The flow-cytometry-based evaluation of cellular immunity in cases of cutaneous leishmaniasis and healthy controls from the endemic area in southern Israel

Only limited data are available on the early immunological events associated with human cutaneous leishmaniasis (CL). In this study, peripheral-blood mononuclear cells were obtained from 66 individuals (34 patients with cutaneous lesions and 32 apparently healthy controls) who had each spent no more than 3 months in the endemic region of Qetzioth, in southern Israel. These cells' responses to Leishmania major antigen were then explored, by the flow-cytometry-based evaluation of blast transformation (BT). The lymphocytes from 17 (50%) of the patients but only one (3%) of the controls displayed BT. When, in an ELISA, most (52) of the subjects were checked for anti-L. major antibodies, none of the 22 controls investigated but 19 (63%) of the 30 patients were found seropositive. Although 14 (47%) of the 30 patients who were checked for antibodies were BT-positive, the seropositive patients were not significantly more or less likely to be BT-positive than the seronegative patients (P<0.919). These data indicate that, in CL, the hosts' cellular and humoral responses develop independently within the first 3 months post-infection, but further investigation is required to confirm this hypothesis.

Atrophy rate in medial temporal lobe during progression of Alzheimer disease

OBJECTIVE

To establish the progression of brain atrophy rates in patients with a known date of onset of Alzheimer disease (AD).

METHODS

Each of 18 subjects had two high-resolution T1-weighted three-dimensional MRI examinations. The two MRIs were coregistered and the annual rate of brain tissue atrophy was derived both for the entire brain and regionally for the left and right medial temporal lobe (MTL). Time since onset (TSO) of AD, defined as the interval between the date of onset and the midpoint of MRI dates, ranged from -2.9 to 4.2 years.

RESULTS

In patients with AD, TSO was a correlate of the atrophy rate for both the left MTL (R2 = 0.58, p = 0.001) and right MTL (R2 = 0.30, p = 0.03). When serial measurements were applied to a control group of 21 cognitively normal elderly subjects, MTL atrophy rate classified the group membership (AD vs normal cognition) with an accuracy of 92.3%.

CONCLUSION

Increased annual atrophy rate in the medial temporal lobe is a potential diagnostic marker of the progression of Alzheimer disease.

Treatment policies among Israeli specialists in paediatric dentistry

AIM

This was to evaluate some suggested diagnostic procedures, treatment policies and professional attitudes of specialists in paediatric dentistry, in light of the periodically published guidelines by The American Academy of Pediatric Dentistry, The European Academy of Paediatric Dentistry and The British Society of Paediatric Dentistry.

METHODS

Using a structured questionnaire, 67% of the Israeli specialists in paediatric dentistry, who agreed to participate in this study, were personally interviewed.

RESULTS

Only 7.5% of the participants reported that they carry out pulp capping of primary teeth in cases of pulp exposure. Over 50% reported restoring teeth after pulpotomy with preformed crowns. Most indicated sealing pit and fissures after considering depth and morphology of the fissures and correlation with the patient's risk to caries. Cleaning teeth after eruption of the first tooth was suggested by 75.5% of the participants. A striking majority (96%) claimed that they restored permanent anterior teeth with composite resins and most used these materials for occlusal restoration in both primary and permanent posterior teeth. Most specialists advocated the use of amalgam in proximal posterior restorations. The presence of a parent in the operatory/surgery was preferred by 85% of the dentists.

CONCLUSIONS

Israeli specialists in paediatric dentistry mostly comply with the mentioned guidelines. Further studies of this nature should also be encouraged in other countries to emphasize the importance of monitoring compliance with established and evidence based guidelines.

Hemodynamic effects of spinal anesthesia and simultaneous intravenous bolus of combined phenylephrine and ephedrine versus ephedrine for cesarean delivery

BACKGROUND

Hypotension following spinal anesthesia for cesarean delivery can produce adverse maternal symptoms and neonatal acid-base effects. Single-agent prophylaxis, most notably with ephedrine, does not reliably prevent spinal anesthesia-induced hypotension; recently, however, the prophylactic use of phenylephrine with ephedrine as an infusion was observed to be effective. We postulated that this combination, when given as an intravenous bolus for prophylaxis and rescue treatment, could be similarly effective.

METHOD

Forty-three term parturients were randomized to receive a bolus of ephedrine 10 mg +/- phenylephrine 40 microg (groups E and EP, respectively) simultaneously with spinal anesthesia. Hypotension was defined as a systolic blood pressure below 100 mmHg or a decrease of 20% from a baseline value. Rescue boluses comprised of ephedrine 5 mg +/- phenylephrine 20 microg.

RESULTS

For groups E and EP, respectively, the incidence of hypotension was 80% vs. 95% (P=0.339), with the mean number of rescue boluses being 3.85+/-3.7 and 3.05+/-1.7 and the mean umbilical artery pH being 7.246+/-0.081 vs. 7.244+/-0.106. All comparisons were not significant (NS).

CONCLUSION

The combination of ephedrine and phenylephrine given as an intravenous bolus at the doses selected is not superior to ephedrine alone in preventing or treating hypotension in healthy parturients undergoing cesarean delivery.

