CROSSED LEG PALSY with Report of a Recurrent Case

A form of peroneal palsy may be caused by crossing the legs. Two physical factors—pressure and tension — are the basic causes, although other factors may be contributory. Direct pressure is applied by the bones of the two legs, compressing the peroneal nerve between them at its superficial part near the head and neck of the fibula.The palsy may be overlooked as an integral part of a widespread disorder so that careful evaluation and observation of the patient''s habits are required. Detection becomes especially difficult when the palsy is bilateral, for then the lesion by virtue of its symmetry blends more readily with associated polyneuritis. A case of recurrent peroneal palsy due to crossing the legs in a prolonged postoperative convalescence is reported in detail.     

Immune Deficiency,Thrombocytopenia and Osteomyelitis in Pediatric Patients

Surgical decompression of osteomyelitis in pediatric patients should be an essential part of therapy in most cases. The initial deferral of prompt decompression in two patients because of underlying chronic, hemorrhagic (thrombocytopenic) disorders—one with Wiskott-Aldrich syndrome and one with Gaucher''s disease—resulted in more serious and prolonged courses of the infectious processes. The complications might have been ameliorated by earlier drainage in each case. Based upon the experience gained from these two patients, we recommend early drainage, with appropriate treatment of the hemorrhagic disorder, to prevent more widespread dissemination or prolongation of osseous infection in similarly affected children.     

Early Standard Electroencephalogram Abnormalities Predict Mortality in Septic Intensive Care Unit Patients

IntroductionSepsis is associated with increased mortality, delirium and long-term cognitive impairment in intensive care unit (ICU) patients. Electroencephalogram (EEG) abnormalities occurring at the acute stage of sepsis may correlate with severity of brain dysfunction. Predictive value of early standard EEG abnormalities for mortality in ICU septic patients remains to be assessed.MethodsIn this prospective, single center, observational study, standard EEG was performed, analyzed and classified according to both Synek and Young EEG scales, in consecutive patients acutely admitted in ICU for sepsis. Delirium, coma and the level of sedation were assessed at the time of EEG recording; and duration of sedation, occurrence of in-ICU delirium or death were assessed during follow-up. Adjusted analyses were carried out using multiple logistic regression.ResultsOne hundred ten patients were included, mean age 63.8 (±18.1) years, median SAPS-II score 38 (29–55). At the time of EEG recording, 46 patients (42%) were sedated and 22 (20%) suffered from delirium. Overall, 54 patients (49%) developed delirium, of which 32 (29%) in the days after EEG recording. 23 (21%) patients died in the ICU. Absence of EEG reactivity was observed in 27 patients (25%), periodic discharges (PDs) in 21 (19%) and electrographic seizures (ESZ) in 17 (15%). ICU mortality was independently associated with a delta-predominant background (OR: 3.36; 95% CI [1.08 to 10.4]), absence of EEG reactivity (OR: 4.44; 95% CI [1.37–14.3], PDs (OR: 3.24; 95% CI [1.03 to 10.2]), Synek grade ≥ 3 (OR: 5.35; 95% CI [1.66–17.2]) and Young grade > 1 (OR: 3.44; 95% CI [1.09–10.8]) after adjustment to Simplified Acute Physiology Score (SAPS-II) at admission and level of sedation. Delirium at the time of EEG was associated with ESZ in non-sedated patients (32% vs 10%, p = 0.037); with Synek grade ≥ 3 (36% vs 7%, p< 0.05) and Young grade > 1 (36% vs 17%, p< 0.001). Occurrence of delirium in the days after EEG was associated with a delta-predominant background (48% vs 15%, p = 0.001); absence of reactivity (39% vs 10%, p = 0.003), Synek grade ≥ 3 (42% vs 17%, p = 0.001) and Young grade >1 (58% vs 17%, p = 0.0001).ConclusionsIn this prospective cohort of 110 septic ICU patients, early standard EEG was significantly disturbed. Absence of EEG reactivity, a delta-predominant background, PDs, Synek grade ≥ 3 and Young grade > 1 at day 1 to 3 following admission were independent predictors of ICU mortality and were associated with occurence of delirium. ESZ and PDs, found in about 20% of our patients. Their prevalence could have been higher, with a still higher predictive value, if they had been diagnosed more thoroughly using continuous EEG.     

