Prenatal sonographic diagnosis of uterine rupture following open fetal surgery

BACKGROUND

Reported cases of uterine rupture diagnosed by ultrasound have shown fetal membranes ballooning through uterine rupture sites, or adjacent areas of hemorrhage.

CASE

A 27-year-old gravida 3, para 2 had open fetal surgery to repair a fetal myelomeningocele at 28 weeks' gestation. Her postoperative course was complicated by threatened preterm labor and anhydramnios. At 33 weeks' gestation, with maternal symptoms of bowel obstruction, ultrasound showed a fetal leg and section of umbilical cord protruding through the uterine wall.

CONCLUSION

Even in the presence of anhydramnios, uterine wall rupture was identified, because ultrasound evaluation of the uterine wall showed prolapsed fetal parts and umbilical cord. Persistent anhydramnios after open fetal surgery should prompt a search for uterine rupture.

Novel and recurrent mutations in keratin 10 causing bullous congenital ichthyosiform erythroderma

Bullous congenital ichthyosiform erythroderma (BCIE) is a dominantly inherited keratinizing disorder characterized by erythroderma and blistering in neonates and generalized epidermolytic hyperkeratosis (EH) in adulthood. Previously, it has been shown that BCIE can be caused by mutations in either of the genes encoding K1 or K10, the keratins predominantly expressed in suprabasal layers of the epidermis. Using direct sequencing of genomic PCR fragments, we have analyzed 4 British families with BCIE, all of whom were found to carry mutations in K10. In 1 family, the affected person was found to have an unusual dinucleotide transversion mutation, 2138CC-->AA, causing two amino acid substitutions, D155E and R156S, also in the 1A domain of the K10 polypeptide. In 2 further kindreds, the previously reported "hotspot" mutations 2139C-->T and 2140G-->A were found. These mutations predict amino acid substitutions in the helix 1A domain of K10, designated R156C and R156H respectively. The proband in the fourth family was found to carry a novel mutation 4724T-->C, predicting the amino acid change L452P in the helix 2B domain of K10. All mutations were confirmed in the affected persons and were excluded from a population of 50 normal, unrelated individuals by restriction enzyme analysis. The location of these mutations in the highly conserved helix boundary motif sequences of K10 are consistent with previously reported dominant negative mutations in K10 and other keratins. Despite the unusual nature of two of these mutations, in particular the double missense mutation, the phenotypes of the affected individuals in these 4 families were entirely typical of BCIE.

Prevention of age-related aneuploidies by polar body testing of oocytes

PURPOSE

We previously demonstrated that aneuploidy-free oocytes may be preselected by testing the first and second polar bodies removed from oocytes following their maturation and fertilization. The present paper describes the results of the application of the method in 659 in vitro fertilization cycles from patients of advanced maternal age.

METHODS

Using micromanipulation techniques, 3943 oocytes were tested by polar body sampling and fluorescent on situ hybridization analysis using specific probes for chromosomes 13, 18, and 21.

RESULTS

Fluorescent in situ hybridization results were available for 3217 (81.6%) of 3943 oocytes studied, of which 1388 (43.1%) had aneuploidies; 35.7% of the aneuploidies were of first meiotic division origin, and 26.1% of second meiotic division origin. Most errors in the first meiotic division were represented by chromatid malsegregation. The transfer of embryos deriving from 1558 of 1829 aneuploidy-free oocytes in 614 treatment cycles resulted in 131 clinical pregnancies and 88 healthy children born after confirmation of the polar body diagnosis.

CONCLUSIONS

Polar body testing of oocytes provides an accurate and reliable approach for prevention of age-related aneuploidies in in vitro fertilization patients of advanced maternal age.