The integrity of cholesterol-enriched microdomains is essential for the constitutive high activity of protein kinase B in tumour cells

A deregulated activity of PKB/Akt (where PKB stands for protein kinase B) renders tumour cells resistant to a variety of apoptosis-inducing stimuli. Elucidation of the mechanisms responsible for this deregulation is of prime importance for the development of novel anti-cancer drugs. Results of the present study demonstrate that the constitutive activity of PKB/Akt in B16BL6 melanoma cells depends on the integrity of cholesterol-enriched membrane microdomains, since the exposure of cells to cholesterol-depleting agents decreases the phosphorylation of this enzyme, with no change in its total protein level. Inhibitors of Hsp90 (heat-shock protein 90) decreased phosphorylation of PKB/Akt with a similar pattern. Dephosphorylation of the enzyme, as a consequence of raft disintegration, could be precluded by inhibition of serine/threonine (but not tyrosine) phosphatases. Our results imply that destabilization of lipid rafts seemingly affects the association of Hsp90 with the respective serine/threonine phosphatases, thereby increasing the accessibility to PKB/Akt to deactivating phosphatases. We have found recently that reconstituted expression of H-2K class I glycoproteins in class I-deficient B16BL6 cells also decreases the phosphorylation of PKB/Akt. Therefore it is possible that raft-associated regulation of this important enzyme involves both H-2K glycoproteins and Hsp90.

MRI and CSF studies in the early diagnosis of Alzheimer's disease

The main goal of our studies has been to use MRI, FDG-PET, and CSF biomarkers to identify in cognitively normal elderly (NL) subjects and in patients with mild cognitive impairment (MCI), the earliest clinically detectable evidence for brain changes due to Alzheimer's disease (AD). A second goal has been to describe the cross-sectional and longitudinal interrelationships amongst anatomical, CSF and cognition measures in these patient groups. It is now well known that MRI-determined hippocampal atrophy predicts the conversion from MCI to AD. In our summarized studies, we show that the conversion of NL subjects to MCI can also be predicted by reduced entorhinal cortex (EC) glucose metabolism, and by the rate of medial temporal lobe atrophy as determined by a semi-automated regional boundary shift analysis (BSA-R). However, whilst atrophy rates are predictive under research conditions, they are not specific for AD and cannot be used as primary evidence for AD. Consequently, we will also review our effort to improve the diagnostic specificity by evaluating the use of CSF biomarkers and to evaluate their performance in combination with neuroimaging. Neuropathology studies of normal ageing and MCI identify the hippocampal formation as an early locus of neuronal damage, tau protein pathology, elevated isoprostane levels, and deposition of amyloid beta 1-42 (Abeta42). Many CSF studies of MCI and AD report elevated T-tau levels (a marker of neuronal damage) and reduced Abeta42 levels (possibly due to increased plaque sequestration). However, CSF T-tau and Abeta42 level elevations may not be specific to AD. Elevated isoprostane levels are also reported in AD and MCI but these too are not specific for AD. Importantly, it has been recently observed that CSF levels of P-tau, tau hyperphosphorylated at threonine 231 (P-tau231) are uniquely elevated in AD and elevations found in MCI are useful in predicting the conversion to AD. In our current MCI studies, we are examining the hypothesis that elevations in P-tau231 are accurate and specific indicators of AD-related changes in brain and cognition. In cross-section and longitudinally, our results show that evaluations of the P-tau231 level are highly correlated with reductions in the MRI hippocampal volume and by using CSF and MRI measures together one improves the separation of NL and MCI. The data suggests that by combining MRI and CSF measures, an early (sensitive) and more specific diagnosis of AD is at hand. Numerous studies show that neither T-tau nor P-tauX (X refers to all hyper-phosphorylation site assays) levels are sensitive to the longitudinal progression of AD. The explanation for the failure to observe longitudinal changes is not known. One possibility is that brain-derived proteins are diluted in the CSF compartment. We recently used MRI to estimate ventricular CSF volume and demonstrated that an MRI-based adjustment for CSF volume dilution enables detection of a diagnostically useful longitudinal P-tau231 elevation. Curiously, our most recent data show that the CSF isoprostane level does show significant longitudinal elevations in MCI in the absence of dilution correction. In summary, we conclude that the combined use of MRI and CSF incrementally contributes to the early diagnosis of AD and to monitor the course of AD. The interim results also suggest that a panel of CSF biomarkers can provide measures both sensitive to longitudinal change as well as measures that lend specificity to the AD diagnosis.

Single dermatome analgesia sparing in an obstetric patient following previous radiation to that region

We present a case of an obstetric patient with prior radiation therapy for Hodgkins lymphoma to the right hip, right flank region and lumbar spine, who suffered persistent right sided L1 dermatone distribution sensory and analgesia sparing after routine epidural placement despite additional boluses of local anesthetic. We postulate that the previous radiation therapy received by our patient left sufficient epidural fibrosis as a barrier to prevent spread of local anesthetic to cover the L1 dermatome. Subsequent replacement, using a combined spinal-epidural technique at a higher lumbar space, overcame this obstruction. In patients who have received substantial radiation therapy to the lumbosacral region in the past, awareness of this potential problem may assist in clinical management.

