Marathon related death due to brainstem herniation in rehydration-related hyponatraemia: a case report

Introduction

The natural history of patients with spontaneous parathyroid necrosis is unknown. In this case report we describe the clinical course, laboratory, radiographic, bone densitometry tests, parathyroid ultrasonography and scintigraphy examinations of a patient performed over a period of eight years after she first presented with a sudden episode of spontaneous resolution of primary hyperparathyroidism (PHPT).

Case presentation

A 24-year-old woman with a clinical history and laboratory and radiographic tests compatible with PHPT suffered a sudden episode of cervical pain and presented with clinical evidence of hypocalcemia. Biopsy of a cervical nodule revealed necrotic material compatible with ischemia of the parathyroid. The follow-up of the patient presented four distinct phases: the first, which lasted two years, was compatible with a period of bone hunger during which it was necessary to introduce calcitriol and calcium carbonate. During this period, the patient showed bone mass gain. The second phase was characterized by normalization of calcium and parathyroid hormone levels and its end was difficult to define. During the third phase there was a recurrence of hypercalcemia associated with elevated parathyroid hormone (PTH) levels and loss of bone mass. The last phase corresponded to the interval after parathyroidectomy, which was characterized by normalization of serum levels of calcium and PTH, as well as bone mass gain.

Conclusion

This case report indicates that spontaneous resolution of PHPT by adenoma necrosis is potentially temporary. Thus, in cases in which a conservative approach is chosen, clinical and laboratory follow-up is indispensable. Bone mass measurement is a useful tool in the follow-up of these cases. However, this option exposes the patient to a potential roller-coaster ride of bone mass gain and loss, whose long term consequences are still unknown.     

Iatrogenic newborn weight loss: knowledge translation using a study protocol for your maternity setting

Background

WHO and UNICEF believe that both antenatal and maternity care organizations are in an excellent position to protect and, if necessary, reinstate a culture that promotes breastfeeding, and that they are responsible for doing so. In Sweden, the number of breastfeeding women has been decreasing annually since 1996. Thus the aim of this study is to identify, describe and analyze the attitude midwives have towards the mother, child and breastfeeding when infant formula is given.

Methods

From the theoretical standpoint of Buber's I-Thou and I-It concept, the different attitudes during breastfeeding consultations are interpreted. By using a phenomenographic approach based on 101 accounts of varying lengths from 39 midwives, different attitudes or approaches were identified.

Results

Four different approaches are distinguished in the breastfeeding consultation. The first is the family as a whole, the second is mother and child as separate and equal, the third views the mother as superior and the fourth views the child as superior.

Conclusions

The approach of the midwife is related to how she defines the overall perspective of the mother-child relationship and how she looks upon her relationship to the mother-child dyad. Her approach varies depending on whether she meets the mother and child as a subject, similar to herself, or whether she sees one of them as an object. A midwife may also take an outside position, as an object, thus excluding a genuine relationship with the mother. The results also indicate that health care professionals focus on parts of the whole instead of maintaining a holistic perspective.     

Haemorrhagic disease of the newborn in the British Isles: two year prospective study.

OBJECTIVE--To determine the incidence of haemorrhagic disease of the newborn in the British Isles, study risk factors, and examine the effect of vitamin K prophylaxis. DESIGN--Prospective survey of all possible cases of haemorrhagic disease of the newborn as reported by consultant paediatricians using the monthly notification cards of the British Paediatric Surveillance Unit and a follow up questionnaire for each case to validate the diagnosis and accrue further data. SETTING--Britain (England, Scotland, and Wales) and Ireland (Northern Ireland and the Irish Republic) during December 1987 to March 1990. PATIENTS--27 infants classified as having confirmed (n = 25) or probable (n = 2) haemorrhagic disease of the newborn. RESULTS--24 of the 27 infants were solely breast fed. 10 suffered intracranial haemorrhage; two of these died and there was clinical concern about the remainder. 20 infants had received no vitamin K prophylaxis, and seven had received oral prophylaxis. Relative risk ratios for these groups compared with babies who had received intramuscular vitamin K were 81:1 and 13:1 respectively. Six infants had hepatitis (alpha 1 antitrypsin deficiency in four), unsuspected until presentation with haemorrhagic disease of the newborn, of whom four had received oral prophylaxis. One other baby had prolonged jaundice. One mother had taken phenytoin during pregnancy. CONCLUSIONS--All newborn infants should receive vitamin K prophylaxis. Intramuscular vitamin K is more effective than oral prophylactic regimens currently used in the British Isles.     

