Thomas C. Hulsey

Immune maladaptation in the etiology of preeclampsia: a review of corroborative epidemiologic studies.

Genuine preeclampsia is a disease of first pregnancies. The protective effect of multiparity, however, is lost with change of partner. Also, exposure to semen provides protection against developing preeclampsia. Analogous to altered paternity, artificial donor insemination and oocyte donation are reported to result in a substantial increase of preeclampsia. Thus, epidemiologic studies strongly suggest that immune maladaptation is involved in the etiology of preeclampsia. Although the exact etiology of preeclampsia remains unknown, the conclusions derived from epidemiologic studies may have consequences for practicing physicians: 1) according to the primipaternity concept, a multiparous women with a new partner should be approached as being a primigravid women; 2) artificial donor insemination and oocyte donation are associated with an increased risk of developing pregnancy-induced hypertensive disorders; 3) a more or less prolonged period of sperm exposure provides a partial protection against pregnancy-induced hypertensive disorders. In the 1990s, all women with changing partners are strongly advised to use condoms to prevent sexually transmitted diseases. However, a certain period of sperm exposure within a stable relation, when pregnancy is aimed for, is associated with a partial protection against preeclampsia.

Increasing Incidence of Kidney Stones in Children Evaluated in the Emergency Department

OBJECTIVE To test the hypothesis that there is an increase in the incidence of childhood nephrolithiasis in the state of South Carolina. STUDY DESIGN We analyzed demographic data from a statewide database on incidence of kidney stones from emergency department data and financial charges. Data were compared with population data from the US Census to control for population growth. RESULTS There was a significant increase in the incidence of kidney stones in children between 1996 and 2007. The greatest rate of increase was seen in adolescents, pre-adolescents, and Caucasian children. Infants, toddlers, and African-American children did not show significantly increased incidence in the period. Girls show a growing predominance in our population. The amount of money charged for care of children with kidney stones has gone up >4-fold in our state. CONCLUSION The incidence of kidney stone disease has risen dramatically in the state of South Carolina since 1996. Further studies investigating potential contributing factors are needed to prevent this costly and painful condition.

Revisiting the epidemiological standard of preeclampsia: primigravidity or primipaternity?

Pregnancy-induced hypertensive disorders, and especially preeclampsia, are documented to occur primarily in first pregnancies and rarely in subsequent pregnancies. Therefore, the concept of primigravidity is the epidemiological cornerstone of this disease. The authors propose a concept in which preeclampsia is a disease of new couples, especially after a short period of sexual cohabitation, and explore if this alternative primipaternity model, as compared with the primigravidity concept, provides a better fit with well-known epidemiologic descriptions. First, the primipaternity model provides a mathematical modelling which may explain the prevalence of approximately 10% in long-term monogamic populations. Further, it proposes explanations for many epidemiological descriptions which were previously difficult to understand and assemble in a single concept.

Contaminant blubber burdens in Atlantic bottlenose dolphins (Tursiops truncatus) from two southeastern US estuarine areas: Concentrations and patterns of PCBs, pesticides, PBDEs, PFCs, and PAHs

Polychlorinated biphenyls (PCBs), chlorinated pesticides (i.e., dichlorodiphenyltrichloroethane (DDT) and its metabolites, chlordanes (CHLs), dieldrin, hexachlorobenzene (HCB), and mirex), polybrominated diphenyl ethers (PBDEs), perfluorinated chemicals (PFCs), and polyaromatic hydrocarbons (PAHs) were measured in blubber biopsy samples collected from 139 wild bottlenose dolphins (Tursiops truncatus) during 2003-2005 in Charleston (CHS), SC and the Indian River Lagoon (IRL), FL. Dolphins accumulated a similar suite of contaminants with summation operatorPCB dominating (CHS 64%, IRL 72%), followed by summation operatorDDT (CHS 20%, IRL 17%), summation operatorCHLs (CHS 7%; IRL 7%), summation operatorPBDE (CHS 4%, IRL 2%), PAH at 2%, and dieldrin, PFCs and mirex each 1% or less. Together summation operatorPCB and summation operatorDDT concentrations contributed approximately 87% of the total POCs measured in blubber of adult males. summation operatorPCBs in adult male dolphins exceed the established PCB threshold of 17mg/kg by a 5-fold order of magnitude with a 15-fold increase for many animals; 88% of the dolphins exceed this threshold. For male dolphins, CHS (93,980ng/g lipid) had a higher summation operatorPCBs geomean compared to the IRL (79,752ng/g lipid) although not statistically different. In adult males, the PBDE geometric mean concentration was significantly higher in CHS (5920ng/g lipid) than the IRL (1487ng/g). Blubber summation operatorPFCs concentrations were significantly higher in CHS dolphins. In addition to differences in concentration of PCB congeners, summation operatorPBDE, TEQ, summation operatorCHLs, mirex, dieldrin, and the ratios summation operatorDDE/ summation operatorDDT and trans-nonachlor/cis-nonachlor were the most informative for discriminating contaminant loads in these two dolphin populations. Collectively, the current summation operatorPCB, summation operatorDDT, and summation operatorPBDEs blubber concentrations found in CHS dolphins are among the highest reported values in marine mammals. Both dolphin populations, particularly those in CHS, carry a suite of organic chemicals at or above the level where adverse effects have been reported in wildlife, humans, and laboratory animals warranting further examination of the potential adverse effects of these exposures.

