Obstetric implications of low-lying placentas diagnosed in the second trimester

OBJECTIVES

To determine the obstetrical outcome of pregnancies initially complicated by a low-lying placenta in the second trimester.

METHODS

We reviewed the obstetric outcome of all women with singleton deliveries from 1 January 1997 to 31 March 1999 and compared the 703 women with low-lying placentas (placentas in the lower uterine segment) with the 6938 women with placentas that were normally situated in the upper uterine segment at 16-22 weeks' gestation.

RESULTS

Pregnancies complicated by a low-lying placenta in the second trimester were not associated with antepartum hemorrhage, preterm births, preterm prelabor rupture of membranes, pregnancy-induced hypertension, fetal growth restriction or cesarean births. However, they had a higher incidence of postpartum hemorrhage (odds ratio 1.768, 95% confidence interval 1.137, 2.748) than women with a normally situated placenta in the second trimester.

CONCLUSIONS

Pregnant women with low-lying placentas in the second trimester have a higher incidence of postpartum hemorrhage and hence, it would be prudent to carefully manage the third stage of labor in these women.

Pericardial Hemangioma Presenting as Thoracic Mass in utero

Pericardial hemangiomas are rare lesions. We present the case of an infant who was referred to our fetal diagnosis and treatment group for the presence of a left thoracic mass, pleural effusion, and mediastinal shift on fetal ultrasound. The characteristics of the lesion suggested the presence of a pulmonary sequestration. A chest radiograph done at birth was normal. At 2 weeks of age, an enhancing lesion of the left pericardium was identified on chest CT. A cardiac MRI demonstrated enhancement of the mass on T2-weighted images. The patient underwent thoracoscopic assessment of the mass for diagnostic purposes. Multiple lesions were identified along the left pericardium and diaphragm. A frozen section biopsy revealed a hemangioma. The natural history for hemangiomas is gradual regression; however, they may increase acutely in size and cause symptoms prior to involution. Investigations should be performed to identify the involvement of other organs. This case illustrates the need to closely follow all patients with prenatally diagnosed thoracic masses with CT imaging, even when they are asymptomatic and have a normal chest radiograph at birth.

Tat1, a novel sulfate transporter specifically expressed in human male germ cells and potentially linked to rhogtpase signaling

RhoGTPases (Rho, Rac, and Cdc42) are known to regulate multiple functions, including cell motility, adhesion, and proliferation; however, the signaling pathways underlying these pleiotropic effects are far from fully understood. We have recently described a new RhoGAP (GTPase activating protein for RhoGTPases) gene, MgcRacGAP, primarily expressed in male germ cells, at the spermatocyte stage. We report here the isolation, through two-hybrid cloning, of a new partner of MgcRacGAP, very specifically expressed in the male germ line and showing structural features of anion transporters. This large protein (970 amino acids and a predicted size of 109 kDa), we provisionally designated Tat1 (for testis anion transporter 1), is closely related to a sulfate permease family comprising three proteins in human (DRA, Pendrin, and DTD); it is predicted to be an integral membrane protein with 14 transmembrane helices and intracytoplasmic NH(2) and COOH termini. In situ hybridization studies demonstrate that Tat1 and MgcRacGAP genes are coexpressed in male germ cells at the spermatocyte stage. On testis sections, Tat1 protein can be immunodetected in spermatocytes and spermatids associated with plasma membrane. Two-hybrid and in vitro binding assays demonstrate that MgcRacGAP stably interacts through its NH(2)-terminal domain with the Tat1 COOH-terminal region. Expression of Tat1 protein in COS7 cells generates a 4,4'-diisothiocyano-2,2'-disulfonic acid stilbene and chloride-sensitive sulfate transport. Therefore we conclude that Tat1 is a novel sulfate transporter specifically expressed in spermatocytes and spermatids and interacts with MgcRacGAP in these cells. These observations raise the possibility of a new regulatory pathway linking sulfate transport to Rho signaling in male germ cells.

Protein feeding pattern does not affect protein retention in young women

This study was undertaken to determine whether a pulse protein feeding pattern was more efficient than a spread pattern to improve protein anabolism in young women as was already shown in elderly women. After a 15-d adaptive period [1.2 g protein/(kg fat-free mass. d)], 16 young women (age 26 +/- 1 y) were given a 14-d diet providing 1.7 g protein/(kg fat-free mass. d), using either a pulse pattern (protein consumed mainly in one meal, n = 8), or a spread pattern (spreading daily protein intake over four meals, n = 8). Nitrogen balance was determined at the end of both the 15-d adaptive and the 14-d experimental periods. Whole-body protein turnover was determined at the end of the 14-d experimental period using [(15)N]glycine as an oral tracer. Nitrogen balance was 17 +/- 5 mg N/(kg fat-free mass. d) during the adaptive period. It was higher during the experimental period, but not significantly different in the women fed the spread or the pulse patterns [59 +/- 12 and 36 +/- 8 mg N/(kg fat-free mass. d) respectively]. No significant effects of the protein feeding pattern were detected on either whole-body protein turnover [5.5 +/- 0.2 vs. 6.1 +/- 0.3 g protein/(kg fat-free mass. d) for spread and pulse pattern, respectively] or whole-body protein synthesis and protein breakdown. Thus, in young women, these protein feeding patterns did not have significantly different effects on protein retention.