Influence of moving to the UK on maternal health behaviours: prospective cohort study

Objective To compare health behaviours during pregnancy (smoking and alcohol consumption) and after birth (initiation and duration of breast feeding) between British/Irish white mothers and mothers from ethnic minority groups; and, in mothers from ethnic minority groups, to examine whether indicators of acculturation (generational status, language spoken at home, length of residency in the United Kingdom) were associated with these health behaviours.Design Prospective nationally representative cohort study.Setting England.Participants 6478 British/Irish white mothers and 2110 mothers from ethnic minority groups.Main outcome measures Any smoking during pregnancy; any alcohol consumption during pregnancy; initiation of breast feeding; breast feeding for at least four months.Results Compared with British/Irish white mothers, mothers from ethnic minority groups were less likely to smoke (15% v 37%) or consume alcohol (14% v 37%) during pregnancy but more likely to initiate breast feeding (86% v 69%) and breast feed for at least four months (40% v 27%). Among mothers from ethnic minority groups, first and second generation mothers were more likely to smoke during pregnancy (odds ratio 3.85, 95% confidence interval 2.50 to 5.93, and 4.70, 2.49 to 8.90, respectively), less likely to initiate breast feeding (0.92, 0.88 to 0.97, and 0.86, 0.75 to 0.99), and less likely to breast feed for at least four months (0.72, 0.62 to 0.83, and 0.52, 0.30 to 0.89) than immigrants, after adjustment for sociodemographic characteristics. There were no consistent differences in alcohol consumption. Among immigrants, for every additional five years spent in the UK the likelihood of mothers smoking during pregnancy increased by 31% (4% to 66%) and they were 5% (0% to 10%) less likely to breast feed for at least four months.Conclusions After immigration, maternal health behaviours worsen with length of residency in the UK. Health professionals should not underestimate women’s likelihood of engaging in risky health behaviours because of their ethnicity.     

Effects of maternal occupational exposure to organic solvents on offspring visual functioning: a prospective controlled study

BACKGROUND: Previous studies in adults and animals with high level exposure to organic solvents suggested impairments in visual functioning. The objective of this pilot study was to examine the effects of maternal occupational exposure to organic solvents during pregnancy on offspring color vision and visual acuity, the development of which may be especially vulnerable to organic solvent exposure. METHODS: We conducted a prospective cohort study of 32 offspring of women who were exposed occupationally to organic solvents during pregnancy compared with 27 nonexposed children. Monocular and binocular color vision and visual acuity were assessed using the Minimalist Test and the Cardiff Cards, respectively. Children with known hereditary color vision loss were excluded. RESULTS: Solvent-exposed children had significantly higher error scores on red-green and blue-yellow color discrimination, as well as poorer visual acuity compared with the control group. Exposure index (an estimated measure of exposure intensity) was not significantly related to color discrimination or visual acuity score. Despite excluding all children with a known family history of color vision loss, clinical red-green color vision loss was found among 3 of the 32 exposed children compared with none of the matched controls. CONCLUSIONS: These preliminary findings suggest that occupational exposure to organic solvents during pregnancy is associated with an increased risk of color vision and visual acuity impairment in offspring. The importance of routine visual function screening in risk assessment after prenatal exposure to chemicals warrants further attention.     

Psychological sequelae to elective sterilisation: a prospective study.

A total of 201 women were interviewed four weeks before elective interval tubal sterilisation, of whom 190 (94.5%) were assessed again six months postoperatively and 193 (96.0%) 18 months postoperatively. Before sterilisation the prevalence of psychiatric morbidity as measured by the present state examination was 10.4% (21 patients), no greater than might be expected in a general population sample; six months after the operation the prevalence was significantly reduced to 4.7% (nine patients); and 18 months postoperatively it had returned almost to the preoperative value (9.3%; 18 patients). Postoperative psychosexual disturbance was rare, only 3% of patients reporting reduced enjoyment of sexual intercourse at either follow-up. Considerable regret was reported by only five patients (2.6%) six months after the operation and by eight (4.1%) 18 months after the operation; however, some dissatisfaction was reported by 15 patients (7.9%) at six months and 21 patients (10.9%) at 18 months. Postoperative psychiatric disturbance and dissatisfaction were largely associated with preoperative psychiatric disturbance. Thus there was no evidence that elective interval sterilisation increased the risk of psychiatric disturbance up to 18 months after the operation.     

Amniocentesis, maternal psychopathology and prenatal representations of attachment: a prospective comparative study

Background

The aim of the study was to characterize the maternal dimensions of anxiety, depression and prenatal attachment in women undergoing an amniocentesis.

Methodology/Principal Findings

A prospective observational study was conducted. Women were referred to early amniocentesis for increased nuchal translucency, elevated biochemical markers or advanced maternal age. All participants had 3 prenatal (16–18, 20–24, 30–34 weeks of gestation) and one postnatal (30–45 days) interviews reviewing for demographic, medical, and psychiatric information (STAI State-Trait Anxiety Inventory; EPDS: Edinburgh Postnatal Depression Scale; IRMAG: Interview of Maternal Representations of Attachment during pregnancy). We investigated 232 pregnant women who undergone an amniocentesis compared with 160 pregnant controls. Following the procedure, the amniocentesis group experienced transiently significantly higher levels of state-anxiety on the STAI (44.6 vs. 39.3) and depression as measured by the EPDS (9.4 vs. 6.3) than the controls. Overall in both groups, the maternal representations of attachment were well integrated and balanced, but the amniocentesis group experienced significantly more mother-directed representations.