Long-term safety and tolerability of tadalafil in the treatment of erectile dysfunction

OBJECTIVE

To assess the long-term safety and tolerability of tadalafil for patients with erectile dysfunction (ED).

PATIENTS AND METHODS

This was a multicentre, open-label, 24-month extension trial involving 1173 men with ED. The mean age was 57 (range 23-83) years and 74.8% of patients were taking concomitant medications for comorbid conditions, including diabetes mellitus in 30.5% of men and hypertension in 29.5%. These patients had participated in 1 of 5 previous 8-week or 12-week randomised, double-blind, placebo-controlled tadalafil studies. In the present trial, the starting 10mg dose of tadalafil could be increased to 20mg if the patient could not achieve satisfactory intercourse or reduced to 5mg for an adverse event that was persistent, intolerable and judged by the investigator to be related to tadalafil.

RESULTS

Four hundred ninety-three (42.0%) men completed 24 months of treatment. In addition, a further 234 (19.9%) completed 18 months of treatment due to a sponsor decision to reduce the study duration. The total tadalafil exposure was 1676.0 patient-years. Tadalafil was safe and well tolerated. Headache (15.8%), dyspepsia (11.8%), nasopharyngitis (11.4%), and back pain (8.2%) were the most common treatment-emergent adverse events. The rate of discontinuations due to adverse events for this 18-24-month study was 6.3% and the rate for any individual event was <1%. Serious adverse events occurred in 8.6% of patients. No consistent pattern of serious adverse events assessed as causally associated with tadalafil administration was observed. None of the four deaths that occurred during the study was assessed as tadalafil related. There were no clinically significant laboratory or electrocardiographic findings or changes in vital signs in mean baseline-to-endpoint analysis attributable to tadalafil. Tadalafil administration was not causally associated with drug-induced hepatotoxicity, neutropenia, thrombocytopenia, or renal dysfunction.

CONCLUSION

Tadalafil at doses of 5, 10, or 20mg taken as needed up to once daily for 18 to 24 months was safe and well tolerated. These findings support the long-term use of tadalafil in the clinical management of erectile dysfunction.

The significance of the degree of myometrial invasion in patients with stage IB endometrial cancer

OBJECTIVE

To study the validity of the FIGO staging classification of endometrial cancer Stage IB by correlating degree of myometrial invasion depth with outcome measures.

STUDY DESIGN

Fifty patients with endometrial adenocarcinoma FIGO Stage IB who underwent hysterectomy between 1989 and 2001 were divided into two groups according to depth of myometrial invasion. The first group comprised of 31 patients with myometrial invasion of less than or equal to one-third. The second group included 19 patients with invasion greater than one-third but less than one-half. The two groups were compared with regard to prognostic factors and outcome measures.

RESULTS

The overall 5-year recurrence-free survival, disease specific survival and overall survival rates were 87%, 94% and 77%, respectively. These outcome measures did not vary significantly between the two groups. There were no statistically significant differences between the two groups with regard to the following parameters: duration of follow-up, age, proportion of patients who underwent complete surgical staging and postoperative adjuvant radiotherapy. Histologic parameters of the two groups, such as histological type, grade and proportion of patients with capillary space-like involvement and lower uterine segment involvement were not significantly different.

CONCLUSIONS

In patients with Stage IB endometrial cancer the amount of myometrial invasion defined as less than one third compared with invasion greater than one third does not appear to correlate with their outcome, thus validating the FIGO staging system.

Non-immune functions of MHC class I glycoproteins in normal and malignant cells

MHC class I glycoproteins play a pivotal role in the regulation of immune responses by presenting antigenic peptides to cytotoxic T lymphocytes and by regulating cytolytic activities of natural killer cells. Cells originating in malignant tumours are often characterized by a profound immune escape phenotype. This phenotype is frequently associated with alterations in MHC class I-related antigen processing and presentation that enable tumours to escape immune surveillance. However, it now becomes clear that MHC class I molecules do not only provide a mechanistic framework for the presentation of antigenic peptides but, rather, possess broader biological functions due to their ability to regulate cell-to-cell communication and receptor-mediated trans-membrane signal transduction. In the present review we made an attempt to reevaluate the significance of an altered MHC class I phenotype for tumour progression in view of the current state of knowledge concerning the aforementioned non-immune functions performed by these membrane glycoproteins.

Vaccines against bacterial meningitis

Meningitis remains an important cause of morbidity and mortality among children >5 years of age and is especially prevalent in developing countries. Effective routine immunization against Hib, pneumococcus and serogroupC meningococcus has had a significant impact on both invasive disease and carriage caused by these encapsulated bacteria. The major challenge in prevention of meningitis remains the delivery of vaccines worldwide, especially to resource-poor regions with the greatest disease burden.

The future of meningitis vaccines

Without effective vaccines meningitis remains a substantial worldwide threat with major health-care implications. A number of advances have been made in vaccine design and implementation over the last decade, with new vaccine initiatives providing substantial promise for the future reduction of global disease burden.

