The effects of mefloquine treatment in pregnancy

We investigated the relationship between mefloquine antimalarial treatment and the outcome of pregnancy in Karen women living in an area along the western border of Thailand where multidrug-resistant Plasmodium falciparum infections are common. Of 3,587 pregnancies investigated, 208 (5.8%) were exposed to mefloquine, 656 (18.3%) to quinine only, and 909 (25.3%) to other antimalarials, and 2,470 (68.9%) had no documented malaria. There were 61 stillbirths and 313 abortions. Women who received mefloquine treatment during but not before pregnancy had a significantly greater risk of stillbirth than did women treated with quinine alone (odds ratio [OR], 4.72; 95% confidence interval [CI], 1.7-12.7), women exposed to other treatments (OR, 5.10; 95% CI, 2-13.1), and women who had no malaria (OR, 3.50; 95% CI, 1.6-7.6) (P < .01). This association remained after adjustment for all identified confounding factors. Mefloquine was not associated with abortion, low birth weight, neurological retardation, or congenital malformations. Mefloquine treatment during pregnancy was associated with an increased risk of stillbirth.

Adverse effects in patients with acute falciparum malaria treated with artemisinin derivatives

In prospective studies of acute uncomplicated, multidrug-resistant falciparum malaria on the western border of Thailand, the oral artemisinin derivatives were used alone in the treatment of 836 patients (artesunate 630, artemether 206), were combined with mefloquine (15-25 mg base/kg) in 2,826 patients, and mefloquine alone was used in 1,303 patients. The combined regimens of mefloquine plus an artemisinin derivative were associated with more side effects than those with an artemisinin derivative alone; acute nausea (31% versus 16%), vomiting (24% versus 11%), anorexia (51% versus 34%), and dizziness (47% versus 15%) (P < 0.001). Oral artesunate and artemether alone were very well tolerated. There was no difference in the incidence of possible adverse effects between the two drugs, and no evidence that either derivative caused allergic reactions, neurologic or psychiatric reactions, or cardiovascular or dermatologic toxicity. Blackwater fever occurred in three patients treated with mefloquine plus artesunate regimens. Oral artesunate and artemether are safe and well tolerated antimalarial drugs.

CYP2D6 status of extensive metabolizers after multiple-dose fluoxetine, fluvoxamine, paroxetine, or sertraline

The aim of this study was to evaluate the CYP2D6 inhibitory effects of four selective rerotonin re-uptake inhibitors (SSRIs). Thirty-one healthy subjects were phenotyped as extensive metabolizers using the dextromethorphan/dextrorphan (DM/DX) urinary ratio as a marker for CYP2D6 activity before and after 8 days of administration of fluoxetine 60 mg (loading dose strategy), fluvoxamine 100 mg, paroxetine 20 mg, or sertraline 100 mg in a parallel-group design. Statistical analysis was performed on log-transformed DM/DX ratios because of variability within and between treatment groups. DM/DX ratios before (DM/DX(BL)) and after (DM/DX(SSRI)) were compared within and between the four SSRI groups. DM/DX(BL) ratios were not significantly different between the four SSRI treatment groups. Comparing within groups, significant differences between DM/DX(BL) and DM/DX(SSRI) were found for the fluoxetine (p < 0.001; ratio values, 0.020 vs. 0.364) and paroxetine (p = 0.0005, ratio values 0.029 vs. 1.085) but not for the fluvoxamine or sertraline groups. Comparing between groups, significant differences in DM/DX(SSRI) ratios were found for fluoxetine versus sertraline (p = 0.0019, DM/DX = 0.364 vs. 0.057), fluoxetine versus fluvoxamine (p < 0.0001, DM/DX = 0.364 vs. 0.019), paroxetine versus sertraline (p = 0.0026, DM/DX = 1.085 vs. 0.057), and paroxetine versus fluvoxamine (p < 0.0001, DM/DX = 1.085 vs. 0.019). No significant differences were noted between the two potent CYP2D6 inhibitors, fluoxetine and paroxetine, or the two weakest inhibitors, fluvoxamine and sertraline. Five subjects in the fluoxetine and four subjects in the paroxetine groups changed to poor metabolizer phenotype (DM/DX > or = 0.3) after treatment. Although CYP2D6 inhibitory effects of fluvoxamine and sertraline did not yield significant differences from baseline, some subjects exhibited DM/DX ratio increases of 150 to 200%. One paroxetine-treated subject did not exhibit any CYP2D6 inhibition. SSRI dose and plasma concentration may be correlated with the extent of CYP2D6 inhibition and should be further investigated.

