Pregnancy outcomes in primigravid women aged 35 years and over in South Australia, 1986-1988

The South Australian perinatal data collection for 1986-1988 was used to compare the characteristics and outcomes of singleton pregnancies in 515 primigravid women aged 35 years and over with those in 4175 younger primigravid women aged 20-29 years. Notable differences observed were a higher prevalence of medical, obstetric and labour complications and assisted deliveries in the older group. Breech presentations were almost twice as common in the older women, as were caesarean sections. Only 27% achieved a spontaneous vaginal delivery. The mean duration of hospital stay for the older women was longer for both vaginal and caesarean deliveries. However, although their babies were more likely to be premature or of low birthweight, the perinatal mortality rate was not significantly increased and the great majority of older primigravid women managed by modern obstetric methods can expect a good pregnancy outcome.

Planned homebirths in South Australia 1976-1987

Homebirths booked with a group of general practitioners and midwives in South Australia in 1976-1987 are described using data obtained from midwives' and hospital records. The births represented 84.7% of all births occurring at home in South Australia in 1984-1987, as assessed by official birth registrations. Of the 799 women intending to deliver at home, 136 (17.0%) required transfer to hospital before or during labour. A further 38 mothers or babies (4.8%) required transfer after delivery. The women tended to be of a relatively high socioeconomic status and older age distribution when compared with women who had hospital births as identified from the State perinatal data collection. Some had recognised pregnancy risk factors. They had lower frequencies of ultrasound examination, induced labour, epidural analgesia, episiotomy, forceps delivery and caesarean section, and a low frequency of use of oxytocics for the third stage. Their rates of postpartum haemorrhage and, in particular, perinatal mortality were higher. Potential sources of risk and difficulty in homebirth care and evaluation of this care are identified and an approach to providing an effective homebirth service is proposed.

Expression of a T cell receptor gamma-chain (V gamma 1.1J gamma 4C gamma 4) transgene in mice influences T cell receptor ontogeny and thymic architecture during development

In this report, we have characterized T cell ontogeny in mice transgenic for the V gamma 1.1J gamma 4C gamma 4 (TcR gamma 4) TCR chain gene by analyzing the T cell surface phenotype and microarchitecture of the transgenic lymphoid organs during development. The first wave of V gamma 3J gamma 1C gamma 1 TCR+ thymocytes that appear in the thymus at day 14 of gestation were virtually absent in the TCR gamma 4 transgenic mice. However, comparable levels of total gamma delta+ thymocytes were present in the TCR gamma 4 transgenic mice, suggesting that these thymocytes expressed a transgene receptor. In addition, the appearance of significant numbers of TCR alpha beta+ T cells occurred earlier (day 17 of fetal development) in the transgenic thymus. After birth, thymuses from TCR gamma 4 transgenic mice were characterized by a consistent increase in the number of TCR gamma delta+ thymocytes and a transient increase (between 2 and 4 wk of age) in the absolute number of TCR+ thymocytes (2- to 4-fold) compared with thymuses from normal mice. Immunohistologic analysis of the thymus, spleen, and lymph nodes from 2-day and 3-wk-old transgenic mice showed significant differences to controls only in regions harboring mature, functional T cell subsets which may be the result of bidirectional signaling between lymphocyte subsets (influenced by transgene expression) and stromal elements. The results demonstrate that striking differences, leading to the earlier appearance of mature T cells, occurred in both the fetal and neonatal thymus and periphery of mice that expressed a TCR gamma 4 transgene. These findings are consistent with the hypothesis that expression of the TCR gamma 4 chain gene, early in ontogeny, has a positive influence on the development of the T cell compartment.