Long branch attraction effects and the status of "basal eukaryotes": phylogeny and structural analysis of the ribosomal RNA gene cluster of the free-living diplomonad Trepomonas agilis

The three taxa emerging at the base of the eukaryotic ribosomal RNA phylogenetic tree (Diplomonadida, Microspora, and Parabasalia) include a wide array of parasitic species. and some free-living organisms that appear to be derived from a parasitic ancestry. The basal position of these taxa, which lack mitochondria, has recently been questioned. I sequenced most of the ribosomal RNA gene cluster of the free-living diplomonad Trepomonas agilis and a secondary structure model was reconstructed for the SSU rRNA. I conducted a RASA matrix analysis to identify, independently from tree reconstruction, putative long branch attraction effects in the data matrix. The results show that each of the basal clades and the euglenozoan clade act, indeed, as long branches and may have been engaged in a process of accelerated rate of evolution. A nucleotide signature analysis was conducted in the conserved regions for positions defining the three great domains of life (Eubacteria, Archea, and Eukaryota). For the three basal taxa, this analysis showed the presence of a significant number of different non-eukaryotic nucleotides. A precise study of the nature and location of these nucleotides led to conclusions supporting the results of the RASA analysis. Altogether, these findings suggest that the basal placement of these taxa in the SSU ribosomal RNA phylogenetic tree is artifactual, and flawed by long branch attraction effects.

Determinants of unexplained antepartum fetal deaths

OBJECTIVE

To assess fetal, maternal, and pregnancy-related determinants of unexplained antepartum fetal death.

METHODS

We conducted a hospital-based cohort study of 84,294 births weighing 500 g or more from 1961-1974 and 1978-1996. Unexplained fetal deaths were defined as fetal deaths occurring before labor without evidence of significant fetal, maternal, or placental pathology.

RESULTS

One hundred ninety-six unexplained antepartum fetal deaths accounted for 27.2% of 721 total fetal deaths. Two thirds of the unexplained fetal deaths occurred after 35 weeks' gestation. The following factors were independently associated with unexplained fetal death: maternal prepregnancy weight greater than 68 kg (adjusted odds ratio [OR] 2.9; 95% confidence interval [CI] 1.85, 4.68), birth weight ratio (defined as ratio of birth weight to mean weight for gestational age) between 0.75 and 0.85 (OR 2.77; 95% CI 1.48, 5.18) or over 1.15 (OR 2.36; 95% CI 1.26, 4.44), fewer than four antenatal visits in women whose fetuses died at 37 weeks or later (OR 2.21; 95% CI 1.08, 4.52), primiparity (OR 1.74; 95% CI 1.26, 2.40), parity of three or more (OR 2.01; 95% CI 1.26, 3.20), low socioeconomic status (OR 1.59; 95% CI 1.14, 2.22), cord loops (OR 1.75; 95% CI 1.04, 2.97) and, for the 1978-1996 period only, maternal age 40 years or more (OR 3.69; 95% CI 1.28, 10.58). Trimester of first antenatal visit, low maternal weight, postdate pregnancy, fetal-to-placental weight ratio, fetal sex, previous fetal death, previous abortion, cigarette smoking, and alcohol use were not significantly associated with unexplained fetal death.

CONCLUSION

In this study, we identified several factors associated with an increased risk of unexplained fetal death.

Messenger RNA in dormant cells of Sterkiella histriomuscorum (Oxytrichiade): indentification of putative regulatory gene transcripts

In the absence of food, the oxytrichid Sterkiella histriomuscorum, like many ciliates, enters into dormancy and transforms into a round and walled encysted cell. When transferred back into a feeding medium, the cyst re-transforms into a vegetative cell in a few hours. This encystment-excystment pathway, which is common to many free-living and parasitic protists, is still poorly understood at the molecular level. In order to identify potential dormant transcripts in the cysts of Sterkiella, we have constructed cDNA libraries from mature cysts. Transcripts have been isolated confirming the presence of a mRNA pool in the dormant cells. The sequence analysis of two cDNA indicates open reading frames which show significant similarities to known proteins involved in mechanisms of regulation: 1) nifR3, an element of the nitrogen regulatory system in bacteria and 2) CROC-1, a newly identified human transcription factor. The two corresponding macronuclear genes represent the first putative regulatory genes isolated in ciliates. From a differential screening of the cDNA library against vegetative cDNA, one cyst-specific (and very abundant) transcript has been isolated but the product has not yet been identified. The possible involvment of these new ciliate genes in the excystment process is discussed.

Prenatal percutaneous needle drainage of cystic sacrococcygeal teratomas

Prenatal ultrasound (US) permits in utero diagnosis of sacrococcygeal teratoma (SCT), follow-up of tumor size, and the early identification of complications, allowing for a more timely and appropriate delivery. The recommended management of large SCTs is delivery by cesarean section (CS) to prevent dystocia, tumor rupture, hemorrhage, and death. However, even delivery by CS can be difficult, necessitating a large hysterotomy that adds to maternal morbidity. The authors report two cases of cystic SCTs in which prenatal percutaneous drainage allowed for an uncomplicated vaginal delivery. In the first case, a large unilocular cystic SCT was diagnosed at 31 weeks' gestation on prenatal US. The fetal presentation was breech, and the mass was steadily increasing in size, preventing spontaneous version. At 37 5/7 weeks, the cyst was percutaneously drained under US guidance allowing for successful external version. Repeat drainage just before induction of labor permitted a successful vaginal delivery. In the second case, the cystic SCT was percutaneously drained just before induction of labor at full term, again allowing for an uncomplicated vaginal delivery. Prenatal percutaneous needle drainage of cystic SCTs offers an alternative to CS that results in decreased risks for both mother and fetus.

