Alterations of pituitary adenylate cyclase-activating polypeptide-like immunoreactivity in the human plasma during pregnancy and after birth

BACKGROUND

Since its discovery, several distinct effects of pituitary adenylate cyclase activating polypeptide (PACAP) have been established - predominantly in animal studies - in the nervous system, various peripheral organs as well as in the endocrine regulation. It is unknown whether PACAP has any effect on human pregnancy regarding either utero-maternal or perinatal aspects of the gestation.

AIM

We investigated alterations of PACAP38-like immunoreactivity (PACAP38-LI) in the human plasma throughout normal pregnancy, during and after delivery, and its level in the umbilical vessels, as well as in the peripheral blood of term healthy newborns.

MATERIALS AND METHODS

A 2 ml blood sample was used for each test, PACAP38-LI was determined by radioimmunoassay.

RESULTS

In the 2nd and 3rd trimester significant elevation was observed in the PACAP38-LI compared to the earlier gestation and non-pregnant conditions. During delivery its level significantly decreased and returned to the original values 3 days after birth. In the neonates PACAP38-LI level of the peripheral blood was similar to that of healthy adults, but umbilical arteries and veins contained significantly lower concentrations of PACAP38-LI. Besides, the levels were lower in the umbilical vein compared to the artery.

CONCLUSIONS

PACAP38-LI levels show sensitive change during normal pregnancy and delivery. Our findings suggest that the fetal organs actively synthesize PACAP. Further investigations are required to elucidate the physiological importance of the alterations observed.

Long-term pain response and quality of life in patients with typical trigeminal neuralgia treated with gamma knife stereotactic radiosurgery

OBJECTIVE

The long-term outcome of patients treated with gamma knife radiosurgery (GKRS) for typical trigeminal neuralgia has not been fully studied. We evaluated 185 patients who underwent their first GKRS treatment between 1997 and 2003 at the Barrow Neurological Institute.

METHODS

Follow-up was obtained by surveys and review of medical records. Outcomes were assessed by the Barrow Neurological Institute Pain Intensity Score and Brief Pain Inventory. The most common maximum dose was 80 Gy targeted at the root entry zone. Outcomes are presented for the 136 (74%) patients for whom more than 4 years of clinical follow-up data were obtained.

RESULTS

Treatment failed in 33% of the cohort within 2 years, but only an additional 1% relapsed after 4 years. Actuarial analysis demonstrated that 32% of patients were pain-free off medication and 63% had at least a good outcome at 7 years. When GKRS was used as the primary treatment, 45% of the patients were pain-free at 7 years. In contrast, 10% of patients in whom previous treatment had failed were pain-free. When needed, salvage therapy with repeat GKRS, microvascular decompression, or percutaneous lesioning was successful in 70%. Posttreatment facial numbness was reported as very bothersome in 5%, most commonly in patients who underwent another invasive treatment. After GKRS, 73% reported that trigeminal neuralgia had no impact on their quality of life.

CONCLUSION

GKRS is a reasonable long-term treatment option for patients with typical trigeminal neuralgia. It yields durable pain control in a majority of patients, as well as improved quality of life with limited complications and it does not significantly affect the efficacy of other surgical treatments, should they be needed.

The use of eidronate disodium in the prevention of heterotopic ossification in burn patients

Heterotopic ossification (HO) is a well-known complication of moderate and severe burn injuries. The development and progression of HO in burn patients are poorly understood phenomena at this time. Numerous measures aimed at preventing or minimizing HO have been described, but no definitive prophylactic modality has been found. Biphosphonate compounds are known to inhibit calcification, but previous studies are equivocal regarding their effectiveness in preventing HO in burn patients. We retrospectively reviewed the effect of etidronate disodium (EDHP), a bisphosphonate, on the development of HO in severely burned patients. We found that not only was EDHP ineffective in preventing HO, the group of patients treated with EDHP demonstrated an increased incidence of HO over that seen in a comparison group. This was true after controlling for age, sex, and %TBSA burned. Based on the results of this study, the routine use of etidronate disodium to prevent HO in burn patients cannot be recommended.

Dental education from the students' perspective: curriculum and climate

This cross-sectional study compares morale among dental students at five western U.S. dental schools, relates morale to various aspects of the school environment, and determines a prioritized list of the most important aspects of dental education from the students' perspective. Survey data were collected from students at the end of their first, second, and third years. Respondents answered several questions associated with student morale and listed the three best aspects and three greatest challenges of their school. Lastly, respondents ranked seven different aspects of dental education in order of importance. Surveys were returned by 742 students (66 percent response). Student morale varied significantly in different educational institutions. Morale tended to be lower among third-year students and higher among first-year students. Poor student-faculty relations was the factor most strongly associated with decreased morale. Similarly, positive atmosphere was the factor most frequently associated with high morale. Faculty and clinic experience were the most frequently cited positive aspects of schools; curriculum and clinic experience were the most commonly cited negative aspects. Students commonly perceived clinical experience to be the most important aspect of their education. As students neared graduation, they perceived business management as more important and lab work as less important.

