Laparoscopic surgical treatment of ectopic pregnancy: salpingectomy or salpingostomy?

There is a widespread belief that salpingostomy is the treatment of choice for ectopic pregnancy. The ability to treat most ectopic pregnancies via a laparoscopic approach has been a major advance in gynaecological surgery. Despite the well publicized benefits of laparoscopy over laparotomy only 50% of patients with ectopic pregnancies in Australia presently benefit from this surgical advance. Although it is clear that laparoscopic treatments are preferable to laparotomy there is no consensus on whether salpingectomy or salpingostomy should be performed, despite over 40 years of research since the introduction of conservative tubal treatment. A systematic review of laparoscopic surgical treatment is needed and could be incorporated into the Cochrane Collaboration. A prospective clinical study, with long-term follow-up, needs to be performed to evaluate fertility prognosis and complications after laparoscopic salpingectomy versus salpingostomy.

Casein kinase II phosphorylates Ser468 in the PEST domain of the Drosophila IkappaB homologue cactus

Cactus protein is a Drosophila homologue of the mammalian IkappaB family of cytoplasmic anchor proteins. In unstimulated cells they function to retain rel/NFkappaB transcription factors in the cytoplasm but are rapidly degraded in response to signalling. The destruction of cactus or IkappaBalpha allows the rel/NFkappaB transcription factor to relocalise to the nucleus. Cactus is a phosphoprotein and has in its C-terminus a PEST protein stability domain. In this paper we show that, like mammalian IkappaBalpha, the PEST domain of cactus is phosphorylated by casein kinase II. We have localised the site of modification to a single residue, Ser468, and find no evidence for additional phosphorylation sites. The conservation of these sites in mammalian and invertebrate cytoplasmic anchor proteins suggests that phosphorylation by casein kinase II may play a critical functional role, plausibly in the regulation of constitutive or inducible proteolysis.

Impact of the 1991 NHS reforms on the availability and use of coronary revascularisation in the UK (1987-1995)

OBJECTIVE

To describe changes in the availability, utilisation, and waiting times for coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) between 1987/88 and 1994/95 and to review commissioning of these services.

DESIGN

A series of cross sectional surveys and interviews with purchasers and providers.

SETTING

Four health regions in the United Kingdom.

PATIENTS

All residents aged 25 years or more who underwent coronary revascularisation.

RESULTS

There has been little change in the availability of consultants in cardiology in specialist centres, while the number of non-consultant cardiologists has risen significantly. The availability of consultant surgeons more than doubled in some regions, while non-consultant surgical staff increased by 40-90%. The NHS rate of use of both CABG and PTCA has increased steadily since 1987/88. In 1994/95, only two districts had CABG rates of less than 300 per million population. The additional contribution of privately funded cases varied between 14-23% for CABG and 7-30% for PTCA. Regional rates varied 1.3-fold for CABG and threefold for PTCA in 1994/95, while district rates of CABG varied 3.6-fold and PTCA 18-fold. Revascularisation rates were higher in districts with least need in 1991/92 and this persisted over the following three years. The overall waiting time for CABG (214 days) was largely unchanged from 1992/93 (234 days). The overall waiting time for PTCA (138 days) was 25% shorter than in 1992/93 (185 days). Prioritisation of patients waiting over a year had not yet adversely affected the waiting time of more urgent patients. Commissioning has faced a complex web of interconnected problems which, in general, caused more problems for purchasers than providers initially but which appear to be of increasing concern to providers.

CONCLUSIONS

The 1991 NHS reforms had had no observable impact on the availability and use of coronary revascularisation by 1995. Continued monitoring is necessary to detect any delayed effect.

Cross validation of the factor structure of the 20-item Toronto Alexithymia Scale: an Italian multicenter study

The 20-item Toronto Alexithymia Scale (TAS-20) has been shown in previous research to measure a general dimension of alexithymia with three intercorrelated factors. This study evaluated the reliability and factorial validity of an Italian translation of the TAS-20 in a group of normal adults (N = 206) and in a mixed group of medical and psychiatric outpatients (N = 642). Using confirmatory factor analyses, the previously established three-factor model of the TAS-20 was found to be replicable in both groups. In addition, the Italian TAS-20 demonstrated adequate estimates of internal reliability and test-retest reliability. Although evaluation of the convergent, discriminant, and concurrent validity of the TAS-20 is required in Italian populations, the present results support the use of the Italian translation of the scale for clinical and research purposes.

