Lack of predictive indices in kernicterus: a comparison of clinical and pathologic factors in infants with or without kernicterus

A review of 398 neonatal autopsies at Downstate Medical Center revealed 27 cases of kernicterus during the seven-year period from 1971 through 1977. With the current intensive care of the sick newborn, kernicterus continues to occur, mainly in premature infants with relatively low levels of serum bilirubin (mean of 11.5 mg/100 ml). To understand the factors contributing to the development of kernicterus, clinical and pathologic findings in 27 infants with kernicterus were compared to 103 "control" infants with retrospectively. Birth weight, gestational age, sex, and Apgar scores were comparable in both groups. The duration of survival was significantly shorter in infants with kernicterus than in the control infants. The clinical signs and symptoms of kernicterus were nonspecific and the premortem diagnosis of kernicterus was not suspected in most of the cases. There were no significant differences in the peak serum bilirubin values, incidence of hypothermia, hypoglycemia, convulsions, anemia, infection, use of phototherapy, transfusion and exchange transfusion in the two groups. Serum albumin values and bilirubin binding capacity measured by 2-(4-hydroxybenzeneazo)benzoic acid were significantly lower in the kernicteric group although the bilirubin-albumin molar ratio was equal in both groups. The incidences of severe acidosis and hypoxic encephalopathy were significantly higher in the kernicteric infants. In this study, acidosis, hypoxia, hypoalbuminemia, and low bilirubin binding capacity were seen more often in kernicteric infants than in control infants. However, analysis of previously suggested risk factors failed to identify any single factor or combination of factors which could be predictive to the development of kernicterus.

High frequency mechanical ventilation in severe hyaline membrane disease an alternative treatment?

Twenty-four preterm infants with respiratory failure from severe hyaline membrane disease (HMD) received mechanical ventilation at high respiratory frequencies. The average birthweight of the infants was 1244 +/- 301 g, and 7 babies weighed less than 1000 g. The average gestational age was 30 +/- 2 weeks, and 6 infants were born at 28 weeks or less. The method of ventilation included (1) respiratory frequencies of 60--110/min, sometimes with brief manual ventilation at more rapid rates, (2) peak inflation pressures (PIP) of less than 35 cm H2O, (3) inspiratory durations of 0.15--0.25 sec, (4) positive end-expiratory pressure (PEEP) of 4--9 cm H2O, and (5) weaning from mechanical ventilation by reducing tidal volume until peak inflation pressure (PIP) reached 20--25 cm H2O, whereupon respiratory frequency was decreased. PaCO2 was kept at 30--40 torr and PaO2 at 60--80 torr. Of the infants, 22 survived (92%) with few major complications.

The effect of ampicillin on oral contraceptive effectiveness

The effectiveness of oral contraceptives with concomitant use of ampicillin has been questioned. Eleven volunteer subjects were studied during 2 consecutive menstrual cycles; they were given Demulen with placebo or ampicillin during each of the cycles. Serum estradiol (E2), progesterone (P4), luteinizing hormone (LH), and follicle-stimulating hormone (FSH) were evaluated on days 13 and 19 of each cycle. Testosterone-binding globulin (TeBG) capacity and ferning of cervical mucus were evaluated on day 13 of each cycle. Subjective symptoms were recorded. All cycles appeared to be anovulatory. Steroid suppression was present in 10 of 11 patients during both cycles. Estrogen-dependent TeBG was not affected by ampicillin. It is possible that cervical mucus ferning was improved by concurrent ampicillin administration. Ampicillin appears unlikely to diminish the effectiveness of the oral contraceptive studied.

Vasoactive intestinal polypeptide in tissues of the human female reproductive tract

Vasoactive intestinal peptide (VIP) is a known potent hypotensive and vasodilatory agent. Studies were performed to determine the possible role of VIP in the human menstrual cycle in 44 patients in the reproductive age group, some of whom were using oral contraceptives, three pregnant patients, and four postmenopausal patients. No significant relationship between VIP and menstrual cycle phase was found.