Prevalence of risk factors for hepatitis C virus in HIV-infected and HIV/hepatitis C virus-coinfected patients

METHODS

A sample of patients with HIV completed a questionnaire identifying their demographic characteristics and risk factors for hepatitis C virus (HCV). A chart review was conducted to confirm the information obtained using the questionnaire. Risk factors associated with coinfection status at alpha level of 0.1 in univariate analysis were entered into a multivariate Cox regression model.

RESULTS

Of the 242 HIV-positive patients analyzed, 168 were HIV-infected and 74 were HIV/HCV-coinfected. Risk factors that were significantly different between HIV-monoinfected and HIV/HCV-coinfected subjects included intravenous drug use, snorting drugs, sharing razors or toothbrushes, being in prison, the presence of one or more tattoos, sex for money or drugs, sex with an intravenous drug user and man who has sex with men. In a multivariate regression model, only intravenous drug use remained as a significant risk factor/predictor of HCV/HIV coinfection. A subanalysis identified risk factors more prevalent among coinfected men who have sex with men, including intravenous drug use, sharing razors/toothbrushes, tattoos, sex for money or drugs, sex with an intravenous drug user, and a history of having 11 or more sexual partners. A history of having had a sexually transmitted disease and 11 or more sex partners was more prevalent among HIV-monoinfected men who have sex with men.

CONCLUSIONS

HIV/HCV coinfection was associated with intravenous drug use but not with sexual risk factors.

Boehler's angle and the critical angle of Gissane are of limited use in diagnosing calcaneus fractures in the ED

STUDY OBJECTIVES

The aim of this study was to determine the use of Boehler's angle (BA) and the critical angle of Gissane (CAG) in diagnosing calcaneus fractures in the ED.

DESIGN

The study was conducted as a randomized, blinded, case-control trial.

CASES

One hundred thirty-three patients older than 15 years were included in the study. Sixty-five patients with computed tomography-verified calcaneus fractures (gold standard) and 68 ED patients with lateral foot or ankle x-rays without calcaneus fractures were included in the study.

METHODS

One second-year emergency medicine resident, 1 third-year emergency medicine resident, 2 board-certified emergency medicine attending physicians, and 1 board-certified radiologist prospectively reviewed all films using the Picture Archival and Communication System digital radiology system. Cases and controls were randomized and the participants were blinded to final radiographic diagnoses. Participants determined whether there was a fracture on each x-ray and measured BA and the CAG using the digital angle tool in the Picture Archival and Communication System.

RESULTS

Emergency physicians were 97.9% accurate in diagnosing calcaneus fractures (range, 97% to 99%). The mean kappa value for emergency physicians was 0.96 (range, 0.94-0.985). Receiver operating characteristic curves were constructed for BA and the CAG. When compared with the gold standard, the area under the curve for BA ranged from 0.82 to 0.88. The area under the curve for the CAG ranged from 0.45 to 0.67. BA had an interclass correlation coefficient of 0.84 (95% confidence interval, 0.79-0.87). The CAG interclass correlation was 0.52 (95% confidence interval, 0.43-0.60). One fracture was missed by the radiologist and all of the emergency physicians because it was only visible on computed tomography.

CONCLUSION

BA is somewhat helpful and the CAG is not useful in diagnosing calcaneus fractures in the ED. Interrater reliability for BA is excellent, but for the CAG, it is poor. Emergency physicians were 97.9% accurate in making the diagnosis by reviewing the plain films without "assistance" of the angle measurements.

Normal cognition and behavior in a Smith-Lemli-Opitz syndrome patient who presented with Hirschsprung disease