Inner ear damage in children due to noise exposure from toy cap pistols and firecrackers: a retrospective review of 53 cases

This retrospective study presents the findings of inner ear damage documented in 53 children exposed to impulsive sound emitted by toy weapons and firecrackers. There were 49 boys and four girls aged between four and fourteen years. Thirty-nine children were affected unilaterally while fourteen had bilateral hearing loss (total of 67 ears). Most of the hearing loss (>70%) was sensorineural high frequency hearing loss, while only nine out of the 67 injured ears had sensorineural mid frequency hearing loss. Seven children sustained a traumatic ear drum perforation. Dizziness or tinnitus was reported by twenty children, with pathological ENG findings in four of them. This paper re-emphasizes the possibility of inner ear damage in children from exposure to noisy toys.

Longitudinal cerebrospinal fluid tau load increases in mild cognitive impairment

Cross-sectional cerebrospinal fluid (CSF) levels of tau and amyloid (A) beta (beta) are of diagnostic importance for Alzheimer's disease (AD) and mild cognitive impairment (MCI). However, most longitudinal studies of tau fail to demonstrate progression. Because predominantly brain-derived proteins such as tau, have higher ventricle to lumbar ratios, we hypothesized that adjusting for the ventricular enlargement of AD would correct for the dilution of tau, and improve detection of longitudinal change. Abeta which is not exclusively brain derived, shows a ratio <1, and no benefit was expected from adjustment. In a 1 year longitudinal study of eight MCI and ten controls, we examined CSF levels of hyperphosphorylated (P) tau231, Abeta40, and Abeta42. In cross-section, MCI patients showed elevated Ptau231 and Abeta40 levels, and greater ventricular volumes. Longitudinally, only after adjusting for the ventricular volume and only for Ptau231, were increases seen in MCI. Further studies are warranted on mechanisms of tau clearance and on using imaging to interpret CSF studies.

Treatment of obstetric hemorrhage with recombinant activated factor VII (rFVIIa)

Recombinant activated factor VII (rFVIIa, NovoSeven) was used in three patients with massive obstetric hemorrhage due to placenta previa accreta, rupture of the uterus and pre-eclampsia with HELLP. Administration of the drug markedly decreased the bleeding and enabled control of the hemorrhage. rFVIIa seems to be an adjunctive hemostatic measure for the treatment of severe obstetric hemorrhage.

Transcutaneous electrical nerve stimulation does not augment epidural labor analgesia

STUDY OBJECTIVE

To evaluate whether transcutaneous electrical nerve stimulation (TENS) can increase the quality and duration of an initiation dose of bupivacaine used for the establishment of epidural labor analgesia.

DESIGN

Randomized, double-blind study.

SETTING

Tertiary-care academic medical center.

PATIENTS

40 ASA physical status I and II parturients in early, active spontaneous labor with a singleton, vertex term fetus, and requesting analgesia.

INTERVENTIONS

A standardized epidural technique with either an active or inactive TENS unit was performed. Before epidural placement, TENS intensity thresholds were determined with electrodes placed over the paraspinus muscles at T(10)-L(1), and S(2)-S(4); TENS settings for mode, cycle, and pulse width were standardized.

MEASUREMENTS

Data were collected at timed intervals on pain as measured by visual analog scale (VAS), sensory level (pinprick), motor blockade (Bromage score), cervical dilation, and duration of analgesia.

MAIN RESULTS

The duration of analgesia produced by the initial dose of epidural bupivacaine did not differ between groups (TENS turned off 82.3 +/- 26 [mean +/- SD] vs. TENS activated 80.7 +/- 40 min, p = 0.88). Kaplan-Meier survival analysis and Mantel-Cox log rank analysis showed no difference between the two treatments (p = 0.75). No difference in the quality of analgesia was observed between the two groups.

CONCLUSIONS

In healthy laboring parturients, the application of a TENS unit did not alter the quality or duration of an initiation dose of bupivacaine utilized for the establishment of epidural labor analgesia.

The effects of maternal and fetal parameters on the quality of nuchal translucency measurement

OBJECTIVE

To evaluate the influence of maternal and fetal parameters on the quality of fetal nuchal translucency measurement.

DESIGN

This was a prospective study in 227 consecutive pregnant women undergoing nuchal translucency screening by transabdominal sonography. The same well-qualified sonographer performed all the scans and in each case the best-quality image was selected and scored according to an image scoring system (total maximum score, 9). The quality of the image was examined in relation to maternal age, weight, abdominal wall thickness, amniotic sac diameter, posterior uterine wall depth (distance between abdominal wall surface and posterior uterine wall surface), placental location, fetal crown-rump length and nuchal translucency thickness. Correlation coefficients were calculated and stepwise linear regression was used to adjust for confounders and to define the predictors for image score.

RESULTS

The only two parameters that provided a significant independent contribution to the prediction of the image score were posterior uterine wall depth and fetal crown-rump length. Intravariable analysis of these two parameters demonstrated that the cut-off associated with a significant change in the image quality was 80 mm for posterior uterine wall depth (score difference, 1.06; P < 0.001) and 70 mm for crown-rump length (score difference, 0.77; P = 0.001). In the group of women with two values above these cut-off points, an average score decrease of 1.90 (P < 0.001) was observed.