Low dose methotrexate, bleomycin, doxorubicin, cyclophosphamide, vincristine, and dexamethasone with zalcitabine in patients with acquired immunodeficiency syndrome-related lymphoma. Effect on human immunodeficiency virus and serum interleukin-6 levels over time

BACKGROUND

Use of multiagent chemotherapy has been associated with complete remission (CR) in approximately 50% of patients with newly diagnosed acquired immunodeficiency syndrome (AIDS)-lymphoma, although additional AIDS-related complications may occur. Both chemotherapy and antiretroviral therapy were employed in an attempt to ascertain if the combination was safe, and associated with changes in human immunodeficiency virus (HIV) p24 antigen levels during the course of treatment.

METHODS

Low dose methotrexate, bleomycin, doxorubicin, cyclophosphamide, vincristine, and dexamethasone(M-BACOD) chemotherapy and zalcitabine (ddC) were employed in 28 patients. Since both vincristine and zalcitabine may cause peripheral neuropathy, a Phase I/II study design was employed. Serum was analyzed for immune complex dissociated (ICD) HIV p24 antigen and interleukin (IL)-6 levels during therapy.

RESULTS

CR was achieved in 14 of 25 patients (56%), with partial response (PR) in 5 (20%). CRs were equivalent in patients with good or poor prognostic indicators, including a history of AIDS prior to lymphoma (CR = 60%); and/or CD4 lymphocytes < 200/mm3 (CR = 53%). Five patients with a CR subsequently relapsed (36%); median survival of CR patients was 29.2 months (4.1-61+), whereas that of all of the treated patients was 8.1 months. No significant peripheral neuropathy or other toxicity was observed. Serum ICD p24 antigen levels either fell (7/14) or remained consistently negative (2/14) in 9 of 14 patients (64%), whereas 36% experienced an increase. Elevated serum IL-6 levels at diagnosis were associated with systemic "B" symptoms (P = 0.023), whereas changes in IL-6 correlated with response to therapy over time (P = 0.006).

CONCLUSIONS

Combination antineoplastic and zalcitabine antiretroviral therapy may be safely administered to patients with AIDS-related lymphoma, resulting in CR in 56%, lack of significant neurotoxicity, and favorable effect on HIV p24 antigen in 50%. Elevation of serum IL-6 is associated with systemic "B" symptoms, whereas changes in serum IL-6 may correlate with response.

Clinical significance of bcl2 and p53 protein expression in diffuse large B-cell lymphoma: a population-based study

PURPOSE

We studied the prognostic significance of bcl2 and p53 protein expression in relation to clinical and pathologic characteristics in patients with diffuse large B-cell lymphoma (LCL).

PATIENTS AND METHODS

Three hundred seventy-two patients with LCL were retrieved from a population-based registry for non-Hodgkin's lymphoma (NHL). bcl2 and p53 protein expression was studied on paraffin-embedded tumor tissue by immunohistochemistry in relation to clinical factors. Response to therapy and survival were analyzed in 165 patients who were uniformly staged and treated and for whom all prognostic data were available according to the International Prognostic Index (IPI).

RESULTS

Forty-five percent of tumors showed strong expression of the bcl2 protein (bcl2++), with a higher frequency in patients with primary nodal involvement. Disease-free survival (DFS) was significantly better in bcl2-negative/intermediate (bcl2-/+) cases as compared with bcl2++ cases (P = .0011). At 5 years, bcl2-/+ patients showed a DFS rate of 74%, in contrast to bcl2++ patients with a DFS rate of 41% (P = .002). Bcl2 was the strongest independent prognostic value in a multivariate analysis, with a relative risk (RR) of 3.0 in comparison to p53 expression and the clinical factors of the IPI. Overall survival (OS) was not significantly influenced by bcl2 protein expression. p53 protein expression was found in 13% of cases, with a higher frequency in patients with extensive disease. p53 expression did not influence the chance to achieve complete remission (CR) and survival.

CONCLUSION

bcl2 protein is frequently expressed in LCL and is a strong independent prognostic factor for DFS. p53 expression is related with high tumor burden, but is not an independent risk factor for CR and survival.