Mechanisms of induction of renal allograft tolerance in CD45RB-treated mice

BACKGROUND

Rejection is the most significant problem in the field of transplantation. The current goal of transplant immunology is to develop better immunotherapeutic protocols that are aimed at specifically suppressing alloreactivity and preserving an otherwise intact immune system. We have previously shown that mice will accept renal allografts indefinitely with normal renal function after two injections of a monoclonal antibody to the CD45RB protein. Furthermore, this antibody will reverse acute rejection when therapy is delayed until day 4 and will still induce tolerance. The mechanisms of this therapeutic benefit are not known.

METHODS

BALB/C mice were used as recipients of major multiple histocompatibility complex-mismatched kidneys using C57BL/6 as donors. Immunoperoxidase microscopy and Northern blots for cytokine gene expression were used to study the renal allografts. Fluorescence-activated cell sorter (FACS) analyses of peripheral blood lymphocytes were performed. Phosphotyrosine peptide phosphatase assays were performed on splenic lymphocyte membranes.

RESULTS

A CD45RB monoclonal antibody (MB23G2) induced tolerance and partially depletes peripheral blood lymphocytes. A therapeutically ineffective CD45RB monoclonal antibody (MB4B4) merely coated the circulating lymphocytes. Furthermore, MB23G2 stimulated more tyrosine phosphatase activity than MB4B4 in mouse T-cell membranes.

CONCLUSIONS

The clearance of peripheral blood lymphocyte populations and stimulation of protein tyrosine phosphatase activity may be important in the mechanism of tolerance induction by CD45RB therapy, which may be clinically relevant in the therapy of organ rejection in humans.

Mediators of inflammation and the inflammatory process

A complex interplay of inflammatory cells and chemical mediators is responsible for allergic inflammation. It is now understood that the allergic reaction consists of an early-phase response involving mast cell degranulation with the release of histamine and a late-phase response characterized by the migration of inflammatory cells. This review provides a summary of the early- and late-phase events associated with allergic inflammation and an overview of the principal chemical mediators involved in the inflammatory process.

Effect-site modelling of propofol using auditory evoked potentials

Auditory evoked potentials (AEP) were used to monitor central nervous system effects during induction and recovery from anaesthesia produced by infusion of propofol 30 mg kg-1 h-1 in 22 healthy male patients. Non-parametric and parametric modelling techniques were used successfully to calculate the parameter keo which linked pharmacokinetic with pharmacodynamic aspects of drug action in only 15 of the study patients. In the non-parametric analysis, keo was found to have a mean value of 0.2 (range 0.1-0.36) min-1. Estimation of keo allowed calculation of the effect-site concentration (Ce50) associated with 50% of AEP effect for the population (2.08 micrograms ml-1; 95% confidence limits 1.7-2.45). There were no significant differences between keo values calculated by non-parametric and individual parametric modelling techniques. During recovery, 50% of patients demonstrated evidence of waking at an effect-site concentration of 2.28 micrograms ml-1.

Effects of age and hypertension on cardiac responses to the alpha1-agonist phenylephrine in humans

Both aging and hypertension decrease the responsiveness of several receptor systems. The purpose of this study was to investigate the effect of aging versus hypertension on the blood pressure (BP), heart rate, and left ventricular (LV) responses to the alpha1-agonist phenylephrine in humans. Fourteen young (age, 21-40 years; range, 30+/-1 years; mean +/- SEM), and 18 older (age, 50-73 years; range, 60+/-1 years) healthy volunteers, as well as 10 young (age, 30-39 years; range, 36+/-1 years) and 15 older (age, 50- 64 years; range, 58+/-1 years) hypertensive subjects were studied. Phenylephrine was administered at four incremental rates for 8 min each. Cardiac responses were assessed by echocardiography. Phenylephrine caused twofold larger increases in systolic BP in young and older hypertensives and older normotensives, compared with young normotensives, but similar decreases in heart rate in all four groups. Younger normotensive subjects exhibited the largest decreases in stroke volume index, ejection fraction, and cardiac index in response to phenylephrine, despite similar increases in end-systolic stress for all groups. There is an age- and hypertension-related decrease in reflex vagal restraint in response to alpha1-adrenoceptor stimulation in humans, which leads to significant attenuation of the decrease in heart rate as well as in LV function in response to a pressor stimulus, and presumably therefore to enhanced systolic BP responses relative to young normotensive subjects.