Expression of a T cell receptor gamma-chain (V gamma 1.1J gamma 4C gamma 4) transgene in mice influences T cell receptor ontogeny and thymic architecture during development

In this report, we have characterized T cell ontogeny in mice transgenic for the V gamma 1.1J gamma 4C gamma 4 (TcR gamma 4) TCR chain gene by analyzing the T cell surface phenotype and microarchitecture of the transgenic lymphoid organs during development. The first wave of V gamma 3J gamma 1C gamma 1 TCR+ thymocytes that appear in the thymus at day 14 of gestation were virtually absent in the TCR gamma 4 transgenic mice. However, comparable levels of total gamma delta+ thymocytes were present in the TCR gamma 4 transgenic mice, suggesting that these thymocytes expressed a transgene receptor. In addition, the appearance of significant numbers of TCR alpha beta+ T cells occurred earlier (day 17 of fetal development) in the transgenic thymus. After birth, thymuses from TCR gamma 4 transgenic mice were characterized by a consistent increase in the number of TCR gamma delta+ thymocytes and a transient increase (between 2 and 4 wk of age) in the absolute number of TCR+ thymocytes (2- to 4-fold) compared with thymuses from normal mice. Immunohistologic analysis of the thymus, spleen, and lymph nodes from 2-day and 3-wk-old transgenic mice showed significant differences to controls only in regions harboring mature, functional T cell subsets which may be the result of bidirectional signaling between lymphocyte subsets (influenced by transgene expression) and stromal elements. The results demonstrate that striking differences, leading to the earlier appearance of mature T cells, occurred in both the fetal and neonatal thymus and periphery of mice that expressed a TCR gamma 4 transgene. These findings are consistent with the hypothesis that expression of the TCR gamma 4 chain gene, early in ontogeny, has a positive influence on the development of the T cell compartment.

Pregnancy and perinatal factors associated with persistently low Apgar scores: an analysis of the birth records of infants born in South Australia

This study included all newborns with Apgar scores below seven at one minute after birth who were born in 1986 and whose births were notified to the South Australian Perinatal Statistics Collection. Univariate comparisons were made of the demographic, obstetric and pregnancy outcome characteristics of the 301 newborns whose Apgar scores remained below seven at five minutes and the 3165 whose scores recovered to seven or more. The results provide a general risk profile of the 301 newborn infants who perform poorly at birth, as indicated by a low Apgar score at both one and five minutes. Adverse risk factors identified in this study were similar to those for intellectual disability (mental retardation) and cerebral palsy in South Australia. It is suggested that persisting low Apgar scores, when combined with the other risk factors demonstrated in this and previous studies, would provide more reliable prognostic information than would Apgar scores alone. The study also shows that the majority of infants with low Apgar scores at one minute scored seven or better at five minutes. This demonstrates, that although a low one minute Apgar score has value in identifying newborns in need of immediate attention, it must be supplemented by the five minute score's stronger association with perinatal morbidity.

Noninvasive imaging of the superficial femoral artery using ultrasound Duplex scanning

A total of 56 lower extremities in 28 patients were evaluated by both conventional arteriography and ultrasound duplex scanning. Overall sensitivity for duplex scanning compared to arteriography in detecting stenotic or occlusive disease was 91%, specificity was 94%, positive predictive value 85% and negative predictive value 97%. Results for Duplex scanning were better in the proximal and middle segment compared to the distal third of the superficial femoral artery. The sensitivity of segmental lower extremity pressures and pulse volume recordings for predicting proximal superficial femoral artery disease compared to arteriography was 82%; specificity was 79% and accuracy 80%, all inferior to that of Duplex scanning. Duplex scanning is a promising technique suitable for noninvasive assessment of patients presenting with suspected superficial femoral artery disease. It should readily identify candidates for percutaneous interventional techniques in which a patent segment of proximal superficial femoral artery is required for access. It will also be useful in follow-up studies of patency of the superficial femoral artery following interventional procedures such as balloon dilatation and laser angioplasty.

Early controlled active mobilization with dynamic splintage for treatment of extensor tendon injuries

Early controlled active mobilization with a dynamic splint for treatment of repaired extensor tendon injuries was studied prospectively. Postoperative dynamic splintage started on the third postoperative day and involved elastic band extension and active flexion of the digits. Mobilization of the digits within the splint was done immediately under supervision. Range of motion was stepped up progressively and splintage was stopped after 5 to 6 weeks. Thirty-eight patients with 48 digits were reviewed. The average follow-up was 6.7 months (range, 4 to 10 months). Injuries involving the fingers showed an average final total active motion of 229 degrees (range, 95 to 270 degrees), whereas injuries involving the thumb was 118 degrees (range, 78 to 150 degrees). Lesions distal to the knuckles (zones II, III, IV) showed the worst results with an average total active motion of only 188 degrees (range, 95 to 270 degrees). The duration out of work was 8.5 weeks (range, 4 to 25 weeks). There was no infection or acute tendon rupture. One patient required reconstruction of a persistent button-hole deformity; two required tenolysis and capsulotomy. Of the six unsatisfactory results with poor total active motion, four had injuries distal to the metacarpophalangeal joint, three of which were crushing injuries.