Social network- and community-level influences on contraceptive use: evidence from rural Poland

The diffusion of ‘modern’ contraceptives—as a proxy for the spread of low-fertility norms—has long interested researchers wishing to understand global fertility decline. A fundamental question is how local cultural norms and other people''s behaviour influence the probability of contraceptive use, independent of women''s socioeconomic and life-history characteristics. However, few studies have combined data at individual, social network and community levels to simultaneously capture multiple levels of influence. Fewer still have tested if the same predictors matter for different contraceptive types. Here, we use new data from 22 high-fertility communities in Poland to compare predictors of the use of (i) any contraceptives—a proxy for the decision to control fertility—with those of (ii) ‘artificial’ contraceptives—a subset of more culturally taboo methods. We find that the contraceptive behaviour of friends and family is more influential than are women''s own characteristics and that community level characteristics additionally influence contraceptive use. Highly educated neighbours accelerate women''s contraceptive use overall, but not their artificial method use. Highly religious neighbours slow women''s artificial method use, but not their contraceptive use overall. Our results highlight different dimensions of sociocultural influence on contraceptive diffusion and suggest that these may be more influential than are individual characteristics. A comparative multilevel framework is needed to understand these dynamics.     

Factors Predict Prolonged Wait Time and Longer Duration of Radiotherapy in Patients with Nasopharyngeal Carcinoma: A Multilevel Analysis

Purpose

Radiotherapy with or without chemotherapy is the primary treatment for patients with nasopharyngeal carcinoma (NPC). It wastes time from diagnosis to treatment. Treatment time of radiotherapy generally takes at least seven weeks. The current study aimed to evaluate factors associated with prolonged wait time and longer duration of radiotherapy in NPC patients.

Methods and Materials

From Taiwan''s National Health Insurance research database, we identified 3,605 NPC patients treated with radiotherapy between 2008 and 2011. Wait time was calculated from the date of diagnosis to the start of radiotherapy. The impact of each variable on wait time and duration of radiotherapy was examined by multilevel analysis using a random-intercept model.

Results

The mean wait time and duration of radiotherapy were 1.78±3.33 and 9.72±7.27 weeks, respectively. Multilevel analysis revealed prolonged wait time in patients aged 45–65 years, those receiving radiotherapy alone, those with more comorbidities, those with low SES, and those living in eastern Taiwan. A prolonged duration of radiotherapy was associated with receipt of concurrent chemoradiotherapy, more comorbidities, and moderate SES.

Conclusions

Understanding the factors associated with longer wait times and duration of radiotherapy in patients with NPC may help healthcare providers better assist both these patients and potentially those with other head-and-neck cancers.     

Physicians' Own Health—Some Advice for the Advisors

Information about physicians'' health and health practices is sparse and scattered. With a few exceptions, however—notably suicide and substance abuse—it appears that physicians'' health and health-promotion activities are at least similar to those of the general public. In some areas, such as smoking cessation, physicians have far outstripped the general public. As physicians gain more insight into their own health and health habits, advice to patients can be realistic and effective. Indeed, several personal health activities, including immunization, have direct, salutary impacts on patient care. Physicians should analyze and change their own health practices as indicated and pay special attention to “high yield” health habits, such as seat-belt use.     

SerRS-tRNASec complex structures reveal mechanism of the first step in selenocysteine biosynthesis

Selenocysteine (Sec) is found in the catalytic centers of many selenoproteins and plays important roles in living organisms. Malfunctions of selenoproteins lead to various human disorders including cancer. Known as the 21st amino acid, the biosynthesis of Sec involves unusual pathways consisting of several stages. While the later stages of the pathways are well elucidated, the molecular basis of the first stage—the serylation of Sec-specific tRNA (tRNA^Sec) catalyzed by seryl-tRNA synthetase (SerRS)—is unclear. Here we present two cocrystal structures of human SerRS bound with tRNA^Sec in different stoichiometry and confirm the formation of both complexes in solution by various characterization techniques. We discovered that the enzyme mainly recognizes the backbone of the long variable arm of tRNA^Sec with few base-specific contacts. The N-terminal coiled-coil region works like a long-range lever to precisely direct tRNA 3′ end to the other protein subunit for aminoacylation in a conformation-dependent manner. Restraints of the flexibility of the coiled-coil greatly reduce serylation efficiencies. Lastly, modeling studies suggest that the local differences present in the D- and T-regions as well as the characteristic U20:G19:C56 base triple in tRNA^Sec may allow SerRS to distinguish tRNA^Sec from closely related tRNA^Ser substrate.     