CONCLUSIONS

The quality of fetal nuchal translucency measurement is poorer when the fetal crown-rump length is > 70 mm and the posterior uterine wall depth is > 80 mm.

Adrenocortical oncocytoma in pregnancy

BACKGROUND

Adrenal oncocytomas are uncommon, nonfunctioning tumors occurring most often in endocrine organs.

CASE

A 32-year-old woman presented at 25 weeks' gestation complaining of right flank pain. Abdominal ultrasonography and computed tomography revealed a 9 x 10-cm solid right-sided adrenal mass. Endocrine evaluation was normal. At 36 weeks' gestation, she underwent cesarean followed by resection of the adrenal mass. Histopathologic and ultrastructural studies revealed a benign adrenocortical oncocytoma.

CONCLUSION

Although rare, adrenocortical oncocytomas should be included in the differential diagnosis of solid, nonfunctioning, adrenal tumors in pregnancy.

Proton magnetic resonance spectroscopy of brain metabolites in galactosemia

Brain edema may occur in infants with galactosemia and has been associated with accumulation of galactitol. Proton magnetic resonance spectra were obtained from 12 patients (four newly diagnosed neonates and eight patients on galactose-restricted diets, age range 1.7-47 years) and control subjects to measure brain galactitol levels in vivo and correlate them with urinary galactitol excretion. The results demonstrate that a markedly elevated brain galactitol level may be present only in newborn infants with galactosemia who exhibit massive urinary galactitol excretion.

Oxidation of galactose by galactose-1-phosphate uridyltransferase-deficient lymphoblasts

The ability of EB virus-transformed lymphoblasts with undetectable galactose-1-phosphate uridyltransferase (GALT) from 15 galactosaemic patients to oxidize [1-(14)C]galactose to 14CO2 was compared to that of cells from 7 normal subjects. The oxidation of galactose but not of glucose was markedly diminished by cells from Q188R homozygous galactosaemic patients but was not absent. After 2.5 h these cells liberated 14CO2 at nearly 3% and at 5 h up to 9% of normal. Cells from patients homozygous for the S135L mutation produced much larger amounts of 14CO2 (15-17% of normal) and were distinguishable from the Q188R homozygous cells. A cell line with a homozygous deletion of the GALT gene oxidized galactose at 7% of the normal rate, suggesting that pathways(s) other than GALT exist in these cells as well as Q188R homozygous cells for oxidation of galactose to CO2. Concentration dependence studies are consistent with the presence of a pathway that is unsaturable or has a very high Km The ability of 10(7) lymphoblasts with the S135L genotype to oxidize more than 7% of the sugar to 14CO2 in 5 h suggests the presence of residual GALT despite the inability to detect the activity by enzymatic analysis.

Sweeping of membranes vs. intracervical prostaglandin E2 gel for cervical ripening. Randomized trial

OBJECTIVE

To compare intracervical prostaglandin E2 gel and membrane sweeping for cervical ripening.

STUDY DESIGN

Fifty patients were randomized to either intracervical prostaglandin E2 or membrane sweeping. A Bishop score was assigned by a blinded examiner prior to and 24 hours following the procedure.

RESULTS

The Bishop scores assigned 24 hours after prostaglandin instillation and membrane sweeping were not significantly different (3.4, SE 0.42, vs. 3.3, SE 0.37, respectively; P > .05). The proportions of women entering active labor or delivering within 24 hours were similar in the prostaglandin and membrane groups (21% and 19%, respectively; P > .05).

CONCLUSION

When both intracervical prostaglandin insertion and membrane sweeping are feasible, their salutary effects are comparable.

[Prenatal Down's syndrome screening at 10-14 weeks gestation using the combined nuchal translucency and maternal serum biochemistry: preliminary results of the first 358 cases]

We report our preliminary experience of prenatal screening for Down's syndrome (DS) using nuchal translucency (NT) measurement combined with the serum biochemistry analysis of Free beta-human chorionic gonadotropin (F beta hCG) and pregnancy associated plasma protein A (PAPP-A) all measurement at 10-14 weeks of gestation. Of the 358 parturient women which enrolled in the study, 9 cases were not included because of fetal anomalies or miscarriages. Thus the study group included 349 singleton pregnancies in which complete prenatal and infant follow-up was available. Forty-four pregnant women were found to be screen positive (12.6%) and in 13 cases (27%) of them fetal chromosomal aneuploidies were diagnosed. Looking into the markers profile we found that the NT was a sensitive marker which was abnormally increased in all the fetal aneuploidies. Serum F beta hCG was found to be a promising marker as well, being significantly elevated (2.26 +/- 0.86 multiple of the medians, MoM) in DS cases, and decreased (< 0.5 MoM) in two cases of Edward's syndrome. On the contrary, PAPP-A was found less sensitive, and its mean MoM values were not significantly different between DS versus euploid fetuses. Our preliminary results support the promising success of DS screening using NT and F beta hCG.

Preoperative CA-125 level as a predictor of non optimal cytoreduction of advanced epithelial ovarian cancer

BACKGROUND

Suboptimal cytoreduction of advanced ovarian cancer is related to initial tumor bulk which correlates with CA125 level.