Protein pulse feeding improves protein retention in elderly women

BACKGROUND

Adequate protein nutrition could be used to limit gradual body protein loss and improve protein anabolism in the elderly.

OBJECTIVE

We tested the hypothesis that an uneven protein feeding pattern was more efficient in improving protein anabolism than was an even pattern.

DESIGN

After a controlled period, 15 elderly women (mean age: 68 y) were fed for 14 d either a pulse diet (n = 7), providing 80% of the daily protein intake at 1200, or a spread diet (n = 8), in which the same daily protein intake was spread over 4 meals. Both diets provided 1.7 g protein x kg fat-free mass (FFM)(-1) x d(-1). Protein accretion and daily protein turnover were determined by using the nitrogen balance method and the end product method (ammonia and urea) after an oral dose of [15N]glycine.

RESULTS

Nitrogen balance was more positive with the pulse than with the spread diet (54 +/- 7 compared with 27 +/- 6 mg N x kg FFM(-1) x d(-1); P < 0.05). Protein turnover rates were also higher with the pulse than with the spread diet (5.58 +/- 0.22 compared with 4.98 +/- 0.17 g protein x kg FFM(-1) x d(-1); P < 0.05), mainly because of higher protein synthesis in the pulse group (4.48 +/- 0.19 g protein x kg FFM(-1) x d(-1)) than in the spread group (3.75 +/- 0.19 g protein x kg FFM(-1) x d(-1)) (P < 0.05).

CONCLUSION

A protein pulse-feeding pattern was more efficient than was a protein spread-feeding pattern in improving, after 14 d, whole-body protein retention in elderly women.

Secular trends in preterm birth: a hospital-based cohort study

CONTEXT

Canada and the United States have reported a recent increase in the incidence of preterm birth, but the reasons for this increase are unknown.

OBJECTIVE

To assess secular trends in preterm birth and its potential determinants.

DESIGN

Hospital-based cohort study.

SETTING

Canadian tertiary care university teaching hospital, 1978-1996.

PARTICIPANTS

A total of 65574 nonreferred live births and stillbirths.

MAIN OUTCOME MEASURES

Changes in occurrence of preterm birth, before and after adjustment for changes in method of gestational age assessment, obstetric intervention, registration of births weighing less than 500 g, and sociodemographic, behavioral, and clinical determinants.

RESULTS

A crude secular increase in preterm births was seen for births less than 37, 34, and 32 completed weeks using 3 alternative gestational age estimation methods. Based on an algorithm incorporating both menstrual and early ultrasound gestational age estimates, rates increased from 6.6% to 9.8% for births at less than 37 weeks' gestation, 1.7% to 2.3% at less than 34 weeks, and 1.0% to 1.2% at less than 32 weeks. Exclusion of births weighing less than 500 g and those with induction or preterm cesarean delivery without labor before each of the corresponding gestational age cutoffs eliminated the secular trends for births before 34 and 32 weeks and attenuated the trend for births before 37 weeks. Nearly half of the remaining trend for births before 37 weeks was accounted for by the increasing use of early ultrasound dating. The residual trend was eliminated after controlling for secular increases in unmarried status and the proportion of women aged 35 years or older. These factors, combined with a decrease in alcohol consumption and increases in histological chorioamnionitis and cocaine use, appear to have counteracted a reduction in preterm birth since the mid-1980s that otherwise would have been observed.

CONCLUSIONS

This hospital's increase in preterm births since 1978 parallels increases reported in population-based national studies from the United States and Canada. This trend appears largely attributable to the increasing use of early ultrasound dating, preterm induction and preterm cesarean delivery without labor, and changes in sociodemographic and behavioral factors.

How small is too small in a twin pregnancy?

OBJECTIVE

The objective was to determine whether small twins had a survival advantage with respect to small singletons after controlling for other factors associated with adverse perinatal outcome.

STUDY DESIGN

A hospital-based cohort study included all births between 1980 and 1995 of babies born between 24 and 43 weeks' gestation. Logistic regression was used to estimate the perinatal mortality risks for monochorionic and dichorionic twins with growth restriction after adjusting for gestational age, maternal age, parity, method of delivery, and the presence or absence of congenital malformations.

RESULTS

The study sample included 1062 dichorionic twins, 354 monochorionic twins, and 59,873 singletons. Small monochorionic and dichorionic twins showed a similar overall risk of perinatal mortality (odds ratio 1.40, confidence interval 0.86 to 2.25). However, monochorionic twins with birth weights <10th percentile faced an increased risk of perinatal death compared with singletons (odds ratio 2.45, confidence interval 1.20 to 5.02). Dichorionic twins had no such increased risk (odds ratio 0.91, confidence interval 0.45 to 1.84).

CONCLUSIONS

Twins with growth restriction are not protected against perinatal loss, even after adjusting for congenital malformations. In fact, monochorionic twins are more than twice as likely to die in the perinatal period as are their singleton counterparts.