Smith-Lemli-Opitz syndrome (SLOS) is an autosomal recessive disorder of cholesterol biosynthesis. It is caused by mutations in the gene encoding the enzyme 7-dehydrocholesterol Delta7-reductase (DHCR7), which catalyzes the final step in cholesterol biosynthesis, usually resulting in cholesterol deficiency. We report a 3.5-year-old girl who has cognition in the low average range and normal behavior, but in whom molecular studies identified two missense mutations in DHCR7: V326L and F284L. She was born at term following an uncomplicated pregnancy and delivery, and presented at 12 days of age with poor feeding, abdominal distention, and jaundice. Colonic biopsy was consistent with Hirschsprung disease. On physical examination she had mild ptosis, a long philtrum, mild micrognathia, a short, upturned nose, and subtle 2,3 syndactyly. Her 7-dehydrocholesterol (7-DHC) level was markedly elevated at 8.7 mg/dl (normal 0.10 +/- 0.05), and her cholesterol level was normal at 61 mg/dl (normal for newborn period 50-80 mg/dl). Karyotype analysis was normal, 46,XX. Breast milk feeding was initiated and continued for 18 months. Cholesterol supplementation was implemented at 100 mg/kg/day at 3 months, which resulted in increased cholesterol levels and reduced dehydrocholesterol levels. Neuropsychological testing has shown functioning in the low average range, between the 14th and 18th centiles when compared to peers. This is markedly higher than most children with SLOS. She has no behavioral problems. MRI and MRS testing of the brain revealed no structural abnormalities. This is in contrast to a recently reported case by Prasad et al. [2002: Am J Med Genet 108:64-68] with a mild phenotype, behavioral problems, and abnormal MRI, who is compound heterozygote for both a null and missense mutation. Our case suggests that patients with severe feeding disorders with or without Hirschprung disease and postnatal onset microcephaly may warrant screening for SLOS.

MRI and 1H MRS findings in Smith-Lemli-Opitz syndrome

Smith-Lemli-Opitz syndrome (SLOS) is an autosomal recessive disorder characterized by a defect in cholesterol biosynthesis, associated with mental retardation and multisystem structural abnormalities. This study investigated the prevalence of congenital CNS abnormalities by MRI in a large series of patients with SLOS and the correlation of the clinical and biochemical findings with the results of MRI and 1H MRS. Eighteen patients were studied; all underwent MRI of the brain, and 16 had 1H MRS of the cerebral white matter. The ratios choline:NAA, lipid:NAA, and lipid:choline metabolite were found to be correlated with the clinical degree of disease severity, serum total sterol ratios (cholesterol/cholesterol + 7-dehydrocholesterol + 8-dehydrocholesterol) and in two cases with the effect of cholesterol therapy. Abnormal CNS findings were noted in five patients, including callosal abnormalities (n = 4), Dandy-Walker variant (n = 1), and arachnoid cyst (n = 1). Holoprosencephaly was noted in one patient with a prevalence of 6%. Choline:NAA was elevated in seven patients. There was a statistically significant positive correlation between the lipid:choline ratio and the serum cholesterol precursor, 8-dehydrocholesterol. In two patients 1H MRS demonstrated abnormally elevated lipids prior to cholesterol therapy, which improved on therapy. The use of MRI and 1H MRS is an effective way to demonstrate brain structural abnormalities in patients with SLOS and may prove to be an effective method for the assessment of the effects of cholesterol replacement therapy in the brain.

Motor vehicle crash fatalities by race/ethnicity in Arizona, 1990-96

OBJECTIVE

To compare rates of motor vehicle crash (MVC) fatalities among different race/ethnic groups in urban and rural Arizona.

METHOD

Using the Fatality Analysis Reporting System and the National Center for Health Statistics Multiple Cause of Death file, MVC fatalities in Arizona from 1990-96 inclusive were classified by gender, race/ethnicity, and urban or rural residence. Age adjusted rates of total, occupant, pedestrian, and alcohol related fatalities were calculated. The total MVC fatality rate for each race/ethnic group was then adjusted for proportion of rural residence.

RESULTS

Compared with non-Hispanic whites (NHWs), American Indians had raised relative risks for MVC fatality in all gender and residence subgroups. Hispanic females and rural Hispanic males had lower relative risks, as did rural African-American men. Raised relative risks for American Indian men and women included all subgroups: total, occupant, pedestrian, and alcohol related. Hispanic and African-American men both had raised relative risks of pedestrian related fatalities, and Hispanic men had a slightly higher relative risk while Hispanic women had a lower relative risks, for alcohol related fatality. Hispanic men and women and African-American men had lower occupant fatality rates. Close to half (45%) of the excess MVC fatality among American Indians can be attributed to residence in rural areas, where MVC fatality rates are higher. There were 1.85 occupants in crashes involving NHW deaths compared with 2.51 for Hispanics and 2.71 for American Indians (p<0.001). The proportion of occupants not using a seatbelt was higher in Hispanics and American Indians in both urban and rural areas.

CONCLUSION

The major disparity in MVC fatality in Arizona is among American Indians. The higher MVC fatality rates among American Indians occur in all age groups, in both urban and rural areas, and among occupants and pedestrians. Rural residence, lower rates of seatbelt use, higher rates of alcohol related crashes, a greater number of occupants, and higher rates of pedestrian deaths all contribute to the American Indian MVC fatality disparity. High rates of pedestrian fatality occur in men in all three race/ethnic minorities in Arizona and among American Indian women. In contrast to other studies, African-Americans and Hispanics did not have raised total MVC fatality rates and compared to NHWs actually had lower rates in the rural areas of the state.