Ovarian hyperandrogenism with normal and abnormal histologic findings of the ovaries

Thirty-one patients with clinical features of polycystic ovary syndrome (PCO) were studied to determine the correlation between biochemical and histologic findings. The biochemical features investigated were the effects of adrenocortical and ovarian suppression by dexamethasone and oral contraceptives (Ovulen) on plasma free androgens. Four patients showed a histologic picture consistent with PCO (Group A), and five had histologically normal ovaries (Group B). The remaining 22 patients had no tissue available for histologic examination (Group C). The baseline values of plasma free testosterone (FTel) were higher and those of testosterone-binding globulin (TeBG) were lower (p less than 0.05) in Group A than in Group B, although plasma total testosterone (T) and the free 17beta-hydroxysteroid androgen index (FHSl) were similar in the two groups. During dexamethasone administration in all study groups, T and FTel fell slightly (17.7% to 33.8%), and FHSl levels decreased moderately (36% to 46.6%); in no case did both indices of free androgen levels fall to the normal range for dexamethasone-suppressed women. However, no change was noted in TeBG in all three groups. On the other hand, Ovulen treatment suppressed T and free androgens to normal in all groups, and raised TeBG more than 350% from the baseline. These data suggest a decrease in androgen production. The effects of dexamethasone and Ovulen on all three groups were similar in percent changes. As Group B patients resemble those of Group A biochemically and clinically, except for possibly being less hyperandrogenic, the concept of ovarian hyperandrogenism should be expanded to include patients with no anatomic ovarian abnormality, particularly in milder cases.

Interfacial behavior of uracil derivatives

The adsorption of a number of methylated uracil derivatives and of 5-fluorouracil has been studied by surface electrochemical methods at a mercury electrode. All derivatives exhibit an initial or dilute adsorption region where they are adsorbed flat on the electrode surface and are bound by pi-electron overlap with the electrode. Uracil, thymine, 1,5-dimethyl-uracil, 5,6-dimethyluracil, 1,5,6-trimethyluracil and 5-fluorouracil undergo a surface reorientation from the initial flat solution activities for each compound. An unsubstituted N(3)-H group is an absolute requirement for a uracil derivative to be capable of adopting the perpendicular surface stance. In the perpendicular orientation the uracil derivative appears to be bound to the electrode primarily via a N(3)-H--(-) electrode bond although a similar but weaker hydrogen bond can be formed via the N(1)-H group for certain compounds.

Pregnancy in a true hermaphrodite

True hermaphroditism is a rare form of intersexuality, and fertility in such an anomaly has been reported only once before in literature. A 19-year-old true hermaphrodite reared as a female with normal secondary sex characteristics and a karyotype of 46,XX was treated by removal of the left ovotestis. The right ovary and other pelvic organs were of a normal female. Ten months after the treatment she became pregnant. The pregnancy was complicated by a premature delivery of a 1500-g male infant that showed no congenital anomalies. Histologic findings of the ovotestis and clinical findings of a true hermaphrodite with pregnancy are presented.

Dysmenorrhea in unicornis with rudimentary uterine cavity

Two adolescents with a rare müllerian anomaly, uterus unicornis with a noncommunicating rudimentary uterine cavity, are presented because of clinical manifestations characterized by dysmenorrhea and pelvic pain requiring multiple hospitalizations and surgical procedures prior to the correct diagnosis. A high index of suspicion and proper diagnostic evaluation are essential for all adolescent patients presenting with dysmenorrhea associated with menarche and subsequent menstruation. The details of 2 cases and their diagnostic and therapeutic emphasis are presented.

Partial gonadotrophin-resistance in pseudohypoparathyroidism

A patient with classical Albright's pseudohypoparathyroidism was investigated because of oligomenorrhoea. Hypo-oestrogenism was associated with elevated basal gonadotrophin values [mean basal serum LH and FSH were 272 +/- 84 (SD) ng/ml and 593 +/- 83 ng/ml, resplectively (normal less than or equal to 220 and less than or equal to 400, respectively)]. The response to gonadotrophin releasing hormone (Gn-RH) was exaggerated, with maximal LH and FSH increments of 1688 and 458 ng/ml, respectively. These results and the findings on ovarian biopsy were compatible with partial ovarian resistance to gonadotrophins. This resistance could be overcome by administration of human menopausal gonadotrophins. This is the first evidence for gonadotrophin resistance in pseudohypoparathyroidism. The plasma cyclic adenosine-3',5'-monophosphate response to glucagon administration by two different protocols was about 70% that of normal control subjects. Other endocrine glands whose responses to hormones are mediated via the adenylate cyclase system evidenced minor abnormalities of questionable significance. This indirect evidence is compatible with a more extensive defect in the adenylate cyclase system in pseudohypoparathyroidism than has hitherto been suspected.