A new system for catheter ablation of atrial fibrillation

Increased attention is now being focused on developing new technologies to cure atrial fibrillation using catheter ablation techniques. The performance of a MAZE-type procedure using standard catheter ablation technologies is arduous and is associated with an unacceptable risk of complications. The Guidant Heart Rhythm Technologies Linear Ablation System was developed to create long transmural linear lesions. Unique features of this system include the availability of different preshaped multi-electrode steerable ablation catheters, the use of phased radiofrequency (RF) energy, and the control of RF output by varying the duty cycle. A prospective multicenter clinical trial to evaluate the safety and efficacy of a right atrial ablation procedure using this technology to treat atrial fibrillation is currently underway. To date, 15 patients have been enrolled and the procedure was acutely effective in 14 of 15 patients with no complications. Atrial fibrillation has recurred during short-term follow-up in 12 of 15 patients, a not surprising result, because this initial phase of testing involved only right-sided ablation. The early results of the phase I clinical trial confirm the findings of others that successful ablation of chronic atrial fibrillation is likely to require a left atrial approach. This clinical trial, as well as others that are currently underway, will be invaluable in the continuing development of catheter ablation of atrial fibrillation and, ultimately, in determining if the routine use of this therapeutic tool can become a reality.

Fine-needle aspiration cytology of adenoid cystic carcinoma of the breast

Adenoid cystic carcinoma (ACC) of the breast is a rare variant of breast malignancy and has a better prognosis than its counterpart in the salivary glands. In this communication, our experience with seven cases of ACC of the breast is presented in which the diagnosis was established on fine-needle aspiration cytology (FNAC). The cytologic samples in all cases were cellular and featured three-dimensional clusters of uniform ductal epithelial cells with cystic spaces, bland nuclei, fine chromatin, and scanty cytoplasm arranged around spheres or cores of homogenous material. The cytodiagnosis of ACC in all cases correlated with subsequent examination of cell blocks of the aspirate and tissue. The cytodiagnostic criteria for ACC of the breast which are useful in a correct FNAC diagnosis are discussed.

A comprehensive breast and cervical cancer screening program for medically underserved women in Connecticut

A comprehensive breast and cervical cancer early detection program supported by federal and state funds and administered by the Connecticut Department of Public Health, is actively recruiting and screening older, uninsured, low income women at contracted health-care facilities throughout the state. The program provides diagnostic testing, treatment referral, outreach, and educational activities. During the first 27 months of the program, 5,509 women were enrolled and screened. Women were recruited primarily through media sources and physician/nurse referrals. The majority of women served were non-Hispanic white, between ages 40 to 59, with annual incomes of less than $10,000, and a high school education or less. Some 62% of enrolled women either never had a mammogram or did not have a repeat mammogram within the time-frames recommended by ACS. Recruitment efforts continue to enroll medically underserved women for breast and cervical cancer screening services. Future efforts will focus on rescreening in order to achieve the program's overall mission of detecting breast and cervical cancers at earlier stages.

The "Rabassa Morta" in Catalan viticulture: the rise and decline of a long-term sharecropping contract, 1670s-1920s

For long periods, and in line with recent theoretical literature, therabassa mortasharecropping contract successfully reduced problems of moral hazard and opportunistic behavior, and provided incentives for sharecroppers to respond to market opportunities. However, from the late nineteenth century, technical change, rising wages, and weak wine prices all increased the incentives for postcontractual opportunistic behavior on the part of the sharecropper, leading to conflicts and loss of trust between the principal and agent.

Ca2+/calcineurin-inhibited adenylyl cyclase, highly abundant in forebrain regions, is important for learning and memory

Activation of cAMP synthesis by intracellular Ca2+ is thought to be the main mode of cAMP generation in the brain. Accordingly, the Ca2+-activated adenylyl cyclases I and VIII are expressed prominently in forebrain neurons. The present study shows that the novel adenylyl cyclase type IX is inhibited by Ca2+ and that this effect is blocked selectively by inhibitors of calcineurin such as FK506 and cyclosporin A. Moreover, adenylyl cyclase IX is inhibited by the same range of intracellular free Ca2+ concentrations that stimulate adenylyl cyclase I. Adenylyl cyclase IX is expressed prominently in the forebrain. Substantial arrays of neurons positive for AC9 mRNA were found in the olfactory lobe, in limbic and neocortical areas, in the striatum, and in the cerebellar system. These data show that the initiation of the cAMP signal by adenylyl cyclase may be controlled by Ca2+/calcineurin and thus provide evidence for a novel mode of tuning the cAMP signal by protein phosphorylation/dephosphorylation cascades.