Studies on prostaglandin and luteolysis in the pseudopregnant rabbit

The ability of pulsatile infusion of prostaglandin F2 alpha (PGF2 alpha) or 13, 14-dihydro prostaglandin F2 alpha to induce corpus luteum regression was examined in the pseudopregnant rabbit. Each prostaglandin was infused in 5, 1-hour pulses (1 per 6 hours) during a 25-hour period starting day 9 or 10 of pseudopregnancy. Although both prostaglandins were capable of inhibiting progesterone secretion, pulse administration was no more effective than continuous infusion. To determine if PGF2 alpha was released into the systemic circulation during spontaneous luteolysis, starting day 12 of pseudopregnancy serial blood samples were collected every 90 minutes from the jugular vein. Prostaglandin F levels remained steady (1-2 ng/ml over the collection period with no apparent increase associated with functional luteolysis. Although prostaglandins may be involved in luteolysis in the rabbit, the present results suggest that it is unlikely that PGF2 alpha by itself is responsible for the sustained fall in progesterone secretion at the end of the pseudopregnancy.

Allelic T-cell receptor alpha complexes have little or no influence on susceptibility to type 1 diabetes

We performed a multiple-affected-sib study to determine if T-cell receptor alpha-chain alleles affect susceptibility to insulin-dependent diabetes mellitus. Restriction fragment length polymorphisms were used to follow the segregation of allelic T-cell receptor alpha complexes within the families. The segregation of T-cell receptor alpha alleles in 29 multiplex families revealed no significant tendency for affected sibs to share T-cell receptor alpha-chain alleles more often than would be expected by chance alone (p greater than 0.2). In contrast, the same type of analysis for HLA alleles easily detected the well-known linkage of insulin-dependent diabetes mellitus susceptibility to the HLA complex (p = 0.003). We suggest that the importance of HLA alleles in insulin-dependent diabetes mellitus susceptibility and the lack of importance of T-cell receptor alpha alleles result from the different strategies by which HLA and T-cell receptor molecules achieve antigen-binding diversity: multiple loci and allelic diversity in the case of HLA; combinatorial, junctional, and N-region diversity in the case of the T-cell receptor. In this paper we also describe three new restriction fragment length polymorphisms of the T-cell receptor alpha complex and a new method for testing the significance of linkage in multiple-affected-sib studies.

Pregnancy and birth risk factors for intellectual disability in South Australia

It is generally accepted that developmental handicaps can often be minimized through early detection and intervention. For this reason, it is normal practice in many hospitals to follow-up and screen infants who present at birth with established risk factors. Clinical judgement will always be important when selecting children for follow-up. However, as hospital data systems improve, automated systems could be developed for listing children potentially "at risk". Where initial clinical decisions not to follow-up individual children prove to be at odds with this automated output, the individual child could be re-assessed clinically. This process could increase the level of quality control. An initial risk-factor model for intellectual disability has been developed, based on the South Australian Perinatal Statistics Collection, for use in this context.

Caesarean section in South Australia, 1986

A profile of Caesarean section in South Australia was obtained by analysing the 19,800 births in the perinatal statistics collection in 1986. The Caesarean confinement rate was 19.0%, of which 9.0% were elective sections and 9.9% emergency sections. The rates were highest in large metropolitan hospitals. Elective rates were highest in metropolitan private hospitals, among older women, among those with a previous perinatal death or where a fetal malpresentation occurred. Emergency sections were more common in primigravidas, non-Caucasian women, those with a poor pregnancy history, few antenatal visits and a medical or obstetric complication of pregnancy. The obstetric complications most commonly encountered with Caesarean sections were fetopelvic disproportion, fetal distress, malposition or malpresentation, pregnancy hypertension and uterine inertia. Neonates born by emergency section were more likely to be premature, or low birth-weight and to manifest depression of vital signs compared with vaginal births. They also required more intensive resuscitation and neonatal care, and neonatal death occurred more frequently. Morbidity was much lower in neonates born by elective than emergency section.