Susan's breast reconstruction: a case study and reflective analysis

This case study describes and analyses selected aspects of the nursing care of Susan during her stay on a plastic surgery unit. The necessity for her breast reconstructive surgery following mastectomy some years earlier is discussed, along with the importance of selection of the appropriate operation and preoperative preparation. A retrospective analysis of aspects of the nursing care is then undertaken, giving insights for possible improvements and role developments. Susan left hospital with a new body shape and was beginning to adapt to her altered body image. Her continued recovery and the restoration of her 'ideal' body image are discussed. Finally, the value of case studies is considered along with an outline of their potential as a tool in professional practice and education.

Cardiopulmonary arrest in pregnancy: successful resuscitation of mother and infant following immediate caesarean section in labour ward

Our patient experienced cardiopulmonary arrest secondary to profound hypotension and was unable to be resuscitated with external cardiac massage and assisted ventilation. This case demonstrates the need for continued vigilance by medical and nursing staff when epidural anaesthesia is being established. Resuscitation equipment should be available in the labour ward as cardiopulmonary resuscitation and immediate Caesarean section can be lifesaving in the event of a cardiopulmonary arrest.

A liver-lung connection

A 35-year-old man presented with cough, expectoration of green sputum, and right-sided pleuritic chest pain. Symptoms had begun the previous day and he had vomited the night before. The patient also complained of chronic fatigue, a 12-lb. weight loss, insomnia, right-sided back pain, and lower extremity myalgias. He denied having had fever, chills, diaphoresis, dyspnea, diarrhea, dysuria, abdominal pain, skin lesions, or jaundice.

Containing abjection in nursing: the end of shift handover as a site of containment

This theoretical paper has arisen out of a national study of the end of shift nursing handover. It draws upon and offers a postmodern reformulation of the psychodynamic concepts of anxiety and defence as articulated by Menzies Lyth in her study of nursing work in the 1950s. It outlines Kristeva's concept of abjection and draws upon Bion's formulation of the concept of containing to offer an account of how, in the current context of hospital nursing, the handover can function to contain abjection.

Operative laparoscopic management of adnexal cysts: initial experience at the Royal Women's Hospital 1991-1994

The introduction of operative laparoscopic surgery for benign adnexal cysts had led to shorter postoperative hospitalization (mean stay of 2.0 days) in association with a low rate of major complications (1.6%). A planned laparoscopic approach was successful in 95.2% (179/188) of patients. The majority of women were premenopausal (93.6%) and the most common procedure performed was an ovarian cystectomy (73.5% of cysts). Three ovarian cysts that were thought to be benign by preoperative and intraoperative assessment were subsequently found to be ovarian tumours of low malignant potential after histological examination. Operative laparoscopy has become the preferred mode of treatment for benign adnexal cysts at the Royal Women's Hospital. It confers a wide range of benefits to patients, reduces health-care costs and appears to be a safe and effective treatment modality.

Videokeratography of Keratoconus in Monozygotic Twins

PURPOSE

To determine the corneal topographic appearance in a pair of monozygotic twins and family members of the twins because one of the twins had keratoconus and the other appeared normal by clinical examination.

METHODS

Clinical examination and videokeratography (Topographic Modeling System, Tomey) of the patient, his monozygotic twin brother, an older brother, and his parents were performed. The I-S values (difference in the average dioptric powers of symmetrical points between the inferior and superior cornea) were calculated.

RESULTS

The patient, a 28-year-old man, had clinical keratoconus confirmed with videokeratography. Clinical examination of family members including a twin brother, an older brother and both parents revealed no corneal abnormalities. Videokeratography of the clinically normal twin brother showed inferior steepening with progression over time. The I-S value of the clinically normal brother was 1.36 (right eye) (greater than 2.00 SD of normal controls), which progressed to 1.69 (right eye), 1.32 (left eye) 5 months later and to 1.87 (right eye), 1.43 diopters (D) (left eye) 14 months later. Minimal asymmetric inferior steepening was noted in an older brother who had an I-S value of 0.81 (right eye), 1.27 (left eye). The mother appeared topographically normal.

CONCLUSIONS

This study lends support to the existence of subclinical keratoconus detectable by videokeratography only.

Analysis of astigmatic keratotomy with a 5.0-mm optical clear zone

PURPOSE

To investigate the surgically induced refractive change after astigmatic keratotomy with a 5.0-mm optical clear zone in patients with severe naturally occurring astigmatism.