MgcRacGAP, a new human GTPase-activating protein for Rac and Cdc42 similar to Drosophila rotundRacGAP gene product, is expressed in male germ cells

In a search for new partners of the activated form of Rac GTPase, we have isolated through a two-hybrid cloning procedure a human cDNA encoding a new GTPase-activating protein (GAP) for Rho family GTPases. A specific mRNA of 3.2 kilobases was detected in low abundance in many cell types and found highly expressed in testis. A protein of the predicted size 58 kDa, which we call MgcRacGAP, was detected in human testis as well as in germ cell tumor extracts by immunoblotting with antibodies specific to recombinant protein. In vitro, the GAP domain of MgcRacGAP strongly stimulates Rac1 and Cdc42 GTPase activity but is almost inactive on RhoA. N-terminal to its GAP domain, MgcRacGAP contains a cysteine-rich zinc finger-like motif characteristic of the Chimaerin family of RhoGAPs. The closest homolog of MgcRacGAP is RotundRacGAP, a product of the Drosophila rotund locus. In situ hybridization experiments in human testis demonstrate a specific expression of mgcRacGAP mRNA in spermatocytes similar to that of rotundRacGAP in Drosophila testis. Therefore, protein sequence similarity and analogous developmental and tissue specificities of gene expression support the hypothesis that RotundRacGAP and MgcRacGAP have equivalent functions in insect and mammalian germ cells. Since rotundRacGAP deletion leads to male sterility in the fruit fly, the mgcRacGAP gene may prove likewise to play a key role in mammalian male fertility.

Enhanced apoptosis in the thymus of transgenic mice expressing constitutively activated forms of human Rac2GTPase

Rac proteins constitute a subgroup of the Rho family of small GTPases and include Rac1, which is expressed ubiquitously, and Rac2, a highly homologous protein only expressed in myelo-monocytic and lymphoid cell lineages. In fibroblasts, Rac1 plays a crucial role in control of actin cytoskeleton organisation, cell growth and Ras-induced transformation. In phagocytes, Rac1 and Rac2 regulate a specific enzymatic complex, NADPH oxidase. These multiple functions have been ascribed to Rac proteins only on the basis of cell culture and in vitro biochemical studies. To examine the role of Rac2 in vivo in a T cell lineage, we have expressed either wild-type or constitutively-activated forms of human Rac2 (Rac2V12 and Rac2L61) in transgenic mice under control of the thymus specific lck proximal promoter. We report here a striking atrophy of the thymus in mice expressing even low levels of either of the activated mutants of Rac2, while expression of Rac2wt has no effect. This phenotype is correlated with a marked decrease in the number of double positive (CD4+ CD8+) and single positive (CD4+ CD8- and CD8+ CD4-) thymocytes. Cellular and molecular analyses demonstrate that this defect is due to an increase in apoptosis among thymocytes. As Rac2 is normally expressed in thymocytes and activated T cells, we propose that Rac2 dependent pathways could play an important role in control of growth and death of T cells.

Impaired phosphoinositide metabolism in glucose-incompetent islets of neonatally streptozotocin-diabetic rats

The effects of nutrient and neurotransmitter stimuli on insulin release, loss of phosphoinositides (PI), and production of inositol phosphates (InsP) were investigated in islets from neonatally streptozotocin-injected (nSTZ) rats. In islets from nSTZ rats, insulin secretory responses to 16.7 mM D-glucose and 10.0 mM D-glyceraldehyde were reduced compared with controls. Contents in phosphatidylinositol 4-monophosphate [PtdIns(4)P] and phosphatidylinositol 4,5-bisphosphate [PtdIns(4,5)P2], but not in phosphatidylinositol, were diminished. Glucose effects on breakdown of PtdIns(4)P and PtdIns(4,5)P2 and on total InsP accumulation were both reduced. D-Glucose was unable to increase the levels of both inositol trisphosphate isomers, Ins(1,3,4)P3 and Ins(1,4,5)P3. Glyceraldehyde also failed to promote InsP formation. By contrast, the ability of 1.0 mM carbachol or 300 nM cholecystokinin to stimulate insulin secretion and InsP generation was still observed. Thus a disturbed coupling between nutrient recognition and activation of phospholipase C, possibly together with a shortage of available polyphosphoinositides, could be responsible for the altered islet PI turnover in the nSTZ rats. It is proposed that such defects may contribute to the impairment of glucose-stimulated insulin secretion in this model of non-insulin-dependent diabetes mellitus.

Decreased ATP-induced synthesis and Ca(2+)-stimulated degradation of polyphosphoinositides in pancreatic islets from neonatally streptozotocin-diabetic rats

Phosphoinositide (PI) synthesis and hydrolysis were investigated in pancreatic islet homogenates from neonatal streptozotocin diabetic (n-STZ) and control rats. In the diabetics, ATP, in absence of Ca2+, failed to increase the amount of phosphatidylinositol 4-phosphate (PtdInsP) and phosphatidyl inositol 4, 5-bisphosphate (PtdInsP2) at variance with the pattern in controls. Also, the Ca(2+)-stimulated generation of inositol phosphates (InsP) was dramatically decreased, whether in the absence or presence of ATP. Moreover, phosphatidylinositol (PtdIns) kinase activity was reduced while PtdInsP kinase activity was not impaired. These data suggest that the suppressed formation of PtdInsP and subsequent PtdInsP2 synthesis, concomitantly with a decreased Ca(2+)-stimulated phospholipase C activity, may participate to the alteration of the PI pathway, the limitation of the InsP production, and finally the impairment of the insulin release in the n-STZ model of non-insulin-dependent diabetes.