Oxidative damage in murine tumor cells treated in vitro by recombinant human tumor necrosis factor

Treatment of three murine tumor cell lines, L929, P388, and Pan-02, in vitro with recombinant human tumor necrosis factor (rhTNF) produced evidence of oxidative damage as measured by (a) increases in intracellular glutathione levels, (b) the formation of intracellular oxidized glutathione and (c) the formation of thymine glycols in DNA. L929, the most sensitive of the three cell lines to the cytotoxic activity of rhTNF, had the lowest total glutathione content and was observed to have the highest levels of oxidized glutathione and thymine glycol formation. In addition, the radical buffering capacity of these cells was significantly compromised within 7 h of treatment with rhTNF. The P388 and Pan-02 cell lines, with total glutathione levels about 50-fold higher than L929, also showed evidence of oxidative attack, although to a lesser extent than L929. The radical buffering capacity of these cell lines was not altered by rhTNF treatment. A rhTNF-resistant subline of L929 (L929r), produced by successive passaging in vitro in the presence of TNF, increased its glutathione and oxidized glutathione levels in response to a subsequent rhTNF challenge. Meth A, a cell line resistant to rhTNF in vitro but not in vivo, showed no evidence of oxidative damage following rhTNF treatment, despite having a low radical scavenging capacity and a sensitivity to H2O2. The results with Meth A suggest that the interaction of rhTNF with this cell line does not occur in the same manner as the other cell lines, perhaps due to receptor differences or to some type of "uncoupling" of the signal-response network between the TNF receptor and a putative secondary messenger(s). These results are consistent with the hypothesis that: (a) the mechanism of action of rhTNF involves the production of oxidative damage, including damage to the DNA; (b) the sensitivity to rhTNF in vitro is related to the radical scavenging capacity of the cell; and (c) cells can respond to rhTNF challenge by increasing their free radical scavenging capacity.

The role of oxidant injury in tumor cell sensitivity to recombinant human tumor necrosis factor in vivo. Implications for mechanisms of action

The intracellular glutathione levels of two human tumor lines and seven murine tumor lines were determined in order to investigate the role of oxidant injury in tumor cell sensitivity to human rTNF (rhTNF). Correlations were found between high intracellular glutathione levels and in vivo tumor resistance to rhTNF, and on the other hand, low glutathione levels and rhTNF sensitivity. The transplantable murine fibrosarcoma, Meth A, a TNF-sensitive line in vivo, was less sensitive to rhTNF and host toxicity was reduced when the hosts were pretreated with uric acid, a major reactive oxygen scavenger in humans and certain other primates. Conversely, pretreatment of the tumor-bearing hosts with DL-buthionine-(S,R)-sulfoximine, an inhibitor of GSH biosynthesis, resulted in an increased sensitivity of Meth A to rhTNF. This effect was not limited to tumor-bearing mice, as rats pretreated with diethyl maleate, a compound which irreversibly binds glutathione, were more sensitive to rhTNF toxicity than control rats. On the other hand, pretreatment with N-acetyl cysteine, an oxidant scavenger, reduced the toxicity of rhTNF treatment in rats. The data are consistent with the hypothesis that tumor cell sensitivity to rhTNF in vivo is dependent on its capacity to buffer oxidative attack. In addition, host toxicity is also related to the production of reactive oxygen species. Activated effector cells such as granulocytes and macrophages are hypothesized to produce most of this damage by their respiratory burst and oxidant release, although the direct action of rhTNF may also contribute to oxidative injury in vivo.