Searching for universals: preliminary evidence for the validity of substance abuse subtypes in a sample of Mexican American youths

Recent studies of substance abuse typologies indicate that multivariate models originally developed for identifying subtypes of alcoholics are valid among users of other substances, including heroin, cocaine, and marijuana. Little is known regarding the generalizability of these subtypes across culturally different subgroups. If substance abuse typologies are universal, then controlling for subtype may prove to be an effective research strategy in studies attempting to distinguish the separate and specific contribution of culturally related factors to risk for substance use and to treatment response. In this article, we present data that replicate the Type A-Type B distinction, developed by Babor et al., in a sample of Hispanic youths with substance involved problems.

Pedestrian fatalities by race/ethnicity in Arizona, 1990-1996

PURPOSE

To explore rates of pedestrian fatalities in Arizona, and how rates and circumstances of pedestrian deaths differ by race/ethnicity, urban or rural residence, age, and gender.

METHODS

Using the Fatality Analysis Reporting System and the National Center for Health Statistics' Multiple Cause of Death file, pedestrian fatalities in Arizona from 1990 through 1996 were classified by gender, race/ethnicity, and urban or rural residence. Age-adjusted rates were calculated and adjusted for the proportion of rural residence. Age analyses compared pedestrian fatality rates in 10-year age groups by race/ethnicity. Conditions associated with pedestrian deaths were examined, including the time and day of occurrence, alcohol involvement, and degree of pedestrian contribution to the crash.

RESULTS

American Indians had rates of pedestrian deaths 6 to 13 times those of non-Hispanic whites. Elevated rates for American Indians were found in urban and rural areas, in both genders, in all age groups in men, and in five of nine age groups in women. American-Indian pedestrian death rates and relative risks (RRs) were higher in rural areas than in urban areas. Compared to non-Hispanic whites, urban Hispanic males had an elevated RR of 1.56, rural Hispanic females had an RR of 2.45, and urban African-American (AA) females had an RR of 2.33. However, significantly elevated rates, compared to non-Hispanic whites, were limited to Hispanic males aged <5 years and African-American females aged 65 to 74 years. In all race/ethnic groups, except rural Hispanics, men had higher rates than women, although American-Indian women had higher rates than non-Hispanic whites, African Americans, and Hispanic men. Rural residence accounted for 27% of the excess American-Indian pedestrian mortality. Sixty-one percent of urban, American-Indian pedestrian deaths occurred on weekends, compared to 29% among non-Hispanic whites and 46% among Hispanics. American Indians had six times the rate of alcohol-related pedestrian deaths as non-Hispanic whites in urban areas and 16 times that respective rate in rural areas. Hispanics had an alcohol- involvement RR of 1.82 in urban areas, but the RR was not elevated in rural areas. When blood alcohol was measured, the blood alcohol concentration was >0.20 g/dL in 64.4% of American Indians, 35% of Hispanics, and 29% of non-Hispanic whites.

CONCLUSION

A major disparity in pedestrian fatalities exists for both American-Indian men and women in urban and rural areas. Other racial/ethnic groups have elevated pedestrian fatality rates that are gender and residence specific, and are limited to specific age groups. Much of the American-Indian excess mortality is alcohol related and associated with residence in rural areas.

Financial aspects of court-ordered evaluations

The authors sought to establish the financial cost of involuntary court-ordered evaluations and potential strategies for reducing these costs. Medical charges from the time of admission to the time of the court hearing were calculated for 998 patients who received involuntary court-ordered evaluations at the department of psychiatry of the Maricopa Medical Center in Phoenix, Arizona, in 1999. The average cost of an involuntary court-ordered evaluation was 8,236 dollars, and the average cost per day was 686 dollars. The analysis showed that several options could be used to reduce costs: expediting evaluations, holding court hearings on weekends and holidays, conducting evaluations on an outpatient basis, and housing patients in a less acute setting.

Neurologic nonmetabolic presentation of propionic acidemia

BACKGROUND

Patients with propionic acidemia usually present in the neonatal period with life-threatening ketoacidosis, often complicated by hyperammonemia. It was thought that the neurologic abnormalities seen in this disease were exclusively the consequences of these acute crises. Experience with 2 patients with propionic acidemia indicates that this disease may present first with prominent neurologic disease without the life-threatening episodes of ketoacidosis that usually serve as the alerting signals for a diagnosis of an organic acidemia.

OBJECTIVE

To examine the clinical and metabolic aspects of 2 patients with a phenotype that suggested disease of the basal ganglia.