METHODS

Retrospective record study of 40 patients with stage III ovarian cancer. The ability of a CA125 threshold level of 500 U/mL to predict suboptimal cytoreduction was determined.

RESULTS

Twenty-four (60%) of the patients were optimally cytoreduced. At the CA125 cut off level of 500 U/mL the sensitivity for predicting suboptimal debulking was 62% and specificity was 83%. Above a CA 125 level of 1500 U/mL none of the patients were optimally cytoreduced.

CONCLUSIONS

More data are needed to determine the CA125 cut off level at which the standard approach of initial laparotomy and cytoreduction may be modified.

Thyroglossal duct cyst: is thyroid scanning necessary in the preoperative evaluation?

BACKGROUND

Evaluation of thyroglossal duct cysts before surgical excision traditionally includes hormonal evaluation, ultrasound of the neck, and thyroid scanning.

OBJECTIVE

To evaluate the need for thyroid scanning in cases of thyroglossal duct cysts scheduled for operation.

METHODS

A retrospective chart review of 100 cases of thyroglossal duct cyst between 1988 and 1995 was carried out.

RESULTS

No cases of ectopic thyroid were detected.

CONCLUSION

Our goal was to document the presence of normal thyroid tissue by non-invasive tools such as ultrasound, rather than to rule out the existence of ectopic thyroid tissue by radionuclide scanning. Radionuclide scanning is justified in cases of lingual thyroid and where a normally located thyroid gland cannot be detected.

Galactose metabolism in normal human lymphoblasts studied by (1)H, (13)C and (31)P NMR spectroscopy of extracts

The development of tools to follow and quantitate the fate of galactose in mammalian cells is crucial to the study and understanding of the inherited disorders of galactose metabolism. In this study we incubated normal human lymphoblasts with 1- or 2-(13)C galactose for 2.5 or 5 h and prepared TCA extracts of the cells. The various galactose metabolites were identified and quantified using a combination of proton, carbon and phosphorus NMR spectra. Galactose-1-phosphate (gal-1P), uridine diphosphogalactose, uridine diphosphoglucose and galactitol were present in the extracts. Average levels for gal-1P were around 10 nmol/mg protein and for uridine diphosphoglucose, uridine diphosphogalactose and galactitol in the range of 0.5-2 nmol/mg protein. Galactonate was never found in any conditions. Percentage labeling could be estimated for gal-1P and for the ribose carbons of AMP. The labeling agrees with a conversion of galactose to glucose through the Leloir pathway.

Hyperacusis: Review and Clinical Guidelines

OBJECTIVE

To review the current known causes of hyperacusis and the different hypotheses concerning its etiology, and to suggest clinical guidelines.

DATA SOURCE

A review of the literature with the aid of the MEDLINE database, using the following key words: hyperacusis, intolerance to sound, loudness discomfort level, and phonophobia.

DATA EXTRACTION

The data collected included clinical studies, case reports and laboratory studies.

CONCLUSION

Hyperacusis was shown to be caused by pathologic conditions of the peripheral auditory system, diseases of the central nervous system diseases, and hormonal and infectious diseases. In some cases there was no known cause. The pathophysiology of hyperacusis probably involves a central mechanism rather than a peripheral one. Suggested clinical guidelines and treatment are discussed.

Galactose metabolism in mice with galactose-1-phosphate uridyltransferase deficiency: sucklings and 7-week-old animals fed a high-galactose diet

Mice deficient in galactose-1-phosphate uridyltransferase (GALT) demonstrate abnormal galactose metabolism but no obvious clinical phenotype. To further dissect the pathways of galactose metabolism in these animals, galactose oxidation and metabolite levels were studied in 16-day-old sucklings and the effect of a 4 week prior exposure to a 40% glucose or 40% galactose diet was determined in 7-week-old mice. Suckling GALT-deficient (G/G) mice slowly oxidized [1-14C]galactose to 14CO2, 4.0% of the dose when fed and 7.9% when fasted compared to normal animals 38.3 and 36.4% in 4 h, respectively. Plasma of G/G sucklings contained 11.1 mM galactose and erythrocyte galactose 1-phosphate levels were 28.2 and 31.9 mg/dl packed cells. Galactose, galactitol, galactonate, and galactose 1-phosphate were found in G/G suckling mouse tissues. The tissue galactose concentrations were 10% or less of that in plasma, suggesting that there was limited cellular entry of galactose. In 7-week-old fasted mice with 4 weeks prior exposure to glucose or galactose-containing diet, 4-h oxidation was 12.9 and 15.0% of the administered radiolabeled galactose, respectively. Normal animals oxidized 33.9 and 37.9% of the dose when fed the same diets, respectively. The ability of G/G mice to oxidize galactose in the absence of GALT activity suggests the presence of alternate metabolic pathways for galactose disposition. G/G mice fed the galactose-free 40% glucose diet had erythrocyte galactose 1-phosphate levels ranging from 6.4 to 17.7 mg/dl packed cells and detectable galactose and galactose metabolites in tissues, suggesting that these animals endogenously produced galactose. The plasma of 40% galactose-fed G/G mice contained 9.1 mM galactose with red blood cell galactose 1-phosphate averaging 43.6 mg/dl. Tissues of these animals also contained high levels of galactose and galactose 1-phosphate. Liver contained over 4 micromol/g galactonate but little galactitol. Despite the elevated galactose and galactose 1-phosphate, the animals tolerated the high-galactose diet and were indistinguishable from normal animals, exhibiting no manifestations of galactose toxicity seen in human GALT-deficient galactosemia. The data suggest that high galactose 1-phosphate levels do not cause galactose toxicity and that high galactitol in combination with galactose 1-phosphate may be a prerequisite. Absence of GALT appears necessary but insufficient to produce human galactosemic phenotype.