Differential distribution of inward rectifier potassium channel transcripts in human atrium versus ventricle

BACKGROUND

The inward rectifier K+ current (IK1) plays an important role in governing cardiac electrical activity and is well known to have different properties in the atrium compared with the ventricle. Several inward rectifier K+ channel (IRK) subunits (hIRK, HH-IRK1, HIR, and TWIK-1) with different properties have been cloned from human tissues, but their relative expression in cardiac tissues has not been quantified. The present study was designed to define the relative levels of mRNA for various IRKs in human atrium and in failing and nonfailing ventricle.

METHODS AND RESULTS

Competitive reverse transcription-polymerase chain reaction was used to quantify in human atrium and ventricle the mRNA levels of hIRK, HH-IRK1, HIR, and TWIK-1. The absence of important noncardiac contamination was confirmed by demonstrating a lack of detectable mRNA markers for neuronal (acetylcholine receptor) and vascular (maxi-K channel) tissue. mRNA of HIR was more abundant in normal atrium (7.1+/-1.3 amol/ microg total RNA) than ventricle (0.6+/-0.1 amol/ microg, P<0. 05), whereas TWIK-1 mRNA was more concentrated in ventricle (18. 1+/-4.3 amol/ microg) than atrium (1.4+/-0.3 amol/ microg, P<0.05). Concentrations of hIRK (42.7+/-6.7 amol/ microg in atrium vs 57. 1+/-9.2 amol/ microg in ventricle) and HH-IRK1 (2.0+/-0.5 amol/ microg in atrium vs 1.5+/-0.5 amol/ microg in ventricle) were comparable. No significant differences in IRK subunit transcript concentrations were found between normal and failing ventricles.

CONCLUSIONS

mRNAs for all 4 IRKs are detected in human atrium and ventricle, but the mRNA copy number of a low-conductance subunit (HIR) is larger in atrium and the copy number of a weakly rectifying subunit (TWIK-1) is larger in ventricle. These differences in relative message levels may provide a potential molecular basis for different properties of IK1 in human atrium compared with ventricle.

Endothelin A receptor blockade causes adverse left ventricular remodeling but improves pulmonary artery pressure after infarction in the rat

BACKGROUND

Endothelin A (ETA) receptor antagonists have been shown to improve ventricular remodeling and survival in rats when started 10 days after infarction. Whether starting them earlier would have a more or less beneficial effect is uncertain.

METHODS AND RESULTS

Rats surviving an acute myocardial infarction (MI) for 24 hours (n=403) were assigned to saline or the ETA receptor antagonist LU 127043 or its active enantiomer LU 135252 for 4 weeks. Chronic LU treatment had no effect on survival, with 46% of LU rats and 47% of saline-treated rats with large MI surviving to the end of the study. LU treatment led to scar thinning, further left ventricular (LV) dilatation, an increase in LV end-diastolic pressure, and an increase in wet lung weight (P<0.05). Despite this detrimental effect on LV function, LU led to a significant decrease in RV systolic (50+/-2 to 44+/-2 mm Hg, P<0.05 vs saline) and right atrial pressures. LU treatment also prevented the increase in pulmonary ET-1 found in saline-treated rats with large MI but did not modify the increase in cardiac ET-1 in hearts with large MI.

CONCLUSIONS

The early use of the ETA receptor antagonists LU 127043 or its active enantiomer LU 135252 after infarction in the rat leads to impaired scar healing and LV dilatation and dysfunction. This is accompanied by a decrease in RV systolic and right atrial pressures and a decrease in pulmonary but not cardiac ET-1 levels. It would thus appear that the early use of ETA receptor antagonists after infarction may be detrimental.