Constraints and variation in food web link-species space

Predicting food web structure in future climates is a pressing goal of ecology. These predictions may be impossible without a solid understanding of the factors that structure current food webs. The most fundamental aspect of food web structure—the relationship between the number of links and species—is still poorly understood. Some species interactions may be physically or physiologically ‘forbidden''—like consumption by non-consumer species—with possible consequences for food web structure. We show that accounting for these ‘forbidden interactions'' constrains the feasible link-species space, in tight agreement with empirical data. Rather than following one particular scaling relationship, food webs are distributed throughout this space according to shared biotic and abiotic features. Our study provides new insights into the long-standing question of which factors determine this fundamental aspect of food web structure.     

Lipsmacking Imitation Skill in Newborn Macaques Is Predictive of Social Partner Discrimination

Newborn rhesus macaques imitate facial gestures even after a delay, revealing the flexible nature of their early communicative exchanges. In the present study we examined whether newborn macaques are also sensitive to the identities of the social partners with whom they are interacting. We measured infant monkeys'' (n = 90) lipsmacking and tongue protrusion gestures in a face-to-face interaction task with a human experimenter in the first week of life. After a one-minute delay, the same person who previously presented gestures or a different person returned and presented a still face to infants. We had two primary predictions: (1) infants would demonstrate higher rates of overall gesturing, and especially lipsmacking—an affiliative gesture—to a familiar person, compared to a novel person, and (2) infants'' imitative skills would positively correlate with gestures to familiar, but not unfamiliar, social partners, as both abilities may reflect a strong general social interest. We found that overall infants did not produce more gestures or more lipsmacking when approached by a familiar person compared to a novel person; however, we did find individual differences in infants'' social responsiveness: lipsmacking imitation was positively correlated with lipsmacking during the return period when the person was the same (p = .025), but not when the person was novel (p = .44). These findings are consistent with the notion that imitative skill is reflective of infants'' more general interest in social interactions.     

PARENT DEVELOPMENT

Today''s parents tend to be overwhelmed with advice from many sources. In his role as family counselor, the pediatrician must understand and consider the emotional development of parents in relation to their child''s development; otherwise, his advice and counsel do not “take” and he becomes tired and frustrated and angry.Parents progress through definite stages of development: Stage 1: Learning the cues—the struggle of the parents to interpret the infant''s needs. Stage 2: Learning to accept growth and development—the parent learning to accept some loss of control of the toddler. Stage 3: Learning to separate—the parent learning to allow the child to develop independently. Stage 4: Learning to accept rejection, without deserting—the struggle of the parents not to intrude and yet to be there when needed. Stage 5: Learning to build a new life having been thoroughly discredited by one''s teenager—the parent learning to live independently while the teenager struggles to develop his own identity.The pediatrician who is accepting, sensitive and a good listener and who keeps in mind that parents as well as children have capacities for growth and development, will be a potent factor in promoting good parent-child relationships and many times more effective in dealing with the child in health and disease.     

The impact of Cenozoic cooling on assemblage diversity in planktonic foraminifera

The Cenozoic planktonic foraminifera (PF) (calcareous zooplankton) have arguably the most detailed fossil record of any group. The quality of this record allows models of environmental controls on macroecology, developed for Recent assemblages, to be tested on intervals with profoundly different climatic conditions. These analyses shed light on the role of long-term global cooling in establishing the modern latitudinal diversity gradient (LDG)—one of the most powerful generalizations in biogeography and macroecology. Here, we test the transferability of environment-diversity models developed for modern PF assemblages to the Eocene epoch (approx. 56–34 Ma), a time of pronounced global warmth. Environmental variables from global climate models are combined with Recent environment–diversity models to predict Eocene richness gradients, which are then compared with observed patterns. The results indicate the modern LDG—lower richness towards the poles—developed through the Eocene. Three possible causes are suggested for the mismatch between statistical model predictions and data in the Early Eocene: the environmental estimates are inaccurate, the statistical model misses a relevant variable, or the intercorrelations among facets of diversity—e.g. richness, evenness, functional diversity—have changed over geological time. By the Late Eocene, environment–diversity relationships were much more similar to those found today.     