The primary function of a redundant Sp1 binding site in the mouse aprt gene promoter is to block epigenetic gene inactivation

The promoter region of the mouse adenine phosphoribosyltransferase (aprt) gene contains one non-consensus Sp1 binding site at its 5' end followed by three consensus Sp1 binding sites. The two 3'-most binding sites are sufficient for maximal expression of aprt , suggesting that the non-consensus and consensus binding sites at the 5' end are redundant. However, the two 3' sites are not sufficient to block epigenetic inactivation, which led to the hypothesis that the redundant consensus and/or non-consensus 5' Sp1 binding sites are required to block inactivation events. To test this hypothesis, promoter region constructs were made in which the two 5' Sp1 binding sites were mutated alone or in tandem, and then each construct was tested for its ability to withstand epigenetic inactivation. A cis -acting methylation center that is normally located 1.2 kb upstream of the promoter was used to induce inactivation. The results demonstrate that the presence of the redundant consensus Sp1 binding site is required to block methylation-associated gene inactivation. Therefore, the Sp1 binding sites comprising the mouse aprt promoter have evolved two distinct functions, one to promote transcription and the other to block epigenetic inactivation.

A 42 bp fragment of the pmas1' promoter containing an ocs-like element confers a developmental, wound- and chemically inducible expression pattern

Synthesis of mannopine in plant tissues infected with Agrobacterium tumefaciens is controlled by a divergent promoter (pmas2' and pmas1') that in 479 bp contains all the cis-acting elements necessary to direct tissue-specific and wound-inducible expression. In this report, using transgenic tobacco plants harboring a pmas1'-beta-glucuronidase (GUS) gene fusion, we investigated the developmental expression pattern directed by pmas1' in the early stages of development and the responses of pmas1' to different chemical inducers. It was found that this promoter can respond to auxins, cytokinins, methyl jasmonate (MJ), salicylic acid (SA) and its analogue 2,6-dichloroisonicotinic acid (iNA). Treatment with chemical inducers also showed that the effects of iNA are organ-dependent, that wound-induction is a complex response mediated by at least two different chemical signals, and that MJ stimulates changes in the tissue-specific and developmental expression pattern directed by the ptmas1' promoter. Using chimeric promoters we demonstrate that an ocs-like element (ocs+1) directs MJ responses in an orientation-dependent manner and that sequences around the ocs+1 are important to maintain the inducible and developmental properties of this cis-regulatory element.

The perplexities of conceptual frameworks

Nursing has had an enduring interest in promoting conceptual frameworks. The sustaining belief is that they provide "the bones" to mold coherent structures of nursing care delivery and a theoretical perspective to help educators, nurses and students serve the best interests of the public. But do they?

Incidence and time trends in Hodgkin's disease: from parts of the United Kingdom (1984-1993)

Over 3,000 cases of Hodgkin's Disease diagnosed between 1984-93 were used to examine incidence and time trends. These data are part of the Leukaemia Research Fund's specialist Data Collection Study, which is the only large, population-based data set of its type in Europe. The age specific incidence curves showed different patterns for nodular sclerosis contrasted with all other subtypes combined (non-nodular sclerosis). For nodular sclerosis, there was a female excess for young adults, while for non-nodular sclerosis a gradual rise in incidence with age in both sexes was observed. Incidence varied over time, showing a complex pattern with a decreasing trend in males in all Rye-subtypes and no significant change among females diagnosed with nodular sclerosis. These complex patterns of change are different from those seen in other countries. It is concluded that the results provide clear evidence of the heterogeneity of Hodgkin's disease between the sexes and between subtypes, which should be taken into account in future studies.

Surgeons' opinions about the NHMRC clinical practice guidelines for the management of early breast cancer

OBJECTIVE

To explore the opinions of surgeons about the NHMRC clinical practice guidelines for the management of early breast cancer (the Guidelines) and their views about and use of the accompanying Consumer's guide.

DESIGN

Cross-sectional telephone survey.

PARTICIPANTS AND SETTING

Surgeons throughout Australia who manage breast cancer, designated as "breast" or "general" (members or non-members of the Royal Australasian College of Surgeons' Section of Breast Surgery) and "urban" or "rural".