DESIGN

Examination of patterns of organic acids of the urine and enzyme assay for propionyl-CoA carboxylase in fibroblasts and lymphocytes.

SETTING

Referral population to a biochemical genetics laboratory.

PATIENTS

Two patients whose prominent features were hypotonia followed by spastic quadriparesis and choreoathetosis. Both had seizures. One patient was mildly mentally retarded but grew normally physically. The other had profound mental retardation and failure to thrive; he also self-mutilated his lower lip. Self-injurious behavior has not been reported in this disease.

MAIN OUTCOME MEASURES

Clinical description, blood ammonia levels, organic acid levels in the urine, and enzyme activity.

RESULTS

Excretion of metabolites, including methylcitrate, was typical. Residual activity of propionyl-CoA carboxylase approximated 5% of the control in each patient.

CONCLUSIONS

Propionic acidemia can present as a pure neurologic disease without acute episodes of massive ketoacidosis. Hyperammonemia may occur after infancy in some patients, presenting as Reye syndrome.

Carbon dioxide dynamics during apneic oxygenation: the effects of preceding hypocapnia

STUDY OBJECTIVE

To compare the rate of increase of arterial carbon dioxide tension (PaCO2) during apneic oxygenation preceded by acute respiratory hypocapnia with that during apnea preceded by respiratory eucapnia.

DESIGN

Randomized, prospective, single crossover study.

SETTING

Operating room at a teaching hospital.

PATIENTS

19 ASA physical status I, II, and III patients requiring general endotracheal anesthesia and invasive monitoring for elective surgery.

INTERVENTIONS

Two ventilatory states preceding apneic oxygenation were studied in each patient. The first respiratory state was established using controlled mechanical ventilation in the stable, anesthetized patient, followed by a 5-minute period of apneic oxygenation. Arterial and mixed central venous blood gas samples were obtained simultaneously prior to and at 1-minute intervals during apnea. Ventilatory parameters were then changed to establish the second respiratory state. During the subsequent period of apnea, the study was repeated as above.

MEASUREMENTS AND MAIN RESULTS

Arterial and mixed central venous partial pressure of carbon dioxide (pCO2) levels were measured. A greater increase in PaCO2 was found during the first minute of apneic oxygenation in the hypocapneic group compared with the eucapneic group. The venoarterial gradient of pCO2 was also greater in the hypocapneic group prior to apnea.

CONCLUSIONS

Acute hypocapnia compared with eucapnia prior to apneic oxygenation is associated with a greater rise in PaCO2 in the anesthetized patient. This finding may be due in part to widening of the venoarterial gradient of pCO2.

The use of albuterol in hospitalized infants with bronchiolitis

OBJECTIVES

To determine whether the use of albuterol by nebulization enhances physiologic or clinical recovery in hospitalized infants with moderate bronchiolitis.

METHODS

This prospective, double-blind, placebo-controlled, randomized clinical trial was performed from December 1995 to March 1996. A total of 52 patients <24 months of age with a diagnosis of moderately severe, acute viral bronchiolitis were enrolled and assigned to receive nebulized albuterol or normal saline placebo for 72 hours under a standardized protocol. Primary outcome measures included improvement in oxygen saturation (SaO2) during hospitalization and survival analysis to assess the time required to reach preestablished discharge criteria on three measures: SaO2, accessory muscle use, and wheezing. An additional secondary outcome measure was actual length of hospital stay. Adverse outcomes also were compared between treatment groups.

RESULTS

There was no significant difference in mean SaO2 between albuterol and placebo at baseline, 24 hours, or maximum SaO2 achieved during hospitalization. Both groups showed significant improvement in oxygen saturation over time, but there was no significant difference in improvement between the two groups. The study had a power of 90% to detect a difference in mean percentage point improvement of 2% SaO2. There was no difference in time to reach discharge criteria as defined by SaO2, accessory muscle use, or wheezing. There was no difference in length of hospital stay or in the frequency of adverse outcomes.

CONCLUSIONS

Nebulized albuterol therapy does not appear to enhance recovery or attenuate severity of illness in infants hospitalized with acute, moderate bronchiolitis, as evidenced by improvement in oxygen saturation, time to meet standardized discharge criteria, or length of hospital stay.