Early‐life conditions impact juvenile telomere length,but do not predict later life‐history strategies or fitness in a wild vertebrate

Environmental conditions experienced during early life may have long‐lasting effects on later‐life phenotypes and fitness. Individuals experiencing poor early‐life conditions may suffer subsequent fitness constraints. Alternatively, individuals may use a strategic “Predictive Adaptive Response” (PAR), whereby they respond—in terms of physiology or life‐history strategy—to the conditions experienced in early life to maximize later‐life fitness. Particularly, the Future Lifespan Expectation (FLE) PAR hypothesis predicts that when poor early‐life conditions negatively impact an individual''s physiological state, it will accelerate its reproductive schedule to maximize fitness during its shorter predicted life span. We aimed to measure the impact of early‐life conditions and resulting fitness across individual lifetimes to test predictions of the FLE hypothesis in a wild, long‐lived model species. Using a long‐term individual‐based dataset, we investigated how early‐life conditions are linked with subsequent fitness in an isolated population of the Seychelles warbler Acrocephalus sechellensis. How individuals experience early‐life environmental conditions may vary greatly, so we also tested whether telomere length—shorter telomers are a biomarker of an individual''s exposure to stress—can provide an effective measure of the individual‐specific impact of early‐life conditions. Specifically, under the FLE hypothesis, we would expect shorter telomeres to be associated with accelerated reproduction. Contrary to expectations, shorter juvenile telomere length was not associated with poor early‐life conditions, but instead with better conditions, probably as a result of faster juvenile growth. Furthermore, neither juvenile telomere length, nor other measures of early‐life conditions, were associated with age of first reproduction or the number of offspring produced during early life in either sex. We found no support for the FLE hypothesis. However, for males, poor early‐life body condition was associated with lower first‐year survival and reduced longevity, indicating that poor early‐life conditions pose subsequent fitness constraints. Our results also showed that using juvenile telomere length as a measure of early‐life conditions requires caution, as it is likely to not only reflect environmental stress but also other processes such as growth.     

The evolutionary ecology of early weaning in Kilimanjaro,Tanzania

Public health recommendations promote prolonged breastfeeding of all children; however, parental investment (PI) theory predicts that breastfeeding will be allocated among a mothers'' offspring to maximize her reproductive success. We evaluated PI in terms of risk for weaning before age two among 283 children in Kilimanjaro, Tanzania. Results demonstrate: (i) a Trivers–Willard effect—high socioeconomic status (SES) females and low SES males were more likely to be weaned early; (ii) later-born children were less likely to be weaned early; (iii) higher birthweight children were less likely to be weaned early, and (iv) no effect of cattle (a source of supplementary milk) ownership. These associations were largely independent and remained significant in models controlling for potential confounders; however, the inverse association between early weaning and birth order lost significance in the model containing birthweight. These patterns were observed despite public health recommendations encouraging breastfeeding for at least two years.     

CANCER DETECTION CENTERS—The Experience to Date in California

Cancer “detection centers” (that is, centers for the examination of presumably well or asymptomatic persons) have been tried out in four different California communities during the last three years. In all instances—as in most other such centers throughout the United States—they have not been successful in restricting examination to well persons.The detection centers in California may therefore be described more accurately as “cancer examination and detection clinics.”Three of the four centers have been closed owing to the small yield of cancer cases discovered, plus the fact that the cost of operation exceeded the total available funds of the local branch of the Cancer Society. In addition, it was extremely difficult to obtain and maintain competence on the part of the professional staff in such centers.A more practical approach to the problem of earlier tumor detection would appear to be emphasis on making “every physician''s office a detection center,” and stressing the annual examination of persons over 40 years of age for tumors in the five common accessible sites. These are the tumors most readily curable today.     

