately and easily discriminate between sites that commonly have small and variable observation count periods. One method that embodies all these advantages is the hierarchical Bayesian model, the method proposed in this paper. The particular hierarchical Bayesian approach that we use incorporates expert knowledge about accident sites as a group believed a priori to be exchangeable, the Poisson assumption and a conjugate gamma prior. We then propose three natural strategies for ranking and selecting the most hazardous subgroup of accident locations. Also presented is an especially useful procedure that gives the probability that each particular site is worst and by how much it is worst. All proposed strategies are illustrated using previously published fatality accident data from 35 sites in Auckland, New Zealand.

Pubovaginal sling versus transurethral Macroplastique for stress urinary incontinence and intrinsic sphincter deficiency: a prospective randomised controlled trial

Objective  To compare the pubovaginal sling and transurethral Macroplastique in the treatment of female stress urinary incontinence (SUI) and intrinsic sphincter deficiency (ISD).