METHODS

We analyzed surgically induced refractive change in 40 consecutive eyes undergoing astigmatic keratotomy with a 5.0-mm optical clear zone. The surgically induced refractive change was calculated according to the method of Holladay, Cravy, and Koch with some modifications. Eyes were divided into two groups: Group I included eyes with mixed astigmatism and a maximum preoperative spherical equivalent of +1.25 diopters that underwent arcuate keratotomy, and Group II included eyes with compound myopic or simple myopic astigmatism (maximum preoperative spherical equivalent of -3.00 diopters) or mixed astigmatism with low minus spherical equivalent that underwent four-incision radial keratotomy and arcuate keratotomy.

RESULTS

After refractive surgery, all eyes experienced a reduction of astigmatism when examined three months or more after surgery. Only one eye from each group was overcorrected. The magnitude of refractive astigmatism of surgically induced refractive change was 3.25 +/- 0.90 diopters for eyes in Group I and 3.25 +/- 0.80 diopters for eyes in Group II. There was minimal axis deviation. Eyes in Group I had more flattening with the wound than steepening against the wound, with a coupling ratio of -0.86 +/- 0.36, whereas in Group II, there was flattening both with the wound and against the wound. The net effect of surgery (sum of the primary and secondary effects) was more flattening than steepening in Group I eyes, and flattening of the circumference of the eye in Group II. A decrease of one line of best-corrected visual acuity was observed in one (6.6%) of 15 eyes in Group I and in two (8%) of 25 eyes in Group II.

CONCLUSIONS

A 5.0-mm optical clear zone arcuate keratotomy is an effective method for correcting moderate to severe naturally occurring astigmatism. Further investigation of this optical clear zone size on glare and contrast sensitivity testing is necessary and is underway.

Laboratory practices in reporting flow cytometry phenotyping results for leukemia/lymphoma specimens: results of a survey

Laboratory directors who routinely utilize flow cytometry for at least part of their diagnostic evaluations in leukemias or lymphomas were surveyed by mail. The survey consisted of 12 questions about the flow cytometry procedures used by the laboratory in evaluating leukemias and lymphomas and on the format and content of their official report. It also requested an example of a typical leukemia/lymphoma report and solicited write-in comments about additional important aspects of using flow cytometry to evaluate leukemia and lymphomas not covered by the questionnaire. The goal of the survey, which was sponsored by the Clinical Cytometry Society (CCS), was to document what directors of flow cytometry laboratories currently consider to be the appropriate contents of a clinical leukemia/lymphoma phenotyping analysis and in what manner and detail they report such flow cytometry results to clinicians. The survey indicated that a large number of markers are routinely evaluated to phenotype leukemias (mean = 19) and lymphomas (mean = 16). Light scatter gating, using CD45/14 to monitor the gate selected, is currently employed by a 2:1 ratio over the next most population gating strategy (CD45 vs. 90 degrees LS). Peripheral blood, bone marrow, and lymphoid tissue constitute the majority of clinical specimens evaluated for leukemia and/or lymphoma. Two-color analysis, primarily for surface markers, is currently the standard method for flow cytometry measurements in routine diagnostic studies of leukemia and lymphoma. The official flow cytometry laboratory report is most commonly an individual-lab-generated, paper report form. A discussion of the potential benefits that might result from the development of improved computerized reporting software and from the increased use of antibody-defined, lineage gating is offered. A composite report format is presented that demonstrates the flow measurements and quality control data included in the best of the example clinical reports submitted as part of the survey and considered important by a majority of our survey respondents. The example report is intended to be a basis for further discussion within the flow cytometry community on whether minimum reporting standards for leukemia and/or lymphoma flow cytometry results can and should be developed.

Right gastroepiploic-to-coronary artery bypass. The first decade of use

BACKGROUND

The right gastroepiploic artery was first used by us as a coronary artery bypass graft (CABG) in June 1984 and has become an accepted alternative conduit for myocardial revascularization.