Maternal Versus Infant Vitamin D Supplementation During Lactation: A Randomized Controlled Trial

OBJECTIVE: Compare effectiveness of maternal vitamin D3 supplementation with 6400 IU per day alone to maternal and infant supplementation with 400 IU per day. METHODS: Exclusively lactating women living in Charleston, SC, or Rochester, NY, at 4 to 6 weeks postpartum were randomized to either 400, 2400, or 6400 IU vitamin D3/day for 6 months. Breastfeeding infants in 400 IU group received oral 400 IU vitamin D3/day; infants in 2400 and 6400 IU groups received 0 IU/day (placebo). Vitamin D deficiency was defined as 25-hydroxy-vitamin D (25(OH)D) <50 nmol/L. 2400 IU group ended in 2009 as greater infant deficiency occurred. Maternal serum vitamin D, 25(OH)D, calcium, and phosphorus concentrations and urinary calcium/creatinine ratios were measured at baseline then monthly, and infant blood parameters were measured at baseline and months 4 and 7. RESULTS: Of the 334 mother-infant pairs in 400 IU and 6400 IU groups at enrollment, 216 (64.7%) were still breastfeeding at visit 1; 148 (44.3%) continued full breastfeeding to 4 months and 95 (28.4%) to 7 months. Vitamin D deficiency in breastfeeding infants was greatly affected by race. Compared with 400 IU vitamin D3 per day, 6400 IU/day safely and significantly increased maternal vitamin D and 25(OH)D from baseline (P < .0001). Compared with breastfeeding infant 25(OH)D in the 400 IU group receiving supplement, infants in the 6400 IU group whose mothers only received supplement did not differ. CONCLUSIONS: Maternal vitamin D supplementation with 6400 IU/day safely supplies breast milk with adequate vitamin D to satisfy her nursing infant’s requirement and offers an alternate strategy to direct infant supplementation.

Fetal anomaly detection by second-trimester ultrasonography in a tertiary center

OBJECTIVE Our purpose was to determine the relative accuracy of indicated versus screening second-trimester ultrasonography for detection of fetal anomalies and to assess the cost effectiveness of anomaly screening. STUDY DESIGN The study population consisted of 2031 pregnant women with singleton gestations who prospectively underwent ultrasonographic scanning between 15 and 22 weeks and received complete obstetric care at the Medical University of South Carolina between July 1, 1993, and June 30, 1996. Patients were divided into two groups: (1) indicated and (2) screening. The cost of screening ultrasonography was compared with the cost of newborn care for selected anomalous fetuses. RESULTS Forty-seven fetuses (2.3%) were diagnosed by ultrasonography as having a major anomaly: 8.6% in the indicated group and 0.68% in the screening group (p=0.001). The sensitivity for detecting the anomalous fetus was 75.0% overall: 89.7% in the indicated group and 47.6% in the screening group (p=0.001). Of the 47 patients diagnosed with fetal anomalies, 11 (23.4%) chose pregnancy termination; of the 35 (74.5%) live-born anomalous infants, 29 (82.9%) were discharged alive. Projected newborn cost savings offset the cost of routine midtrimester screening. CONCLUSIONS Detection of anomalous fetuses was significantly better in the indicated compared with the screening group. Nevertheless, routine ultrasonographic screening appeared cost-effective in our population.