Primary structure and phylogenetic relationships of glyceraldehyde-3-phosphate dehydrogenase genes of free-living and parasitic diplomonad flagellates

Complete nucleotide sequences have been established for two genes (gap1 and gap2) coding for glyceraldehyde-3-phosphate dehydrogenase (GAPDH, EC 1.2.1.12) homologs in the diplomonad Giardia lamblia. In addition, almost complete sequences of the GAPDH open reading frames were obtained from PCR products for two free-living diplomonad species, Trepomonas agillis and Hexamita inflata, and a parasite of Atlantic salmon, an as yet unnamed species with morphological affinities to Spironucleus. Giardia lamblia gap1 and the genes from the three other diplomonad species show high similarity to each other and to other glycolytic GAPDH genes. All amino-acyl residues known to be highly conserved in this enzyme are also conserved in these sequences. Giardia lamblia gap2 gene is more divergent and its putative translation reveals the presence of a cysteine and serine-rich insertion resembling a metal binding finger. This motif has not yet been noted in other GAPDH molecules. All sequences contain an S-loop signature with characteristics close to those of eukaryotes. In phylogenetic reconstructions based on the derived amino acid sequences with neighbor-joining, parsimony and maximum-likelihood methods the four typical GAPDH sequences of diplomonads cluster into a single clade. Within this clade, G. lambia gap1 shares a common ancestor with the rest of the genes. The latter are more closely related to each other, indicating an early separation of the lineage leading to the genus Giardia from the lineage encompassing the morphologically less differentiated genera, Trepomonas, Hexamita and that of the unnamed species. This result is discordant with the orthogonal evolution of diplomonads suggested on the basis of comparative morphology. In neighbor-joining reconstructions G. lamblia gap2 occupies a variable position, due to its great divergence. In parsimony and maximum likelihood analysis however, it shares a most recent common ancestor with the typical G. lamblia gap1 gene, suggesting that it diverged after the separation of the Giardia lineage. The position of the diplomonad clade in broader phylogenetic reconstructions is firmly within the typical cytosolic glycolytic representatives of GAPDH of eukaryotes.

Minimal hydronephrosis in the fetus: clinical significance and implications for management

PURPOSE

We further define the natural history and management of minimal fetal hydronephrosis.

MATERIALS AND METHODS

Experience with minimal fetal hydronephrosis (renal pelvic diameter 4 to 10 mm. before 20 weeks of gestation and 5 to 10 mm. from 20 to 24 weeks) was reviewed for 18 months at New England Medical Center.

RESULTS

The incidence of minimal fetal hydronephrosis was 2.2% in the 5,900 fetuses screened by ultrasound. In 63% of cases prenatal ultrasound was done more than once, and revealed that dilatation of the urinary tract was stable during gestation in 31 (25%), and became normal in 35 (29%) and worse in 11 (9%). A total of 63 patients (103 renal units) followed for up to 1 year underwent postnatal sonography. Those with abnormalities were screened with a voiding cystourethrogram and renal scan, including 40 with normal postnatal ultrasound and no changes on subsequent evaluation. Of the 23 patients with abnormal findings 4 had functionally significant ureteropelvic junction obstruction and 1 had severe vesicoureteral reflux. A retrospective analysis of the sonograms of patients with minimal fetal hydronephrosis and persistence or progression of hydronephrosis revealed calicectasis, progression of minimal fetal hydronephrosis in utero and/or abnormal renal echogenicity in each fetus.

CONCLUSIONS

Our study shows that in a small but significant number of fetuses minimal fetal hydronephrosis will progress, whereas in most it will resolve.

Bronchopulmonary sequestration: prenatal diagnosis with clinicopathologic correlation

A patient was referred at 21 weeks' gestation for evaluation of an echogenic mass in the fetal right chest. Color-doppler sonography facilitated the diagnosis of a bronchopulmonary sequestration. Clinicopathologic correlation was possible after termination at 2.3 weeks' gestation. Pathologic examination confirmed the prenatal diagnosis and demonstrated the systemic vascular supply seen on color-doppler sonography. Color doppler is a useful adjunct in the sonographic evaluation of the fetus with an echogenic chest mass.

Prenatal diagnosis and management of fetal thoracic lesions

There have been significant strides made during the last decade in understanding the natural history and pathophysiology of fetal thoracic lesions. Largely as a result of advances in prenatal ultrasound, we are not only able to diagnose these lesions and advise parents about prognosis, but also offer the possibility of fetal intervention for the most severely affected fetuses. However, large gaps remain in the current state of knowledge of fetal thoracic lesions. We are unable to accurately predict pulmonary hypoplasia, the most devastating consequence of fetal thoracic lesions. In lesions, such as CDH, the selection criteria for fetal intervention remain ill defined. Proof of the efficacy and superiority of fetal surgery over conventional postnatal therapies for diaphragmatic hernia await the results of prospective trials. Fetal surgery in lesions such as CCAM and BPS is currently reserved for only those fetuses with hydrops and a uniformly fatal outcome. Whether fetal surgery in these cases would be beneficial in the absence of hydrops is difficult to say especially given the possibility of spontaneous regression. During the next decade we anticipate continued growth in our understanding of these lesions, refinement in selection criteria for intervention, and advances in techniques for salvaging these severely compromised fetuses. The diagnosis and treatment of fetal thoracic lesions remains a formidable challenge, but one which can be met with cautious optimism, due to the availability of fetal interventions not previously available.