Prenatal sonographic appearance of hemorrhagic cerebellar infarction

To date, the prenatal diagnosis of cerebellar hemorrhage has been limited to isolated case reports, which have demonstrated either a hyperechoic cerebellar hemisphere or a hyperechoic mass within the cerebellum in near-term fetuses. We demonstrate the ultrasonographic findings of intracerebellar hemorrhagic infarction in a fetus at approximately 21 weeks' gestation. In contrast to previous case reports, the hemorrhagic infarcts seen in our case were hypoechoic.

A comparison of two methods of oral endotracheal tube stabilization in neonatal patients

OBJECTIVE

To determine if an endotracheal tube stabilization method using an umbilical clamp reduces accidental extubations when compared with a more traditional method of endotracheal tube stabilization.

STUDY DESIGN

From January 1, 1994 through April 30, 1997, the frequency of accidental extubations per 100 ventilator days was tracked for the Neonatal Intensive Care Unit (NICU) Quality Assurance Committee of William Beaumont Hospital (Royal Oak, MI). From January 1, 1994 through December 31, 1995, all endotracheal tubes were stabilized using a traditional taping method. From March 1, 1996 through April 30, 1997, the endotracheal tubes were stabilized using a modified umbilical clamp and tape. The incidence of extubation using each stabilization method was compared by chi2 analysis.

RESULTS

The umbilical clamp resulted in a significantly lower (p=0.001) rate of accidental extubations.

CONCLUSION

The umbilical clamp taping method appears to have lowered the incidence of accidental extubation in our NICU when compared with a standard method of oral endotracheal tube stabilization.

Listeriosis in pediatric oncology patients

BACKGROUND

Adult cancer patients are considered to be at an increased risk for Listeria monocytogenes infections, but, to the authors' knowledge, little information regarding this infection in the pediatric oncology population has been published.

METHODS

The Memorial Sloan-Kettering Cancer Center microbiology laboratory's database was searched for cases of Listeria monocytogenes infection during the period from January 1981 to December 1996, and thorough chart reviews of the cases identified in patients age < 21 years were performed.

RESULTS

Listerial infections occurred in 5 children (3 with leukemia, 1 with lymphoma, and 1 with a brain tumor) among 20,612 admissions to the pediatric department during this period. All five children were actively receiving therapy for their malignancy, and two also were receiving other potentially immunosuppressive therapies. None was receiving co-trimoxazole prophylaxis. All were treated successfully for the Listeria monocytogenes infection with ampicillin and gentamicin (four patients) or ampicillin alone (one patient). At last follow-up two patients were long term, event-free survivors, two had died of their underlying malignancy, and one patient had died of cytomegalovirus pneumonitis.

CONCLUSIONS

Listeria monocytogenes infections in pediatric oncology patients can be treated successfully with ampicillin-containing antibiotic regimens.

Patients' experiences using a computerized program with a touch-sensitive video monitor for the assessment of health-related quality of life

This study assessed patients' experiences using a computerized program with a touch-sensitive video monitor (TSVM) for the assessment of health-related quality of life (HRQoL). A software program was developed for a computerized form of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, the QLQ-C30. One hundred and seventy-eight patients completed the QLQ-C30, followed by a structured interview designed to assess perceived difficulties with the use of the TSVM. Patients were asked to evaluate the ease of use of different aspects of the TSVM system (using the touch-sensitive screen, entering the patient identification number, reading the screen and following the on-screen instructions). The majority of patients found all aspects of the TSVM system 'very easy' to use. A few patients (1-2%) admitted finding any aspect of the TSVM use 'somewhat difficult' and none ranked any aspect as 'very difficult'. There were no unanswered items in the QLQ-C30. All patients found the amount of time spent on answering the questionnaire acceptable, (the mean time to complete was 6.8 min with a median of 5 min) and 96% stated they were willing to complete a similar questionnaire on a future occasion. From the patients' perspective the TSVM system appears to be a highly acceptable approach for the collection of HRQoL data in clinical practice.