Investigation of the dynamics underlying periodic complexes in the EEG

Periodic complexes (PC), occurring lateralised or diffuse, are relatively rare EEG phenomena which reflect acute severe brain disease. The pathophysiology is still incompletely understood. One hypothesis suggested by the alpha rhythm model of Lopes da Silva is that periodic complexes reflect limit cycle dynamics of cortical networks caused by excessive excitatory feedback. We examined this hypothesis by applying a recently developed technique to EEGs displaying periodic complexes and to periodic complexes generated by the model. The technique, non-linear cross prediction, characterises how well a time series can be predicted, and how much amplitude and time asymmetry is present. Amplitude and time asymmetry are indications of non-linearity. In accordance with the model, most EEG channels with PC showed clear evidence of amplitude and time asymmetry, pointing to non-linear dynamics. However, the non-linear predictability of true PC was substantially lower than that of PC generated by the model. Furthermore, no finite value for the correlation dimension could be obtained for the real EEG data, whereas the model time series had a dimension slighter higher than one, consistent with a limit cycle attractor. Thus we can conclude that PC reflect non-linear dynamics, but a limit cycle attractor is too simple an explanation. The possibility of more complex (high dimensional and spatio-temporal) non-linear dynamics should be investigated. Received: 26 February 1998 / Accepted in revised form: 24 August 1998     

Vaccines against enteric infections for the developing world

Since the first licensure of the Sabin oral polio vaccine more than 50 years ago, only eight enteric vaccines have been licensed for four disease indications, and all are given orally. While mucosal vaccines offer programmatically attractive tools for facilitating vaccine deployment, their development remains hampered by several factors:

• — limited knowledge regarding the properties of the gut immune system during early life;
• — lack of mucosal adjuvants, limiting mucosal vaccine development to live-attenuated or killed whole virus and bacterial vaccines;
• — lack of correlates/surrogates of mucosal immune protection; and
• — limited knowledge of the factors contributing to oral vaccine underperformance in children from developing countries.

There are now reasons to believe that the development of safe and effective mucosal adjuvants and of programmatically sound intervention strategies could enhance the efficacy of current and next-generation enteric vaccines, especially in lesser developed countries which are often co-endemic for enteric infections and malnutrition. These vaccines must be safe and affordable for the world''s poorest, confer long-term protection and herd immunity, and must be able to contain epidemics.     

Treatment of Paget's Disease of Bone with Synthetic Salmon Calcitonin

Thirteen patients with painful Paget''s disease of bone were treated as outpatients with low doses of synthetic salmon calcitonin 22·5-50 μg three times weekly. Treatment produced full remission of pain in a mean time of 5·5 weeks and a mean depression of serum alkaline phosphatase activity of 33%.The interval before symptomatic relief could not be predicted from the variables studied. The ultimate fall in serum alkaline phosphatase activity, however, could be predicted from the initial levels and from the early rate of decrease (P < 0·001). Biochemical resistance to treatment, which occurred in three cases, could be related to the dose and duration of treatment.Prolonged remissions of pain may occur which are not related to biochemical remission, to the dose of calcitonin, or to the duration of treatment. The side effects attributable to salmon calcitonin were transient nausea (in nine patients), transient flushing (in four), diarrhoea (in two), and rash (in one) though in only one patient did treatment have to be withdrawn prematurely because of these effects.     

Knowing Right From Wrong In Mental Arithmetic Judgments: Calibration Of Confidence Predicts The Development Of Accuracy

Does knowing when mental arithmetic judgments are right—and when they are wrong—lead to more accurate judgments over time? We hypothesize that the successful detection of errors (and avoidance of false alarms) may contribute to the development of mental arithmetic performance. Insight into error detection abilities can be gained by examining the “calibration” of mental arithmetic judgments—that is, the alignment between confidence in judgments and the accuracy of those judgments. Calibration may be viewed as a measure of metacognitive monitoring ability. We conducted a developmental longitudinal investigation of the relationship between the calibration of children''s mental arithmetic judgments and their performance on a mental arithmetic task. Annually between Grades 5 and 8, children completed a problem verification task in which they rapidly judged the accuracy of arithmetic expressions (e.g., 25+50 = 75) and rated their confidence in each judgment. Results showed that calibration was strongly related to concurrent mental arithmetic performance, that calibration continued to develop even as mental arithmetic accuracy approached ceiling, that poor calibration distinguished children with mathematics learning disability from both low and typically achieving children, and that better calibration in Grade 5 predicted larger gains in mental arithmetic accuracy between Grades 5 and 8. We propose that good calibration supports the implementation of cognitive control, leading to long-term improvement in mental arithmetic accuracy. Because mental arithmetic “fluency” is critical for higher-level mathematics competence, calibration of confidence in mental arithmetic judgments may represent a novel and important developmental predictor of future mathematics performance.