RESULTS

Among 150 respondents (64% response rate) more than 80% of surgeons reported having read all or most of the Guidelines and believed they were useful in improving women's management and wellbeing, easy to understand, evidence-based, a good summary of recent evidence, and that they would assist agreement between women and healthcare providers. Surgeons agreed with most of the recommendations in the Guidelines, but 26% disagreed that "women should ideally be treated by a specialist who treats a large number of similar patients and who has access to the full range of treatment options in a multidisciplinary setting". In terms of medicolegal implications, 41% believed that the Guidelines would protect clinicians, while, of the 37% of surgeons who believed that they would expose doctors to increased problems, significantly more breast than general surgeons believed this (50% v. 19%; P < 0.001). Only 37% of surgeons routinely gave the Consumer's guide to all or more than half their patients.

CONCLUSIONS

Surgeons are generally positive about the Guidelines, but certain issues should be addressed if they are to be optimally implemented, including confusion about the medicolegal implications, perceived difficulties with providing multidisciplinary care and poor use of the Consumer's guide.

Molecular characterization of two genes encoding betaine aldehyde dehydrogenase from amaranth. Expression in leaves under short-term exposure to osmotic stress or abscisic acid

A genomic clone (ahybadh4) and a cDNA (ahybadh17) both encoding betaine aldehyde dehydrogenase (BADH; EC 1.2.1.8) were isolated from the plant Amaranthus hypochondriacus L. The ahybadh4 gene extends 9 kilobases (kb) containing 15 exons with an open reading frame (ORF) of 501 amino acids (aa), a 1.3kb 5' untranslated region (UTR) and a 3' UTR of 0.3kb. The ahybadh17 cDNA encodes a BADH isoform of 500aa which contains 10aa substitutions with respect to AHYBADH4. Both encoded proteins share 98% identity at the amino acid level. Comparison of amaranth BADHs with other reported sequences showed high similarity. Analysis of ahybadh17 expression in amaranth leaves showed that mRNA and BADH protein are present in non-treated amaranth leaves and both transiently increased under short-term exposure to abscisic acid (ABA) and osmotic stress treatments.

Quinine and mefloquine in the treatment of multidrug-resistant Plasmodium falciparum malaria in pregnancy

Between 1991 and 1996, 372 pregnant women with uncomplicated, multidrug-resistant Plasmodium falciparum malaria, living on the western border of Thailand, were treated with either mefloquine (N = 194), quinine (N = 93) or both drugs (N = 85). Antimalarial treatment was generally well tolerated; the most common side-effects were dizziness (42%) and tinnitus (35%) following quinine, and anorexia (23%) and dizziness (36%) following mefloquine. In the patients treated for primary infections with melfloquine, 6% failed to clear their parasitaemia by day 7 and 28% failed by day 42. The corresponding figures for quinine were 4% and 23%, respectively. The failure rates in the 117 women treated for recrudescent infections were higher, the increase being significant for quinine (38%; P = 0.03) but not for mefloquine (37%). The percentage of pregnant women who had patent gametocytaemia on presentation ranged from 4%-19%. Over 50% of the patients were anaemic (haematocrit < 30%) on presentation and 52% of those not anaemic on enrolment developed anaemia during follow-up. Mefloquine and quinine, the only antimalarials generally available for the treatment of highly drug-resistant P. falciparum in pregnancy, give unsatisfactory treatment responses when used as single agents. New, safe and effective regimens are needed for the treatment of pregnant women with multidrug-resistant falciparum malaria.

Sonographic features of ovarian remnants

Ovarian remnants occur after a portion of ovarian tissue is left behind unintentionally after oophorectomy. The ovarian remnant may be functional and cystic, producing pelvic pain and, in some patients, extrinsic compression of the distal ureter. Ovarian remnants frequently are associated with adhesions from previous pelvic surgery for endometriosis or pelvic inflammatory disease. Ovarian remnants also may be included within pelvic peritoneal inclusion cysts. In this retrospective study, the sonographic features of ovarian remnants in 10 patients with surgical proof or clinical follow-up data are described. Most ovarian remnants were simple cysts (seven of 10), three had multiple septations, and six had a rim of presumably ovarian tissue with arterial and venous flow. Three patients with ovarian remnant masses that were aspirated had symptomatic relief without recurrence. In one patient, guided aspiration was unsuccessful, probably owing to the presence of organized hemorrhage within the mass. Extrinsic compression of the distal ureter was observed in one patient, who was treated with gonadotropin releasing hormone agonist (Lupron). The sonographic findings of a completely cystic or multiseptated pelvic mass with a rim of vascularized solid tissue in a postoophorectomy patient, although such cases are rare, suggest the diagnosis of an ovarian remnant. If the diagnosis can be established with a high degree of certainty, sonographically guided aspiration may be attempted in an effort to provide symptomatic relief. Otherwise, sonography is useful in serial assessment of these masses in patients receiving medical treatment.