Immunoglobulins, proteinase inhibitors, albumin, and lysozyme in human cervical mucus. I. Communication: hormonal profiles and cervical mucus changes--methods and results

The serum levels of luteinizing hormone (LH), estradiol-17beta, and progesterone were determined simultaneously with the concentrations of immunoglobulin (Ig) G, IgA, C'3, alpha1-antitrypsin, inter-alpha-trypsin inhibitor, alpha1x-antichymotrypsin, albumin, and lysozyme in cervical mucus during nine ovulatory cycles. Spinnbarkeit and ferning were also assessed, and the basal body temperature was measured and recorded during these cycles. The profiles were synchronized according to the LH peak. The midcycle period, characterized by the rapid increase and decline of estrogen and the beginning rise of progesterone, shows a prounced minimum of immunoglobulins, C'3, proteinase inhibitors, albumin, and lysozyme in cervical mucus, which is known to be most receptive to sperm penetration at this time. Although the variation of cervical mucus values is considerable during the early proliferative and the luteal phases, the midcycle values appear to be constantly low, showing slight differences among the profiles of the different parameters. The statistical evaluation and the assessment of the significance of parameters for ovulation detection and the assessment of the fertile period as well as the correlation of these parameters with basal body temperature will be the subject of the second communication of this series.

The effects of dexamethasone on plasma free androgens during the normal menstrual cycle

In order to evaluate the ovarian and adrenal contribution to peripheral plasma concentrations of total testosterone (TTe), indixes of the plasma concentrations of free testosterone (FTeI), free 17 beta-hydroxysteroid androgens (FHSI), and testosterone-binding globulin (TeBG) during the menstrual cycle, women were examined during three normal cycles and three other cycles under dexamethasone (0.5 mg., four times a day) suppression. All study cycles were apparently ovulatory. The mean TTe and FTeI during the midcycle period were significantly higher than during the early follicular (P less than 0.005) and the midluteal periods (P less than 0.01 and P less than 0.001, respectively). During the menstrual cycles under dexamethasone suppression only the difference in TTe and FTeI between the midcycle (37 +/- 12.4 (S.D.) ng. per 100 ml. and 10.5 +/- 4.0 (S.D.), respectively) and the midluteal (26.0 +/- 10.1 (S.D.) ng. per 100 ml and 7.2 +/- 3.2 (S.D.), respectively) periods was significant statistically (P less than 0.05). No significant differences in the mean levels of FHSI and TeBG between three periods within the cycle were noted in either the control or the dexamethasone-treated cycle. When each phase was compared, the mean levels of TTe, FTel, and FSHI were significantly lower in the dexamethasone-treated cycles than in the normal cycles. The data suggest that the level of TeBG is not perceptibly affected by physiologic fluctuation of estrogen levels during the menstrual cycle, and the FHSI levels are stable throughout the ovulatory cycle. Decrease in levels of TTe, FTeI, and FHSI during dexamethasone suppression seems to be due to reduction of androgen production as TeBG, a major determinant of the metabolic clearance rate of androgens, was not affected by dexamethasone.

Endocrinologic characteristics of partial ovarian failure

Three young women with primary ovarian failure, secondary amenorrhea or oligo-ovulation, and normal gonadotropin levels are reported on here. Vaginal cytology and serum estradiol levels indicated the two women to be persistently hypoestrogenic. The third case, who had the Turner phenotype, was hypoestrogenic during anovulatory cycles but occasionally ovulated. Basal serum LH and FSH were normal. All were tested with synthetic LH-releasing hormone and had a brisk response, LH levels rising 51-198 ng/ml above baseline and FSH rising 278-536 ng/ml. Plasma levels of testosterone, dehydroepiandrosterone sulfate, and progesterone were normal. Gonadal dysgenesis was suggested in two on the basis of an abnormal karyotype, and isochromosome of the short arm of X in Case 2, and an isochromosome of the long arm of X in Case 3. The diagnosis of primary hypogonadism was established by laparoscopy and ovarian biopsy. The latter studies revealed small ovaries with a scarcity of primordial and primary follicles, yet with evidence of current or previous follicular activity. The observation that hypoestrogenism was so marked in two of our patients that elevated serum FSH would have been expected, suggests that the presence of a limited number of ovarian follicles suffices to prevent hypergonagotropism in hypoestrogenic women by a mechanism which does not involve elaboration of sex steroids.