The rat subcutaneous air sac model: a new and simple method for in vivo screening of antiangiogenesis

An experimental rat model, the Subcutaneous Air Sac (SAS) model, was developed to provide an animal model in which neo-vascularization can be easily assessed in situ and quantified using a radiolabelled plasma marker. The SAS model was designed to replace a previous model where neovascularization was induced by chemical injury of rat or rabbit cornea or by implantation of tumour cells intracorneally, a methodology which is believed to cause severe pain to the animals. In the SAS model the air sac replaces the cornea as a transparent avascular substratum in which vascularization can be observed. The air sac is induced by injection of air subcutaneously on the back of the animal. After 8 to 10 days a sufficient air sac has been established. The animal is anaesthesized and by a minor operation the cellulose sponge is implanted upon the air sac under the skin. The vasoproliferative effect of the cellulose sponge causes formation of new vessels which are macroscopically visible 10 days after implantation. The ability of the in vivo SAS model to show an antiangiogenic effect of a systemically applied test compound was investigated using the fumagillin analogue TNP-470 (ochloro-acetylcarbamoyl)-fumagillol) as a positive control at dose levels of 0, 1, 2.5, 5 and 10 mg/kg/day given subcutaneously for 10 days. The neo-angiogenesis was scored both in situ using a subjective point system and by measuring the 125I-activity of the implant and the membrane after an intravenous injection of 125I-labelled antibodies. The neo-angiogenesis was reduced by approximately 45-50% in animals treated with 5 or 10 mg/kg/day of TNP-470 compared to animals treated with the vehicle. The animals treated with 10 mg/kg/day TNP-470 showed signs of toxicity. The SAS model is considered highly relevant for in vivo testing of potential antiangiogenic drugs on humane grounds. The high reproducibility, the low cost and the technical simplicity of the method makes it attractive.

Analgesia for emergency centers' orthopaedic patients: does an ethnic bias exist?

Several prior studies have demonstrated that Hispanics treated in some emergency centers were prescribed less analgesia than white patients with similar extremity trauma. The purpose of this study was to determine if other institutions had a similar experience with regard to undermedication of certain ethnic groups. Two cohorts were studied, 1 adult and 1 pediatric group. The adult group consisted of 84 patients seen at Maricopa Medical Center, Phoenix, Arizona, between January 1, 1992, and December 31, 1992, who were treated for isolated long bone fractures requiring a closed reduction. The pediatric group consisted of 63 children younger than 16 years, seen between January 1, 1992, and April 30, 1993, with isolated distal radius or ulna fractures requiring a closed reduction. Results indicated that Hispanics were not likely to be undermedicated for fracture reduction in this level I trauma emergency center compared with whites. It is thought that a hospital with a larger populations of underrepresented minorities may be more sensitive than other private institutions.

Is academic managed care an oxymoron?

BACKGROUND

A review of 1993 data on length of stay (LOS) and charges for diagnosis-related group (DRG) 195 (complicated cholecystectomies) showed that Maricopa Medical Center charged more and had longer LOS than all other area hospitals.

METHODS

Twenty DRG 195 charts were analyzed for the causes of the inefficiencies. The remaining cholecystectomy DRGs were similarly analyzed.

RESULTS

Analysis of the charts for DRG 195 showed that 55% of the patients had laparoscopic conversions. Charges and LOS varied significantly because of the conversions, increased preoperative hospital days and increased operative times. Moreover, 30% of patients were more than 70 years old. Comparisons of other cholecystectomy DRGs showed similar inefficiencies, indicating a hospital system's problem.

CONCLUSIONS

Diagnosis-related group delta analysis is a powerful performance improvement tool. Once problem areas are identified and corrected, monitoring prospective data produces rapid analysis of quality of care and cost improvements. The models can serve as a means for teaching hospitals to become more competitive and satisfy the Joint Commission on Accreditation of Healthcare Organizations requirements for patient-care improvements.

Linkage of a human brain malformation, familial holoprosencephaly, to chromosome 7 and evidence for genetic heterogeneity

Holoprosencephaly (HPE) is a common malformation of the developing forebrain and midface characterized by incomplete penetrance and variable expressivity. Familial HPE has been reported in many families with autosomal dominant inheritance in some and apparent autosomal recessive inheritance in others. We have examined 125 individuals from nine families with autosomal dominant HPE. Expression in gene carriers varied from alobar HPE and cyclopia through microforms such as microcephaly or single central incisor to normal phenotype. We performed linkage studies by either Southern blot or polymerase chain reaction analyses with DNA markers (D7S22, D7S550, and D7S483) that are deleted from some patients with sporadic HPE and flank a translocation breakpoint in 7q36 associated with HPE. The strongest support for linkage was with D7S22, which was linked with no recombination to autosomal dominant HPE in eight of nine families with a combined logarithm of odds score of 6.4 with an affected-only model-free analysis and 8.2 with a reduced-penetrance model and all phenotypes. Close linkage to this region could be excluded in one family, and there was significant evidence of genetic heterogeneity. These results show that a gene for autosomal dominant HPE is located in a chromosomal region (7q36) known to be involved in sporadic HPE with visible cytogenetic deletions. They also demonstrate genetic heterogeneity in familial HPE. We hypothesize that mutations of a gene in 7q36, designated HPE3, are responsible for both sporadic HPE and a majority of families with autosomal dominant HPE.