Facilitated vascular anastomoses: the one-shot device

BACKGROUND

A mechanical system for facilitating vascular anastomosis (end-to-side, end-to-end) is described that enables the rapid construction of nonpenetrated, compliant junctions. The instrument (United States Surgical One-Shot system) simultaneously applies either 10 or 12 nonpenetrating, arcuate-legged titanium clips to everted vessel or prosthetic conduit edges.

METHODS AND RESULTS

The instrument has been tested in animals (jugular and femoral vein jump grafts in carotid and femoral arteries, interpositional grafts, 20 pigs) and human cadaveric constructs (saphenous veins to left anterior descending coronary arteries, 20 cases, 5 brachiocephalic access fistulas) as end-to-side constructs. Clipped constructs have equivalent or superior physical properties to control sutured constructs (6-0 polypropylene) as gauged by burst and tensile strength. All studies were performed under Food and Drug Administration Good Laboratory Practice standards, and the device has been approved for marketing by the Food and Drug Administration.

CONCLUSIONS

The device enables rapid and reproducible vascular anastomotic constructs with vessels as small as 1.8 mm outer diameter. The constructs are flanged, interrupted, and nonpenetrated.

A specific method for the measurement of cyclosporin A in human whole blood by liquid chromatography-tandem mass spectrometry

Therapeutic monitoring of the immunosuppressant cyclosporin A (CsA) is routinely performed by immunoassays to make individual dosage adjustments for patients after organ transplantation. High-performance liquid chromatography with ultraviolet detection (HPLC-UV) has been used as the reference method. However, HPLC-UV methods frequently suffer from chromatographic interferences that affect accuracy and reproducibility. A sensitive, specific HPLC-tandem mass spectrometry (HPLC/MS/MS) method for the quantitation of CsA has been developed. One hundred microliters CsA whole blood sample containing cyclosporin C (CsC) as the internal standard was extracted with ethyl ether. High-performance liquid chromatography separation was accomplished on an RP-C18 narrow-bore column at 50 degrees C with a linear gradient elution followed by on-line ion-spray ionization MS/MS analysis. The standard curve was established in the range of 10 to 1000 microg/l (r = 0.9989, n = 8). Limits of detection and quantitation were 1 microg/l and 5 microg/l, respectively. Imprecision was <4% across three control levels. Cyclosporine A recovery averaged 88%. Six metabolites: AM1, AM9, AM4N, Am1c, AM1a, and AM19 were identified with this method. AM1, AM9, and AM1c were further differentiated with a modification to the MS/MS conditions. This method was used in a comparison study with an HPLC-UV method: HPLC = 1.055 LC/MS/MS + 7.05 (microg/l), (Sy/x = 25.7), r2 = 0.982. With its high degree of sensitivity and specificity, this LC/MS/MS method offers a valuable reference method for immunoassay evaluation and a tool for metabolite investigation.

Pneumoperitoneum without peritonitis after allogeneic peripheral blood stem cell transplantation

Allogeneic blood stem cell transplantation is associated with multiple complications. We report a case of pneumoperitoneum without peritonitis associated with colonic pneumatosis in a patient who had undergone an allogeneic peripheral blood cell transplant

Characterization of Mexican Isolates of Colletotrichum lindemuthianum by Using Differential Cultivars and Molecular Markers

ABSTRACT Differential cultivars and molecular markers were used to analyze 59 isolates of the bean anthracnose pathogen, Colletotrichum lindemuthianum, from different regions of Mexico. Ten distinct races were determined, three of which had not been reported previously in Mexico. Isolates were found to infect only a narrow range of the differential cultivars used and were restricted to cultivars of Middle American origin. A comparison of random amplified polymorphic DNA and amplified fragment length polymorphism (AFLP) analyses was carried out on a subset of the fungal isolates. Determination of genetic distances based on AFLP data and production of a dendrogram demonstrated two levels of association: i) isolates classified into two major groups according to the type of cultivar or system of cultivation from which they originated, and ii) isolates could be classified into smaller subgroups generally associated with the geographic location from which they were obtained. Bootstrap analysis and determination of confidence intervals showed these geographic groupings to be extremely robust.