Obesity and oligomenorrhea are associated with hyperandrogenism independent of hirsutism

Obesity, oligomenorrhea, and hirsutism are frequently associated with high plasma androgen levels and/or low testosterone-binding globulin (TEBG) levels. Studied have been undertaken to determine the extent to which each of these clinical features may be related to this hormonal profile. Indexes of plasma free (unbound) androgen levels were focused upon because this fraction appears to be the biologically active portion of the plasma androgens. The hormonal profile was normal in women with either obesity or oligomenorrhea alone and abnormal in those with severe hirsutism alone. On striking new finding was that subjects with the combination of obesity and oligomenorrhea had elevated plasma total and free androgens and depressed TEBG even in the absence of hirsutism. Furthermore, the androgen levels were higher in obese oligomenorrheic women with mild hirsutism than in severely hirsute women who were not obese. Plasma estradiol concentrations were normal in these obese women. A simple explanation for elevated free plasma androgen levels in obese women who were oligomenorrheic yet had little if any hirsutism is not possible. The data are compatible with the concept that obesity is a variably expressed manifestation of slightly elevated plasma free androgen levels or that obesity is an incidental finding which somehow blunts the effect of high androgen levels on hair follicles. Regardless of the explanation, oligomenorrheic obese women must be suspected of having high androgen production even in the absence of hirsutism.

Predetermination of ovulation timing by luteinizing hormone assay

A modified rapid,solid-phase radioimmunoassay for serum luteinizing hormone requiring only 1 1/2 hours of incubation is presented. The method has been used to predetermine the time of ovulation in six infertile patients. Its advantages are presented in these cases. The simplicity and accuracy of the method make it practical, and it can serve well in the management of infertility.

Pituitary responses to LRH in the postpartum periods

Pituitary responses to luteinizing-hormone-releasing-hormone (LRH) in the postpartum periods were studied. Following a subcutaneous injection of 100 mug of synthetic LRH to postpartum subjects, no statistically significant changes in the levels of LH and FSH could be demonstrated in five subjects on postpartum day 1 or 3 and the three subjects on postpartum day 8. A normal elevation of LH and FSH following LRH was demonstrated in one subject 36 days post partum. The findings are in agreement with previous studies demonstrating a persistence of pituitary suppression during the early postpartum period. No correlation could be drawn between the pituitary responses to LRH and the plasma levels of estradiol-17 beta and progesterone.

Study on maternal, fetal, and amniotic human prolactin at term

Prolactin present in maternal blood, fetal blood, and amniotic fluid samples obtained simultaneously at term was examined. The relative concentrations of prolactin in maternal and fetal serum samples were found to vary with each individual case. However, amniotic fluid samples contained a much higher level of prolactin than did both maternal and fetal serum samples in every case. After gel filtration, three separate peaks of immunoreactive prolactin were observed, probably representing three different sizes of the hormone molecule. The main component was small prolactin, constituting at least 69% of the total prolactin immunoreactivity in blood samples and 90% in amniotic fluids. Prolactin was found to be very similar in cord venous and arterial sera, both quantitatively and in terms of heterogeneity. There were more noticeable differences in the percentages of medium and small prolactin present in serum samples than in amniotic fluid samples. Big prolactin was present in all samples; its percentage in maternal serum was slightly higher than its percentages in the other samples. These results suggest that: 1) The mother and fetus carry on independent secretion of prolactin during gestation. 2) The size heterogeneity of prolactin in amniotic fluid differs from maternal hPRL to a greater degree than it does from fetal hPRL. 3) The prolactin in amniotic fluid appears to be of fetal origin.