Modulation of stress proteins by Cd2+ in a human T cell line

We previously showed in a human T cell line (CEM-C12 cells) that Cd2+ induced gene expression of stress proteins, metallothionein-IIA and heat shock protein 70 in a time- and dose-dependent manner. In the present study, CEM-C12 cells were pretreated for 24 h with 1 microM Cd2+ and then challenged with toxic concentrations of this metal. We found that maximal expression of the metallothionein-IIA and heat shock protein 70 genes was increased and this maximal level occurred at higher Cd2+ toxic concentrations. Actinomycin D chase experiments indicated that Cd2+ pretreatment did not modify metallothionein-IIA mRNA stability. The modulatory effect of Cd2+ pretreatment was dose-dependent from 100 pM to 1 microM. Such pretreatment also enhanced resistance to Cd2+ toxicity. Finally, verapamil, a calcium/potassium channel blocker displaced the dose-response curve for Cd2+ toxicity as well as metallothionein-IIA and heat shock protein 70 gene expression to higher Cd2+ concentrations.

Glucose refractoriness of pancreatic beta-cells in rat models of non-insulin dependent diabetes

A decreased insulin response, preferentially to glucose, has been considered a hallmark of non-insulin dependent diabetes mellitus (Type 2) in humans. Syndromes resembling human diabetes occur spontaneously in many animal species and can also be induced by treating animals with drugs or viruses, excising their pancreases or manipulating their diet. Among these models, rat diabetes induced by neonatal streptozotocin administration (n-STZ models) has been first recognized as an adequate tool to study the long-term consequences of a gradually reduced beta-cell mass. More recently, the GK (Goto Kakisaki) Wistar rat has become available and is now considered as a promising spontaneous rat model of non-insulin dependent diabetes. We and others have found that defects in insulin secretion and action develop in the n-STZ and the GK models, which in many ways resemble those described in human non-insulin dependent diabetes. This review is aimed to sum up with a comparative approach, the informations so far collected in the n-STZ and GK models concerning the cellular mechanisms leading to the desensitization of their beta-cells to glucose. Taken together, the data reinforce the view that the impairment of glucose-induced insulin release in n-STZ and GK rats is clearly related to a defect in oxidative glycolysis. This leads to a severe decrease in the mitochondrial oxidative catabolism of glucose-derived pyruvate. Its coincides with a lower ATP/ADP ratio in glucose-stimulated islets and a subsequent alteration of ionic events tightly coupled to the fuel function of the hexose in islet cells, i.e. the decrease in K+ conductance.(ABSTRACT TRUNCATED AT 250 WORDS)

[Deinstitutionalization of severely mentally retarded patients: impact on prescription of neuroleptics]

The neuroleptic medication prescribed over a period of 12 years for three groups of severely developmentally handicapped patients is analyzed retrospectively. The average daily doses prescribed for two groups of patients, deinstitutionalized either to foster homes or group homes, are compared to those prescribed for a third group of patients who were not deinstitutionalized. The results show that deinstitutionalization had no impact on the prescribing of neuroleptics, regardless of the type of residence: group home or foster home. The results show, moreover, that for the three groups of patients, time spent without medication decreased significantly over the 12 years of this study. These results are discussed in relation to the problem of the patients' social reintegration into the community.

HLA DQB1*0301 allele is involved in the susceptibility to erythema multiforme

Erythema multiforme (EM) is an acute, episodic inflammatory disorder of the skin and mucous membranes of various etiology that could be related to immunologic hypersensitivity response. EM has been previously reported to be associated with serologically defined HLA-DRw53 and DQw3 antigens. In this report, we reevaluate the role of HLA class II alleles in EM manifestations. With use of the polymerase chain reaction, followed by sequence-specific oligonucleotide hybridization, 35 unrelated Caucasian EM patients and 80 randomly selected healthy subjects were studied, and the DRB3, DRB4, DQA1, and DQB1 alleles were analyzed. The comparison of frequencies of these alleles indicates that (i) susceptibility to EM disease is more associated with the HLA-DQ than the HLA-DR subregions and (ii) that the DQB1*0301 is the most frequent allele among EM patients. Sixty-six percent of the patients had the DQB1*0301 allele compared to 31% of the controls (RR = 4.1; p less than 0.001). An even stronger DQB1*0301 association was found in the patient group with herpes-associated EM (76%; RR = 6.5; p less than 0.001). Our data demonstrate a clear association between an HLA-DQB1 allele and susceptibility to EM.