Mild Brachmann-de Lange syndrome. Delineation of the clinical phenotype, and characteristic behaviors in a six-year-old boy

Brachmann-de Lange syndrome (BDLS) is a rare multiple congenital anomaly/mental retardation (MCA/MR) syndrome with variable expression, making diagnosis of mild cases difficult. The most consistent manifestations appear to be the characteristic face, which can be subtle in children who are mildly affected [Ireland and Burn, 1991: Twelfth Annual David W. Smith Workshop on Malformations and Morphogenesis]. Other aspects of the syndrome include variable degrees of mental retardation, growth retardation, structural abnormalities of the limbs, and behavior abnormalities, noted to be "autistic" [Jones, 1988: "Smith's recognizable patterns of human malformation"]. Johnson et al. [1976: Pediatr Res 10:843-850] described a behavior phenotype felt to be common in patients with BDLS. They predicted that patients with BDLS may respond to "behavioral intervention". Other behavior abnormalities in BDLS have been reported [Barr et al., 1971: Neuropadiatrie 3:46-66; Hawley et al., 1985: Am J Med Genet 20:453-459]. We report on a 6-year-old boy with the facial characteristics of BDLS, normal birth weight, prenatal onset of a small head relative to length, postnatal onset growth deficiency, nearly normal psychomotor development with onset of clear developmental delays by 2 years. He developed behavior problems similar to those seen in other patients with BDLS. These behaviors are most consistent with Pervasive Development Disorder-NOS (PDD), and Autistic Disorder [DSM-III-R, 1987] which encompasses a spectrum of mild to severe autistic behaviors. We report successful in-patient care utilizing medical and behavioral techniques to reduce the frequency of the behaviors. We feel that the presence of the characteristic behaviors may be helpful in confirming the diagnosis of BDLS.

Studies on requirements for amino acids in infants with disorders of amino acid metabolism. I. Effect of alanine

Two infants with disorders of propionate metabolism were studied at 7 months of age to determine optimum levels of intake of protein and calories to meet the requirements for essential amino acid for growth in infancy, and at the same time minimize the accumulation of toxic intermediates. An effect of alanine was found that permitted growth at otherwise limiting levels of protein intake. This was not simply an effect of nonessential nitrogen as neither glycine nor glutamic acid could substitute for alanine in this protein-sparing effect. This appears to represent further evidence of the relationship between alanine and the branched-chain amino acids and of the importance of the alanine-glucose cycle in human physiology.

An evaluation of protein requirements in methylmalonic acidaemia

A 3-month-old girl and a 13-month-old boy with vitamin B12-unresponsive methylmalonic acidaemia were studied to determine responses to varying levels of protein intake of growth, nitrogen balance and organic acid metabolism. A linear increase in the excretion of methylmalonic acid was observed in both patients above a critical level of protein intake. The inflection point was judged to reflect a ceiling above which amino acid intake exceeded requirements and catabolism was initiated. Below this point in each infant there was a plateau of minimal excretion of methylmalonic acid. Within this plateau level a reasonable rate of growth and metabolic stability were achieved at intakes between 0.70 and 0.75 and between 0.75 and 1.17 g protein kg-1, respectively, indicating that there is a range of protein tolerance and the importance of an individual approach to the provision of protein in patients with methylmalonic acidaemia. In the 3-month-old infant, nitrogen equilibrium was achieved at protein intakes above 0.6 g kg-1 and modest nitrogen retention was attained at a protein intake of 0.75 g kg-1, a level at which the excretion of methylmalonic acid was minimal and weight gain satisfactory. A protein intake of 1.25 g kg-1 was required to achieve a level of nitrogen retention often considered optimal for normal growth; however, this infant demonstrated an elevated excretion of methylmalonic acid and was close to clinical illness at this level of protein intake. The 13-month-old infant demonstrated a normal level of nitrogen retention, minimal excretion of methylmalonic acid, and a satisfactory rate of growth at protein intakes of 1.0-1.17 g kg-1. The values should prove useful guidelines for the management of infants requiring minimal intakes of protein. In studies carried out at 18-20 months of age, supplementation of the basic diet containing 0.75 g kg protein-1 with a mixture of amino acids not containing the precursors of methylmalonic acid was associated with increase of retention of nitrogen and increased concentrations of some essential amino acids in plasma, but effects on growth and the excretion of methylmalonic acid were not significant.