Conclusions/Significance

Amniocentesis is associated with higher affective adaptive reactions that tend to normalize during the pregnancy, with overall preserved maternal fetal representations of attachment.     

The perinatal thyroid in iodine deficient regions: risks of radioiodines--hazards of stable iodine overload. A study in the newborn rat.

Administration of large quantities of stable iodine is an effective means of reducing the radiation burden on the thyroid in the event of a nuclear power-plant accident. Such administration may involve countries with low baseline dietary iodine intake. It is questioned whether stable iodine overload is safe, and in particular, what are its effects in newborn infants? Iodine-deficient newborn rats were submitted to a single acute administration of stable iodine (100 microg) on the second day of life. The effects on thyroid structure were studied, after 24 hr and after 7 days, using light microscopy. Compared to controls, the thyroids of animals submitted to stable iodine overload showed, 7 days after treatment, signs of acute toxicity including marked desquamation of epithelial cells and rupture of a large number of thyroid follicles. Our findings in iodine deficient newborn rats suggest that stable iodine overload may have side effects during perinatal life. This prophylactic measure should, therefore, be accompanied by follow-up of thyroid function. Thyroid hormones are critical for brain development, during the first period of life.     

Acute haemolysis due to concentrated dialysis fluid.

Fatal acute haemolysis occurred in a 65-year-old man undergoing regular home haemodialysis for terminal renal failure. Circumstantial evidence indicating that the haemolysis resulted from exposure to concentrated dialysis solution was supported by in-vitro studies. Frank haemolysis in blood samples occurred at a dilution of greater than or equal to 1/2 of dialysis fluid. Osmotic fragility tests of surviving red blood cells showed 47% haemolysis at a dilution of 1/2 and greater than 90% haemolysis at a dilution of 1/1. Urgent design modifications to the proportionating machine are being undertaken to prevent such an accident recurring.     

Anomalous diffusion due to binding: a Monte Carlo study.

In classical diffusion, the mean-square displacement increases linearly with time. But in the presence of obstacles or binding sites, anomalous diffusion may occur, in which the mean-square displacement is proportional to a nonintegral power of time for some or all times. Anomalous diffusion is discussed for various models of binding, including an obstruction/binding model in which immobile membrane proteins are represented by obstacles that bind diffusing particles in nearest-neighbor sites. The classification of binding models is considered, including the distinction between valley and mountain models and the distinction between singular and nonsingular distributions of binding energies. Anomalous diffusion is sensitive to the initial conditions of the measurement. In valley models, diffusion is anomalous if the diffusing particles start at random positions but normal if the particles start at thermal equilibrium positions. Thermal equilibration leads to normal diffusion, or to diffusion as normal as the obstacles allow.     

Influence of maternal nutrition on outcome of pregnancy: prospective cohort study

ObjectiveTo investigate the relations of maternal diet and smoking during pregnancy to placental and birth weights at term.DesignProspective cohort study.SettingDistrict general hospital in the south of England.Participants693 pregnant nulliparous white women with singleton pregnancies who were selected from antenatal booking clinics with stratified random sampling.ResultsPlacental and birth weights were unrelated to the intake of any macronutrient. Early in pregnancy, vitamin C was the only micronutrient independently associated with birth weight after adjustment for maternal height and smoking. Each ln mg increase in vitamin C was associated with a 50.8 g (95% confidence interval 4.6 g to 97.0 g) increase in birth weight. Vitamin C, vitamin E, and folate were each associated with placental weight after adjustment for maternal characteristics. In simultaneous regression, however, vitamin C was the only nutrient predictive of placental weight: each ln mg increase in vitamin C was associated with a 3.2% (0.4 to 6.1) rise in placental weight. No nutrient late in pregnancy was associated with either placental or birth weight.ConclusionsConcern over the impact of maternal nutrition on the health of the infant has been premature. Maternal nutrition, at least in industrialised populations, seems to have only a small effect on placental and birth weights. Other possible determinants of fetal and placental growth should be investigated.

Key messages

• Placental and infant birth weights were not associated with the intake of any macronutrient early or later in pregnancy
• After adjustment for the effects of maternal height and smoking, only vitamin C independently predicted birth weight. The expected mean difference in birth weight for infants with mothers in the upper and lower thirds of intake was about 70 g
• Vitamin C was the only nutrient that independently predicted placental weight, but again this relation was of doubtful clinical significance
• Among relatively well nourished women in industrialised countries, maternal nutrition seems to have only a marginal impact on infant and placental size. Other causes of variation in the size of clinically normal infants should now be investigated