Family dynamics of families with cancer in Finland

The purpose of this study was to describe family dynamics of families with cancer on the basis of Barnhill's framework for healthy family systems. The sample consisted of families in which one member had cancer. Both the patients (n = 96) and their relatives (n = 96) participated in the study (n = 192). The data for the study were collected using the Family Dynamics Questionnaire and the Family Dynamics Measure. The results indicated that the cancer of a single family member did not impair family functioning, but that family dynamics were considered quite good. There were no statistically significant differences between cancer patients and relatives on any of the family dynamics dimensions. However, an examination of sociodemographic characteristics did reveal some differences. Older relatives reported more enmeshment and rigidity than did younger relatives, whereas the latter reported more role conflict than older relatives. Older patients reported more rigidity than younger patients. Relatives who were men reported more enmeshment than women, whereas women reported more role conflict. Relatives of two-member families reported more rigidity than relatives with a larger family. Patients who reported a serious illness in the family described more mutuality, better flexibility, and clearer communication than patients who did not report such an illness. Also, relatives who mentioned a serious illness reported more mutuality and flexibility.

Breast cancer detection: maps of 2 San Francisco Bay area counties

OBJECTIVES

This study describes the incidence of late-stage and in situ breast cancer among White women, using specialized mapping techniques that reflect incidence adjusted for the population at risk, and applies these maps to characterize areas with high and low risk of breast cancer.

METHODS

Data from the Surveillance, Epidemiology, and End Results (SEER) database and the US Census Bureau were used to study the geographic distribution of breast cancer at the census-tract level in 2 San Francisco Bay Area counties for the years 1978 through 1982. Sociodemographic characteristics of areas with high and low incidence of the stage-specific disease were compared by means of a linear discriminant function.

RESULTS

For late-stage breast cancer, the most important variables in discriminating high-risk from low-risk areas were college education, percentage of residents over age 65, and median income. The strongest ecologic indicators of high risk for in situ breast cancer were median income and percentage unemployed.

CONCLUSIONS

This study demonstrates the usefulness of census tracts and sociodemographic measures of income and education in describing in situ and late-stage breast cancer.

Comparison of the current WHO and new ADA criteria for the diagnosis of diabetes mellitus in three ethnic groups in the UK. American Diabetes Association

The American Diabetes Association have recommended that the fasting plasma glucose level for the diagnosis of diabetes is lowered and that this becomes the main diagnostic test. We have used population-based data from three ethnic groups in Newcastle upon Tyne to examine the implications of this change. Data were available on 824 European (25-74 years), 375 Chinese (25-64 years), and 680 South Asian (25-74 years) subjects. All subjects apart from those reporting a prior diagnosis of diabetes underwent a standard 75 g oral glucose tolerance test (WHO criteria) which included the measurement of fasting glucose. The prevalence of diabetes was higher in all three ethnic groups using the new ADA criteria compared to the WHO criteria: 7.1% vs 4.8% in Europeans; 6.2% vs 4.7% in Chinese; and 21.4% vs 20.1% in South Asians. There was much variation in individuals categorized by the ADA and WHO criteria. Agreement between the two for the diagnosis of previously unknown diabetes was only moderate (kappa statistics 0.42 to 0.59). Thus in the populations studied the new criteria would increase the prevalence of diabetes in addition to classifying some individuals diabetic by current criteria as non-diabetic. It should be stressed however that diagnosis of the individual should not be based on a single test.