Dietary management of oculocutaneous tyrosinemia in an 11-year-old child

An 11-year-old girl with keratitis and plantar keratosis had tyrosinemia. The concentration of tyrosine in the plasma was 16.5 mg/dL. Dietary intake of phenylalanine and tyrosine was systematically varied, and the plasma concentrations of tyrosine and nitrogen balance were studied. It was necessary to achieve a total intake of phenylalanine and tyrosine less than 100 mg/kg/day to obtain plasma concentrations of tyrosine of less than 10 mg/dL. After dietary therapy was started, the keratitis resolved promptly, and the patient remained asymptomatic during a period of 16 months in which the mean plasma concentration of tyrosine was 11.1 mg/dL. The dietary management of a child at this age presents a different problem from that of a young infant. It can be successfully pursued at home, as well as in the carefully regulated environment of a clinical research center.

Lesch-Nyhan disease: clinical experience with nineteen patients

The clinical phenotype in Lesch-Nyhan disease has been analyzed in 19 patients studied in hospital. In each case the diagnosis was made on the basis of inactivity of the enzyme hypoxanthine guanine phosphoribosyltransferase in erythrocyte lysates. All had hyperuricemia, and the presence of 'orange sand' in the diaper was a prominent early complaint. All had self-mutilative behavior, of which the most characteristic form was biting the fingers or lips. All had the neurological syndrome of spasticity and choreoathetoid involuntary movements. All but one had less-than-normal intelligence.

Joseph disease and Huntington disease: protein patterns in fibroblasts and brain

Proteins were separated on two-dimensional acrylamide gels obtained from brain samples of patients with Joseph disease, Huntington disease (HD) and multiple sclerosis. Similar protein separations were made from cultured skin fibroblasts of Joseph disease patients. Two major classes of proteins, one with a MW of 50,000 probably representing the glial filamentous acidic protein, or another class with a MW of 40,000 (proteins Jc, Jd, L1 and L2) were increased in the cerebellum of six Joseph disease patients. The same protein species were abnormally increased in HD brains, mainly in the basal ganglia and frontal cortex. These identical classes of protein changes were present in two nosologically separate autosomal dominant neurological disorders, Joseph disease (a spinocerebellar degeneration) and HD (a basal ganglia and cerebral cortical degeneration) and may reflect a biochemical correlation of gliosis and neuronal disease. However, these changes may be evidence that the two diseases are allelic mutations of the same gene. The dominantly inherited spinocerebellar degenerations may result from a primary deficit of glial-neuronal interaction, resulting in neuronal loss but with a compensatory increase in the number of glial cells attempting to provide additional trophic-metabolic support.

Joseph disease: protein patterns in fibroblasts and brain

The separation of brain and fibroblast proteins was analyzed on two-dimensional acrylamide gels. Proteins were examined from skin fibroblast cultures and brain homogenates from the frontal cerebral cortex, putamen, and cerebellum. Protein species from skin fibroblast cultures of controls and patients with Joseph disease or Huntington disease were not significantly different. The proteins from homogenates of the cerebral cortex, putamen, and cerebellum from controls differed from those of one Joseph disease patient. Two major classes of proteins were increased in the patient's putamen and cerebellum. Proteins of 40,000 and 50,000 daltons--including the glial filamentous acidic protein complex (molecular weight 50,000), and two proteins which migrated near actin--were increased in the cerebellum. The glial filamentous acidic protein complex increased 3.7-fold in the putamen of the patient. These protein changes probably represent gliosis, but may also be an expression of the primary genetic mutation.

Two forms of cutis laxa presenting in the newborn period

Two infants are described with congenital cutis laxa. They represent two distinct disorders. In the first, congenital cutis laxa is associated with a generalized disorder of elastic tissue in which there may be diaphragmatic or other hernias, diverticula of the gastrointestinal or urinary tract and infantile emphysema. The disease is fatal often within the first year. In the second, congenital cutis laxa is associated with widely patent anterior fontanel, a variety of malformations, and retarded growth and development. Recognition of these distinct syndromes in the newborn period and their recessive inheritance permit realistic discussion of the prognosis which is very different from the benign dominant forms of cutis laxa.

Autosomal dominant striatonigral degeneration. A clinical, pathologic, and biochemical study of a new genetic disorder

An autosomal dominant striatonigral degeneration is present in a family of Portuguese ancestry numbering in excess of 329 persons in eight generations. The illness begins in the second, third, or fourth decade, and progresses for about 15 years with parkinsonian rigidity, spasticity, spastic dysarthria, and abnormalities of eye movement. Neuropathologic findings are severe neuronal loss and astrocytic gliosis in the corpus striatum and substantia nigra, with a moderate neuronal loss in the dentate nucleus of the cerebellum and nucleus ruber of the midbrain. This is a new genetic entity, distinct from other autosomal dominant neurologic disorders such as nigrospinodentatal degeneration, olivopontocerebellar degeneration, dystonia musculorum deformans, Machado's disease, and Huntington's disease.