METHODS AND RESULTS

We have now performed this operation in 126 patients (111 of whom were men) aged 32 to 78 years. The right gastroepiploic artery was used as a pedicle graft to the right main coronary artery in 25 patients, to its posterior descending branch in 90, to a left ventricular branch in 2, to branches of the circumflex system in 6, and to the left anterior descending artery in 1. Free (aortocoronary) gastroepiploic grafts were placed to circumflex branches in 2 patients. There were 2 hospital deaths (stroke, arrhythmia), and mean +/- SD postoperative stay was 7.5 +/- 2.0 days. All survivors were symptomatically improved and are functionally in New York Heart Association functional class I or II. There have been 3 late deaths (at 34, 50, and 84 months) in 2 to 120 months of follow-up (mean, 41.4 months). Angiography of bypass grafts and coronary arteries was performed in 44 patients at 7 days to 80 months postoperatively, providing direct evidence of gastroepiploic graft patency in 34 patients and strong indirect evidence in another 6; adequate data could not be obtained in 3 patients for technical reasons, and 1 graft was occluded.

CONCLUSIONS

These short-term, intermediate, and long-term results demonstrate the suitability of the right gastroepiploic artery as a CABG. The use of the right gastroepiploic artery as a graft to coronary arteries on the posterior wall of the heart, in conjunction with one or both internal mammary arteries, has the potential to allow complete myocardial revascularization with viable arterial grafts.

Prostaglandin A2 protein interactions and inhibition of cellular proliferation

Some prostaglandins inhibit cellular proliferation in a wide variety of cell types, but the mechanism of inhibition is not known. The most potent inhibitors of proliferation appear to be prostaglandins of the A and J series. These prostaglandins have been reported to form covalent bonds to cellular proteins (Narumiya, S., Ohno, K., Fukushima, M., Fujiwara, M. (1987) J. Pharm. Exp. Ther., 242, 306-311). However, the proteins have not been identified or shown to be involved in the inhibition of proliferation. Prostaglandin A2-biotin provided a sensitive method to demonstrate binding of prostaglandin A2 (PGA2) to cellular proteins of 43, 50, and 56 kilodaltons in K562 erythroleukemia cells. Similar PGA2-binding proteins were also present in mouse fibroblasts and porcine aortic endothelial cells. The PGA2-binding proteins preexist in K562 cells and were not induced by exposure to the prostaglandin. Furthermore, binding of PGA2 to these proteins correlated to the inhibition of proliferation. Therefore, one or more of the PGA2-binding proteins may be involved in the inhibition of cellular proliferation by PGA2.

Male and female flowers of the dioecious plant sorrel show different patterns of MADS box gene expression

Male and female flowers of the dioecious plant sorrel (Rumex acetosa) each produce three whorls of developed floral organs: two similar whorls of three perianth segments and either six stamens (in the male) or a gynoecium consisting of a fertile carpel and two sterile carpels (in the female). In the developing male flower, there is no significant proliferation of cells in the center of the flower, in the position normally occupied by the carpels of a hermaphrodite plant. In the female flower, small stamen primordia are formed. To determine whether the organ differences are associated with differences in the expression of organ identity genes, cDNA clones representing the putative homologs of B and C function MADS box genes were isolated and used in an in situ hybridization analysis. The expression of RAD1 and RAD2 (two different DEFICIENS homologs) in males and females was confined to the stamen whorl; the lack of expression in the second, inner perianth whorl correlated with the sepaloid nature of the inner whorl of perianth segments. Expression of RAP1 (a PLENA homolog) occurred in the carpel and stamen whorls in very young flower primordia from both males and females. However, as soon as the inappropriate set of organs ceased to develop, RAP1 expression became undetectable in those organs. The absence of expression of RAP1 may be the cause of the arrest in organ development or may be a consequence.

Further characterization of Chlamydia pneumoniae specific monoclonal antibodies

Studies using monoclonal antibodies have demonstrated species-specific reactivities with Chlamydia pneumoniae. In this study, further characterization of C. pneumoniae specific monoclonal antibodies TT-205 and RR-402 and description of C. pneumoniae specific antibodies prepared against other isolates are presented. TT-205 and RR-402 were shown to neutralize infectivity. Neutralization in cell culture was specific and enhanced by complement. Attempts to characterize the reactive antigen by immunoblotting, immunoaffinity chromatography and radioimmunoprecipitation were unsuccessful, probably due to difficulties in solubilizing the immunoreactive epitope without denaturing it. Recognition of the determinant by the monoclonal antibodies is labile to physical and chemical treatments suggesting that the reactive epitope is conformational.