Disulfiram-cotrimoxazole reaction

The disulfiram-ethanol reaction is a well-known clinical phenomenon occurring as a result of acetaldehyde accumulation in the blood. Symptoms usually begin within 5-15 minutes after ingestion of ethanol in patients who have taken disulfiram 3-123 hours earlier, and generally occur in the following order: flushing, sweating, palpitations, dyspnea, hyperventilation, increased pulse rate, fall in blood pressure, nausea, vomiting, and drowsiness. Patients need not experience all these symptoms, and recovery is generally complete. Trimethoprim-sulfamethoxazole (cotrimoxazole) is a commonly prescribed antimicrobial agent that may produce a reaction similar to that of disulfiram when taken by patients who drink ethanol. This drug-chemical interaction may result in accumulation of acetaldehyde in the blood.

A specific increased expression of insulin receptor substrate 2 in pancreatic beta-cell lines is involved in mediating serum-stimulated beta-cell growth

Certain nutrients and growth factors can stimulate pancreatic beta-cell growth. However, the appropriate mitogenic signaling pathways in beta-cells have been relatively undefined. In this study, differential gene expression in NEDH rat insulinoma was compared with NEDH rat primary islet beta-cells. Differential mRNA display analysis revealed an elevated expression in insulinoma of VL30 transposons, S24 ribosomal protein, and cytochrome-C oxidaseVIIc that is typical for cells undergoing mitosis. A gene candidate approach revealed that mRNA levels of the oncogenes c-fos and c-jun were equivalently expressed in insulinoma and islet cells, as was the mRNA for the mitogenic signal transduction molecule insulin receptor substrate (IRS)-1. However, in contrast to that of IRS-1, IRS-2 gene expression was 60- to 70-fold higher in the insulinoma tissue compared with islets, which was reflected at the protein as well as the mRNA level. The specific elevated IRS-2 expression was a consistent observation across all rodent pancreatic beta-cell lines. To investigate whether IRS-2 was functional, serum-stimulated beta-cell proliferation was examined in isolated insulinoma cells. After a 48-h period of serum withdrawal, 24 h of serum refeeding rendered an 8- to 10-fold increase in [3H]thymidine incorporation into insulinoma cells. This serum-stimulated DNA synthesis was prevented by inhibitors of tyrosine protein kinase and phosphatidylinositol (PI) 3-kinase activities, as well as the activation of mitogen-activated protein (MAP) kinase and p70S6K. Examination of IRS-mediated signal transduction pathways indicated that after 10-15 min of serum refeeding, there was increased tyrosine phosphorylation of IRS-2 and pp60, and PI 3-kinase recruitment to IRS-2. Serum also increased the association of growth factor-bound protein 2/murine sons of sevenless 1 protein to a PI 3-kinase/IRS-2 protein complex. Moreover, serum also activated MAP-kinase (erk-1 and erk-2 isoforms) and 70 kD S6 kinase. Thus IRS-mediated signal transduction pathways are functional in pancreatic beta-cells. It is conceivable that IRS-2 expression in beta-cells contributes to maintaining the islet beta-cell population, complementary to observations in the IRS-2 knockout mouse in which beta-cell mass is markedly reduced.

Subungual haematomas: is simple trephining enough?

OBJECTIVES

To determine the outcome of treating subungual haematomas by simple trephining, in terms of nail appearance and function, and to identify factors associated with a poor outcome.

METHODS

Patients with subungual haematomas attending an accident and emergency department over a 12 month period were identified; 5-13 months after injury a telephone and postal survey of patient's assessment of their own outcome was made using a proforma. Outcome was graded according to published criteria.

RESULTS

123 patients with 127 subungual haematomas were identified and 74% were followed up; 85% achieved an "excellent" or "very good" result, with 67% reporting no residual abnormalities. A "poor" outcome occurred in only 2% owing to nail splitting. No correlation was found between adverse outcome and haematoma size, presence of fracture, or infection.

CONCLUSIONS

Treatment of subungual haematomas by simple trephining gives an acceptable result in the majority of patients and those with a poor outcome cannot be predicted at presentation. The findings suggest that only simple trephining for symptomatic relief is required for subungual haematomas and that aggressive surgical treatment is unnecessary.