Evidence for alternate galactose oxidation in a patient with deletion of the galactose-1-phosphate uridyltransferase gene

The persistent, dietary-independent elevation of galactose metabolites in patients with galactose-1-phosphate uridyltransferase (GALT) deficiency is probably secondary to de novo synthesis of galactose. Relatively constant steady-state levels of galactose metabolites in patients also suggest that non-GALT metabolic pathways must function to dispose of the galactose synthesized each day. The discovery of a patient with a rare deletion of the GALT gene provided a unique opportunity to examine the availability of any alternate galactose oxidative capacity both in vivo and in vitro. Utilizing genomic DNA from the patient, Southern blot data demonstrated that 10 of the 11 GALT exons were homozygously deleted. By measurement of 13CO2 in expired air for up to 24 h after an oral bolus of [1-13C]galactose, it was demonstrated that 17% of the galactose was metabolized, a value comparable to the 3-h elimination rate in a control subject. Furthermore, lymphoblasts prepared from the patient could also convert [1-14C]galactose to 14CO2. This unique study provides the first unambiguous evidence that another pathway exists in man that can be responsible for galactose disposal. Further knowledge of this alternate galactose oxidative route and its regulation may aid in formulating new strategies for the treatment of galactosemia.

Comparative pharmacokinetics of once daily intravenous and intramuscular gentamicin in patients with post partum endometritis

In patients with post partum endometritis once daily intramuscular administration of gentamicin may be convenient in certain clinical settings. However pharmacokinetic data on once daily intramuscular gentamicin are not reported. In this study 10 women with post partum endometritis were given once daily intravenous gentamicin (4 mg/kg ideal body weight) followed at a later day by a similar intramuscular dose. Gentamicin levels coincided at 30 min. Levels at 60 and 90 min were lower with the intravenous route. Further clinical studies are needed to confirm reduced nephrotoxicity and ototxicity with the intramuscular route.

The role of MHC class I glycoproteins in the regulation of induction of cell death in immunocytes by malignant melanoma cells

A deranged expression of MHC class I glycoproteins, characteristic of a variety of malignancies, contributes to the ability of cancer to avoid destruction by T cell-mediated immunity. An abrogation of the metastatic capacity of B16 melanoma cells has been achieved by transfecting an MHC class I-encoding vector into class I-deficient B16 melanoma clones [Gorelik, E., Kim, M., Duty, L. & Galili, U. (1993) Clin. Exp. Metastasis 11, 439-452]. We report here that the deranged expression of class I molecules by B16 melanoma cells is more than a mere acquisition of the capacity to escape immune recognition. Namely, cells of the B16 melanoma prompted splenic lymphocytes to commit death after coculture. However, a class I-expressing and nonmetastatic CL8-2 clone was found to be less potent as an inducer of apoptosis than class I-deficient and metastatic BL9 and BL12 clones. Both Thy1.2(+) and Thy1.2(-) splenocytes underwent cell death when exposed to the class I-deficient BL9 clone. A proportion of CD4(+) and CD8(+) cells among splenocytes exposed to the BL9 clone was lower than that observed in a coculture with cells of the CL8-2 clone. Consistently, none of the melanoma clones studied produced a ligand to the FAS receptor (FAS-L). Thus, our results provide evidence that (i) the production of FAS-L may not be the sole mechanism by which malignant cells induce apoptosis in immunocytes, and (ii) absence of MHC class I glycoproteins plays an important role in preventing the elimination of potential effector immunocytes by tumor cells.

In vivo evidence of brain galactitol accumulation in an infant with galactosemia and encephalopathy

In a newborn infant with galactose-1-phosphate uridyltransferase deficiency and encephalopathy, brain magnetic resonance imaging revealed cytotoxic edema in white matter. Using in vivo proton magnetic resonance spectroscopy, we detected approximately 8 mmol galactitol per kilogram of brain tissue, an amount potentially relevant to the pathogenesis of brain edema.

Survey of the use of intracranial pressure monitoring in children in the United Kingdom

OBJECTIVE

To establish current practice for the monitoring and management of acute intracranial hypertension in children in United Kingdom intensive care units (ICUs).

DESIGN

Postal questionnaire, targetted by prior telephone survey, to all ICUs admitting five or more children per annum with acute neurological illness.