The role of oxidant injury in tumor cell sensitivity to recombinant human tumor necrosis factor in vivo. Implications for mechanisms of action

The intracellular glutathione levels of two human tumor lines and seven murine tumor lines were determined in order to investigate the role of oxidant injury in tumor cell sensitivity to human rTNF (rhTNF). Correlations were found between high intracellular glutathione levels and in vivo tumor resistance to rhTNF, and on the other hand, low glutathione levels and rhTNF sensitivity. The transplantable murine fibrosarcoma, Meth A, a TNF-sensitive line in vivo, was less sensitive to rhTNF and host toxicity was reduced when the hosts were pretreated with uric acid, a major reactive oxygen scavenger in humans and certain other primates. Conversely, pretreatment of the tumor-bearing hosts with DL-buthionine-(S,R)-sulfoximine, an inhibitor of GSH biosynthesis, resulted in an increased sensitivity of Meth A to rhTNF. This effect was not limited to tumor-bearing mice, as rats pretreated with diethyl maleate, a compound which irreversibly binds glutathione, were more sensitive to rhTNF toxicity than control rats. On the other hand, pretreatment with N-acetyl cysteine, an oxidant scavenger, reduced the toxicity of rhTNF treatment in rats. The data are consistent with the hypothesis that tumor cell sensitivity to rhTNF in vivo is dependent on its capacity to buffer oxidative attack. In addition, host toxicity is also related to the production of reactive oxygen species. Activated effector cells such as granulocytes and macrophages are hypothesized to produce most of this damage by their respiratory burst and oxidant release, although the direct action of rhTNF may also contribute to oxidative injury in vivo.

Sequence dependence of administration of human recombinant tumor necrosis factor and interleukin-2 in murine tumor therapy

Simultaneous administration of recombinant human tumor necrosis factor (rhTNF) and interleukin-2 (rhIL-2) has been shown to block tumor take in murine models. We investigated the effects of sequence and schedule of administration as a function of tumor burden with two tumor models (B16 and Meth A). rhTNF followed by rhIL-2 had extraordinary antitumor efficacy, but rhIL-2 followed by rhTNF was much less effective. Sequential rhTNF/rhIL-2 therapy resulted in complete tumor regression, whereas simultaneous therapy resulted in complete tumor regression, whereas simultaneous therapy resulted in only reduced growth rate. Experiments with genetically immunodeficient mice suggested that T cell factors may be required for synergistic antitumor activity.

Concomitant 5-fluorouracil infusion, mitomycin C and radical radiation therapy in esophageal squamous cell carcinoma

This is a retrospective comparison of patients with unresected esophageal squamous cell carcinoma treated by radiation therapy and chemotherapy (21 patients) versus radiation therapy alone (34 patients). Pretreatment characteristics were comparable in both groups. In the combined modality group, treatment was given in split courses with concomitant radiation therapy (20 to 25 Gy in 10 fractions on days 1-12 and days 42-54) and chemotherapy (bolus Mitomycin C on day 1; 96 hr. of continuous 5 Fluorouracil infusion on days 1-4 and days 42-46). There was improvement in local disease control with the combined modality approach. Initial complete response was achieved in 86% of the radiation and chemotherapy group, versus 57% of the radiation alone group. The one-year local relapse-free rate was 67% versus 35%, and 2 year rate was 41% versus 28%. (p less than 0.05). The 1-year and 2-year survival was 64% and 32% respectively, for the radiation and chemotherapy group, versus 28% and 10% respectively for the radiation alone group (p less than 0.05). The majority of patients had disease relapsed, 81% of the combined modality group and 97% of the radiation alone group. However, the pattern of failure was different in the two groups. In the radiation and chemotherapy group, 29% had local failure alone, 53% had distant failure alone, and 18% had both local and distant failure. In the radiation alone group, 33% had local failure alone, 24% had distant failure alone, and 43% had both local and distant failure. Concomitant radiation therapy, 5 Fluorouracil infusion and bolus Mitomycin C is effective treatment for local control in esophageal squamous cell carcinoma, but not for distant hematogenous metastases. This combined modality treatment was well tolerated, with little additional hematological toxicity, esophagitis and stomatitis over radiation therapy alone.

Polymorphism of the human T cell receptor alpha chain variable genes: identification of a highly polymorphic V gene probe

In this study, we report the RFLP of the human T cell receptor (TCR) alpha chain variable gene segments. Using DNA samples from 20 individuals and three restriction endonucleases (BamHI, EcoRI and HindIII), the degree of RFLP of a number of different V gene segments was defined. Half of the V alpha subfamilies (6/12) were characterized by a predominant hybridization pattern, with only a few individuals displaying a second pattern. However, one particular V gene family, V alpha 6, has at least five allelic forms that segregated consistently in familial studies. The V alpha polymorphisms revealed in this study, together with those exhibited by V beta gene subfamilies, should prove useful in studying possible associations between TCR gene usage and disorders of the immune system.