A combination of HLA-DQ beta Asp57-negative and HLA DQ alpha Arg52 confers susceptibility to insulin-dependent diabetes mellitus

Family and population studies indicate that predisposition to insulin-dependent (type I) diabetes mellitus (IDDM) is polygenic. It has been shown that the absence of the aspartic acid in position 57 (Asp57) of the DQ beta chain is positively correlated to IDDM. However, Asp57-negative haplotypes do not always confer susceptibility and conversely, some Asp57-positive haplotypes seem to be disease associated. It has been suggested that other HLA class II sequences, probably belonging to the HLA DQA1 gene, confer susceptibility to IDDM. This report, based on extensive oligonucleotide dot blot hybridization of PCR-amplified DQA1 and DQB1 genes, reinforces the importance of the Asp57-negative DQ beta chain, but also introduces the possibility that a DQ alpha chain bearing an arginine in position 52 (Arg52) confers susceptibility to IDDM. A molecular model of susceptibility to IDDM is proposed. This model strongly suggests that the disease susceptibility correlates quantitatively with the expression at the cell surface of a heterodimer, composed of a DQ alpha-chain bearing an Arg52 and a DQ beta chain lacking an Asp57. In view of the respective positions of the two residues and their charge, we might anticipate that both residues DQ beta Asp57 and DQ alpha Arg52 are critical for modulation of susceptibility, presumably via viral-antigenic peptide and/or autoantigen presentation.

Conscious-sedation analgesia during craniotomy for intractable epilepsy: a review of 354 consecutive cases

The perioperative records of 354 consecutive patients undergoing craniotomy for surgical treatment of intractable epilepsy performed with conscious-sedation analgesia were reviewed retrospectively. There was no perioperative morbidity or mortality identified which could be attributed to the anaesthetic technique. The technique was not suitable for seven patients, in whom general anaesthesia was induced. The most frequent intraoperative problems were convulsions (16 per cent) and nausea and vomiting (eight per cent). Less frequent problems included excessive sedation (three per cent), "tight brain" (1.4 per cent) and local anaesthetic toxicity (two per cent). This study confirms that conscious-sedation analgesia provides suitable conditions for craniotomies when brain mapping is required.

Removal of the 33, 23 and 18 kDa extrinsic proteins of photosystem II by sulfite treatment at alkaline pH

We found that sulfite incubation of photosystem II submembrane fractions can induce selective depletion of the 18, 23 and 33 kDa polypeptides of the PSII oxygen evolving complex. When the sulfite treatment was done at pH 8.0, the 18 and 23 kDa proteins were removed efficiently from the PSII oxygen evolving complex. Under the same conditions, the 33 kDa subunit remained bound (even when 2 M sodium sulfite was used). However, in more alkaline conditions (pH 9.8), we show extensive removal of the 33 kDa in the presence of a low sulfite concentration (50 mM). The different extraction affinity for the 18, 23 and 33 kDa of the photosystem II complex was interpreted to mean that the 33 kDa polypeptides are bound to photosystem II by both electrostatic and hydrogen bonding forces.

Outflow resistance measurement during infrainguinal arterial reconstructions: a reliable predictor of limb salvage

Criteria for abandoning infrainguinal arterial reconstructions in favor of major amputations should include reliable predictors not only of graft patency, but more importantly, of limb salvage. To evaluate the efficacy of intraoperative outflow resistance measurements in predicting limb salvage after infrainguinal bypasses, we have reviewed 134 such operations (64 femoropopliteal and 70 femorodistal bypasses) performed for critical ischemia. Outflow resistance measurements were divided into quartiles for femoropopliteal bypasses (Group A 0.17 mm Hg/ml/min or less, Group B 0.18 to 0.24 mm Hg/ml/min, Group C 0.25 to 0.4 mm Hg/ml/min, and Group D greater than 0.4 mm Hg/ml/min) and femorodistal bypasses (Group A 0.4 mm Hg/ml/min or less, Group B 0.4 to 0.58 mm Hg/ml/min or less, Group C 0.6 to 1 mm Hg/ml/min, and Group D 1 mm Hg/ml/min or greater). One year limb salvage rates for patients who underwent femoropopliteal bypass were 95 percent, 92 percent, 87 percent, and 67 percent from the lowest to the highest quartile (difference not statistically significant), and for those who had femorodistal bypass, they were 51 percent, 75 percent, 48 percent, and 0, respectively (p less than 0.05). Interestingly, 12 month graft patency and limb salvage rates for patients who underwent femorodistal bypass with outflow resistances between 0.59 and 1 mm Hg/ml/min did not correlate well (22 percent and 48 percent, respectively), whereas for those with outflow resistance greater than 1 mm Hg/ml/min, they were 22 percent and 22 percent, respectively. Thus, measurement of intraoperative outflow resistance is a very accurate predictor of limb salvage after infrainguinal bypass operations.