RESULTS

Of the units contacted 70 % responded, approximately one-half of which reported the use of intracranial pressure (ICP) monitoring. Only data from these units are presented. Nearly all of these units consider monitoring following serious head injury, but its use in non-traumatic brain injury is less widespread. The decision to institute ICP monitoring is based mainly upon neuroimaging appearances and Glasgow Coma Scale score. ICP and cerebral perfusion pressure targets differ markedly between centres, with only 46 % and 65 % of units, respectively, setting age-dependent parameters. Mannitol and varying degrees of hyperventilation are employed by all units to lower ICP. The majority also use barbiturates, diuretics, and fluid restriction. Controlled hypothermia is used in 52 % of units. Paediatric units are more likely to employ age-dependent cerebral perfusion pressure targets. Specific therapies employed to lower ICP are similar to those used in adult centres.

CONCLUSION

Faced with a lack of both evidence and consensus, the management of acute intracranial hypertension in childhood varies widely. National or international guidelines for the management of children with raised intracranial pressure are needed. These should incorporate the physiological differences between children of different ages.

Nasal obstruction in the adult: is CT scan of the sinuses necessary?

OBJECTIVE

To determine whether CT (computerized tomography) scan of the paranasal sinuses is essential in the diagnosis and medical/surgical management of nasal obstruction.

DESIGN

One hundred thirteen adult patients with nasal obstruction but without signs of sinusitis who underwent CT examination prior to surgery, were included in the study.

RESULTS

Fifty seven percent of the CT scans revealed a variety of abnormal findings. Of the patients with an abnormal CT scan, surgical planning had to be altered in 16 patients due to significant abnormalities found on the CT scans.

CONCLUSIONS

We conclude that CT scan of the nose and paranasal sinuses is an effective presurgical planning tool in patients with nasal obstruction.

Thyroid hormone levels in cord blood of infants with acidemia at birth

OBJECTIVE

To study the funic thyroid hormone levels in cases were fetal distress during labor resulted in acidemia at birth.

MATERIAL AND METHODS

Arterial and venous levels of TSH, total T4, free T4 and total T3 obtained from cord blood at birth of twelve acidemic fetuses were compared with normal controls.

RESULTS

Acidemic fetuses had a significanly higher TSH levels than controls (16.5+/-2. 1 microI/dl vs. 9.6+/-1.4 microI/dl, P=0.01). Total T3 levels were significantly lower in acidemic fetuses (49.2+/-2.9 ng/dl vs. 63+/-5. 5 ng/dl, P=0.04). Total and free T4 levels were similar and there was no difference between arterial and venous levels of the hormones.

CONCLUSIONS

Birth acidemia from fetal distress during labor is associated with higher TSH levels and lower T3 levels.

Plasma galactose and galactitol concentration in patients with galactose-1-phosphate uridyltransferase deficiency galactosemia: determination by gas chromatography/mass spectrometry

The plasma concentration of galactose and galactitol was measured in 27 patients with galactose-1-phosphate uridyltransferase (GALT) deficiency galactosemia on a lactose-restricted diet, 17 infants on lactose-free formula, and 21 infants and children on a normal diet, by a newly devised isotope dilution gas chromatograph/mass spectrometry (GC/MS) method. The method was linear in the range of 0.1 to 10 micromol/L for galactose and 1 to 20 micromol/L for galactitol with good reproducibility and a coefficient of variation less than 3%. The mean plasma galactose in 15 patients who were homozygous for the most common Q188R mutation of the GALT gene was 2.72 +/- 0.70 micromol/L (mean +/- SE) with a range of 0.58 to 3.98 in specimens obtained at regular clinic visits. In 12 patients with other GALT mutations, it was 2.45 +/- 0.75 micromol/L. The mean value in nongalactosemic subjects on lactose-free formula was 0.52 +/- 0.08 micromol/L, with a range of 0.12 to 1.25. The range in 21 normal subjects without diet restriction was 0.11 to 6.33 micromol/L, with a mean of 1.48 +/- 0.32. The plasma galactitol level was 11.63 +/- 0.46 and 10.85 +/- 1.38 micromol/L in the 2 galactosemic groups. There was no relationship between plasma galactose and galactitol levels, with variable ratios of the two substances in the galactosemic patients. Galactitol was not detectable in the plasma of normal subjects. The red blood cell galactose-1-phosphate level was also measured in the galactosemic patients, and no relationship between plasma galactose and red blood cell galactose-1-phosphate was found. The galactose-1-phosphate concentration was 28 to 54 times higher than the ambient galactose. The low galactose concentration in the plasma of galactosemics on galactose-restricted diets in relation to the higher plasma galactitol and red blood cell galactose-1-phosphate is a metabolic enigma. The ability to measure plasma galactose accurately presents a new way of characterizing the galactosemic patient and the levels monitored over time may provide insight into the development of long-term complications associated with the disorder.

Pain as a mutual experience for patients, nurses and families: a perspective from New York

New York was unique among the cities included in this study. The most striking finding was that the self-described ethnic background of both nurses and patients was so varied. Many patients and nurses were born elsewhere and were nonnative speakers. The results cannot be described as cross-countries when so many nations are represented. Multinational is, perhaps, a more accurate description, but even that seems inadequate to describe a population as diverse as was this one.