Hyaline membrane disease: The role of ethnicity and maternal risk characteristics

OBJECTIVE Our objective was to explore the association between maternal ethnicity and maternal antepartum complications of pregnancy, maternal sociodemographic factors, and newborn characteristics with the incidence of hyaline membrane disease. STUDY DESIGN By using a retrospective cohort analysis the incidence of hyaline membrane disease was determined for 2295 preterm infants. The study population consisted of all live, inborn infants delivered vaginally from 1982 to 1987. Statistical differences were assessed by use of chi 2 and Students t tests. A logistic regression procedure determined the relationship of ethnicity and hyaline membrane disease after the study was controlled for all other significant population differences. RESULTS The differences between black and white populations in marital status, were statistically significant years of education, prolonged rupture of membranes, anemia, and chronic hypertension were statistically significant. Infants of black mothers were diagnosed with hyaline membrane disease less often than infants of white mothers (overall and at each gestational age interval). After the study was controlled for population differences, infants of black mothers were still found to experience hyaline membrane disease less often. CONCLUSION These data suggest that hyaline membrane disease occurs less frequently, is less severe, and is accompanied by fewer related complications in black preterm infants.

Time Required for Blood Lead Levels to Decline in Nonchelated Children

Objective: To determine the time for a decline in blood lead to less than 10 μg/ dL in nonchelated children who are enrolled in case management. Study Design: Retrospective analysis of venous blood lead data of lead-poisoned children followed in a case management program designed to decrease lead exposure. Children were excluded if their blood lead had not yet declined to less than 10 μg/dL, if they received chelation therapy, or if they had not received follow-up for more than 15 months. We calculated the time between peak elevation of lead and decline to less than 10 μg/dL. Data were categorized based on the childs peak blood lead and season in which their peak blood lead occurred. Data were analyzed using ANOVA and linear regression. Kaplan-Meier survival analysis was used to describe data in population form. Results: 579 patients were included in the analysis. Blood leads of 25–29, 20–24, 15–19, and 10–14 μg/dL required 24.0, 20.9, 14.3, and 9.2 months, respectively, to decline to less than 10 μg/dL. For continuous data, a linear relationship was described by the following equation: Time (# of months required to achieve a blood lead less than 10 μg/dL) = 0.845 × peak lead; p < 0.0001. Kaplan-Meier curves complement the findings in a population-based fashion. Conclusions: The mean time for blood lead to decline was linearly related to the peak in blood lead. The time for 50% of the blood lead to decline to less than 10 μg/dL was not linear and varied with peak lead.

An Exploratory Study of Postpartum Depression and Vitamin D

BACKGROUND: Low levels of serum 25-hydroxyvitamin D (25[OH]D), a reliable measurement of vitamin D, have been implicated in several mood disorders. To date, studies exploring the relationship between vitamin D and postpartum depression are absent from the literature. OBJECTIVES: To determine whether a relationship exists between symptoms associated with postpartum depression and vitamin D levels and to determine if serum 25(OH) D levels can predict the incidence of symptoms associated with postpartum depression. STUDY DESIGN: An exploratory, descriptive study using a convenience sample of 97 postpartum women attending seven monthly visits. Women provided serum 25(OH)D samples and completed the Edinburgh Postpartum Depression Scale (EPDS) at each visit. RESULTS: A significant relationship over time was found between low 25(OH)D levels and high EPDS scores, indicative of postpartum depression. CONCLUSIONS: Future rigorous studies investigating vitamin D and postpartum depression are warranted with larger sample sizes using confirmatory methods to diagnose postpartum depression.

Randomized, controlled trial of nasopharyngeal continuous positive airway pressure in the extubation of very low birth weight infants

We conducted a prospective, randomized controlled trial to determine whether extubation of very low birth weight infants was facilitated by the use of nasopharyngeal continuous positive airway pressure (CPAP). Eligible infants included patients weighing 600 to 1500 gm at birth who required tracheal intubation within 48 hours of birth and who met specific predetermined criteria for extubation by day 14 of life. We also sought to determine whether varying the duration of nasopharyngeal CPAP influenced the likelihood of successful extubation. Infants underwent random assignment to receive nasopharyngeal CPAP until resolution of lung disease (n = 40), 6 hours of nasopharyngeal CPAP (n = 42), or oxygen supplementation delivered by hood (n = 42). Extubation failure was predefined as a requirement for > or = 80% oxygen, pH < or = 7.20, severe apnea, or predefined clinical deterioration, and extubation success was predefined as the ability to remain free of a requirement for mechanical ventilation for 7 days and a 66% reduction in the need for supplemental oxygen. Each group was similar with regard to race, sex, and birth weight. Extubation was successful in 62%, 61%, and 60% of infants. After stratification by birth weight, there were no significant differences in the rates of successful extubation among the treatment groups. We conclude that nasopharyngeal CPAP does not improve the likelihood of successful extubation of very low birth weight infants who are ready for extubation within the first 2 weeks of life.