Intraoperative outflow resistance as a predictor of late patency of femoropopliteal and infrapopliteal arterial bypasses

To evaluate the efficacy of intraoperative outflow resistance (OR) measurements in predicting late graft patency rates (PR) for femoropopliteal (FP) and femoroinfrapopliteal (FD) bypasses, we have reviewed 134 such cases performed during the past 3 years at our institution. Of these, 64 bypasses were FP (13 autogenous saphenous vein [ASV] and 51 polytetrafluoroethylene [PTFE]) and 70 were FD (43 ASV and 27 PTFE). Total and distal OR measurements (measured in millimeters of mercury per milliliter per minute) were divided into four groups each for all infrainguinal bypasses combined and for FP and FD bypasses separately. The relationship of PR to total and distal OR measurements were analyzed according to the product limit method. Overall 1- and 2-year PRs were 64% and 56%, respectively. For FP bypasses the same PRs were 78% and 67% whereas for FD bypasses, they were 52% and 45%, respectively. The 1-year PRs for FP and FD bypasses within each respective OR group were analyzed. For FP bypasses in the lowest to the highest total OR groups, the 1-year PRs were 86%, 75%, 78%, and 62% (NS), and for FD bypasses they were 72%, 89%, 23%, and 22% (p less than 0.001). Similar trends were observed when distal OR measurements were analyzed. For infrainguinal PTFE bypasses, both total and distal OR measurements were significant predictors of patency, whereas for those with ASV only distal OR measurements were predictive. These data reaffirm our early experience with OR measurements. Although a trend for predicting graft patency was noted for FP bypasses, OR measurements were highly predictive only for FD bypasses.

Components of outflow resistance and their correlation with graft patency in lower extremity arterial reconstructions

We have used a simple reproducible method to measure total outflow resistance (OR) and its proximal and distal components in 101 bypasses (46 femoropopliteal [FP] and 55 femorodistal [FD]). All bypasses with a distal OR greater than 1.2 mm Hg/ml/min failed within 3 months and all with distal OR less than 1.2 mm Hg/ml/min remained patent for at least 3 months. To evaluate the contribution of vasospasm to OR and its role in graft failure, 60 bypasses (29 FP, 31 FD) had OR measurements before and after local infusion of papaverine hydrochloride (60 mg). Within 3 months, nine grafts (all FD) occluded and 51 remained patent. All nine failures had distal OR greater than 1.2 mm Hg/ml/min before papaverine infusion. After infusion, the mean percentage decrease in both total and distal OR for all grafts was 30% and 31%, respectively. However, there was no significant difference between these papaverine-induced decreases in OR and 3-month graft failure or success. Moreover, in three bypasses, even though papaverine lowered the distal OR from greater than 1.2 to less than 1.2 mm Hg/ml/min, early occlusion occurred. In six grafts (1 FP, 5 FD) when total and distal OR before and after papaverine was greater than 1.2 mm Hg/ml/min, the graft was extended to a second distal artery as a sequential bypass. These six grafts have remained patent over 3 months. Thus measurement of OR and particularly distal OR is a most accurate predictor of early graft success or failure. Pharmacologic manipulation does not enhance the predictive value of the OR measurement. OR measurements also help to select those FD bypass cases in which extension to a second distal artery as a sequential bypass improves patency.

Quantitative assessment of outflow resistance in lower extremity arterial reconstructions

Graft patency is thought to correlate with resistance in the runoff bed or outflow resistance. However, accurate measurement of this parameter has been difficult. A simple and reproducible method for direct measurement of outflow resistance following completion of the distal anastomosis of a bypass graft has been developed. This method employs injection of a fixed amount of normal saline through the proximal end of the graft and measurement of the resulting integrated pressure increment by an analog computer. Division of this pressure integral by the volume injected is a measure of the outflow resistance expressed in resistance units (mm Hg/ml/min). The median outflow resistance in 31 femoropopliteal bypasses was 0.29 units with a range of 0.08-1.38 units. The median outflow resistance in 33 femorodistal bypasses was 0.7 units with a range of 0.18-2.34 units. All bypasses with an outflow resistance of 1.1 units or less remained patent for 3 months. There were 51 grafts in this group (30 femoropopliteal; 21 femorodistal) and their outflow resistance ranged from 0.08 to 1.1 units. All bypasses with an outflow resistance of 1.2 units or higher thrombosed within the first postoperative month. There were 13 grafts in this group (1 femoropopliteal; 12 femorodistal) and their outflow resistance ranged from 1.2 to 2.38 units. Eight of the 13 grafts that failed originally were subjected to thrombectomy, which was uniformly unsuccessful. Although this method does not yet allow bypass surgery to be denied to any patient, it does define a group of patients in whom thrombectomy will not be effective and should not be attempted.(ABSTRACT TRUNCATED AT 250 WORDS)

Anaesthetic considerations in percutaneous radiofrequency coagulation of the Gasserian ganglion

This study determined the cardiovascular effects of percutaneous radiofrequency coagulation of the Gasserian ganglion, performed under neuroleptanalgesia and intermittent ultrashort-acting barbiturate anaesthesia. Twelve ASA physical status class II patients were studied. Highly significant increases in mean heart rate and arterial blood pressure followed the insertion of the cannula electrode into the Gasserian ganglion (p less than 0.001). In six randomly assigned patients severe tachycardia and hypertension also accompanied the progress of the thermal lesion (p less than 0.0001). Three patients developed premature ventricular contractions, and two developed significant ST segment depression. Intravenous nitroglycerin, used during current generation, successfully controlled the hypertensive response in the other six patients. In percutaneous thermocoagulation of the Gasserian ganglion the patient's co-operation is essential. In addition to providing suitable operating conditions for both surgeons and patient, we should also be able to maintain normal and stable cardiovascular haemodynamics. Intravenous nitroglycerin used as an adjunct to light general anaesthesia safely maintained intraoperative normotension. It is also suggested that patients with coronary artery disease be adequately monitored and protected during the procedure.