Identification of a T cell subset using a rabbit antibody raised against a T suppressor molecule

Rabbit antiserum to a unique component of an Ag-binding Ts-factor was generated by repeated immunization with purified 30-kDa protein isolated from Fd11 Ts factor (11). This antiserum (anti-p30) was shown to recognize cell surface determinants expressed on the Ts hybridomas Fd11 and A10 but not the fusion partner BW5147. Furthermore, this antiserum was shown to bind to approximately 4% of thymocytes and 10% of nylon wool-purified splenic T cells from all strains of mice tested. Sorting nylon wool-purified T cells from DBA/2 mice for the CD4+ and CD8+ subsets revealed both populations contained cells that bound anti-p30. In addition, when CD4-8- thymocytes were examined for anti-p30 labeling, it was found that about 30% of this enriched population also expressed p30 molecules. In a functional study, anti-p30 was able to neutralize the suppressive effects of Fd11 on a specific assay for in vitro antibody synthesis against ferredoxin.

Identification of a T cell subset using a rabbit antibody raised against a T suppressor molecule

Rabbit antiserum to a unique component of an Ag-binding Ts-factor was generated by repeated immunization with purified 30-kDa protein isolated from Fd11 Ts factor (11). This antiserum (anti-p30) was shown to recognize cell surface determinants expressed on the Ts hybridomas Fd11 and A10 but not the fusion partner BW5147. Furthermore, this antiserum was shown to bind to approximately 4% of thymocytes and 10% of nylon wool-purified splenic T cells from all strains of mice tested. Sorting nylon wool-purified T cells from DBA/2 mice for the CD4+ and CD8+ subsets revealed both populations contained cells that bound anti-p30. In addition, when CD4-8- thymocytes were examined for anti-p30 labeling, it was found that about 30% of this enriched population also expressed p30 molecules. In a functional study, anti-p30 was able to neutralize the suppressive effects of Fd11 on a specific assay for in vitro antibody synthesis against ferredoxin.

Obstetric profiles of immigrant women from non-English speaking countries in South Australia, 1981-1983

Obstetric profiles of non-English speaking immigrant women in South Australia are presented to assist in planning for health services. They were derived from perinatal data routinely collected by midwives and neonatal nurses. The characteristics of 5,675 immigrant women were compared with those of a random sample of approximately 5% of Australian-born women who delivered babies in 1981-1983 in South Australia. This study demonstrates that immigrant women tended to be urban dwellers and to deliver their babies in large metropolitan hospitals. They were less often from unemployed families but more often from those of low occupational status. They were older, with fewer teenagers and single women among them. They were of higher parity, and tended to commence antenatal care later. They had lower incidences of pregnancy hypertension and induced labour, but were more likely to have anaemia, antepartum haemorrhage and a Caesarean section. There were also important differences between the 7 largest immigrant groups. For example, the very high Caesarean section rate (36%) in Filipino women is of concern. Also, the mean birth-weight of babies of Vietnamese women was 263g lower than that of babies of Australian-born women. Support services need to be logistically located and address the findings of this study in a culturally acceptable way.

Ultrasound screening for clinically occult abdominal aortic aneurysm

In a review of the records of 74 patients who had undergone repair of an abdominal aortic aneurysm at a community hospital between 1977 and 1983 we found that the aneurysm had been undiagnosed before rupture in 35%; these patients had an operative death rate of 50%, whereas elective repair carried a death rate of 4%. The characteristic patient was an obese man over the age of 55 years with hypertension, coronary artery disease, cerebrovascular disease or peripheral vascular disease. Ultrasound examination was performed in 45 patients with these characteristics, and six aneurysms were diagnosed. Either surgery or computed tomography confirmed the diagnosis. The rate of false-negative results was estimated by review of the charts of 100 men over the age of 55 years who had undergone abdominal ultrasonography for other indications: no undetected aneurysms were discovered over 3 years of follow-up. Routine screening in this high-risk group would improve the rate of diagnosis of this potentially fatal condition before rupture and offer the patient the lower mortality rate associated with elective surgery.