The ABCs of measuring intracerebral hemorrhage volumes

BACKGROUND AND PURPOSE

Hemorrhage volume is a powerful predictor of 30-day mortality after spontaneous intracerebral hemorrhage (ICH). We compared a bedside method of measuring CT ICH volume with measurements made by computer-assisted planimetric image analysis.

METHODS

The formula ABC/2 was used, where A is the greatest hemorrhage diameter by CT, B is the diameter 90 degrees to A, and C is the approximate number of CT slices with hemorrhage multiplied by the slice thickness.

RESULTS

The ICH volumes for 118 patients were evaluated in a mean of 38 seconds and correlated with planimetric measurements (R2 = 9.6). Interrater and intrarater reliability were excellent, with an intraclass correlation of .99 for both.

CONCLUSIONS

We conclude that ICH volume can be accurately estimated in less than 1 minute with the simple formula ABC/2.

Ragweed immunotherapy in adult asthma

BACKGROUND

Although allergen immunotherapy is effective for allergic rhinitis, its role in treating asthma is unclear.

METHODS

We examined the efficacy of immunotherapy for asthma exacerbated by seasonal ragweed exposure. During an observation phase, adults with asthma who were sensitive to ragweed kept daily diaries and recorded peak expiratory flow rates between July and October. Those who reported seasonal asthma symptoms and medication use as well as decreased peak expiratory flow were randomly assigned to receive placebo or ragweed-extract immunotherapy in doses that increased weekly for an additional two years.

RESULTS

During the observation phase, the mean (+/- SE) peak expiratory flow rate measured in the morning during the three weeks representing the height of the pollination season was 454 +/- 20 liters per minute in the immunotherapy group and 444 +/- 16 liters per minute in the placebo group. Of the 77 patients who began the treatment phase, 64 completed one year of the study treatment and 53 completed two years. During the two treatment years, the mean peak expiratory flow rate was higher in the immunotherapy group (489 +/- 16 liters per minute, vs. 453 +/- 17 in the placebo group [P = 0.06] during the first year, and 480 +/- 12 liters per minute, vs. 461 +/- 13 in the placebo group [P = 0.03] during the second). Medication use was higher in the immunotherapy group than in the placebo group during observation and lower during the first treatment year (P = 0.01) but did not differ in the two groups during the second year (P = 0.7). Asthma-symptom scores were similar in the two groups (P = 0.08 in year 1 and P = 0.3 in year 2). The immunotherapy group had reduced hay-fever symptoms, skin-test sensitivity to ragweed, and sensitivity to bronchial challenges and increased IgG antibodies to ragweed as compared with the placebo group; there was no longer a seasonal increase in IgE antibodies to ragweed allergen in the immunotherapy group after two years of treatment. Reduced medication costs were counterbalanced by the costs of immunotherapy.

CONCLUSIONS

Although immunotherapy for adults with asthma exacerbated by seasonal ragweed exposure had positive effects on objective measures of asthma and allergy, the clinical effects were limited and many were not sustained for two years.

Platelet-activating factor stimulates lung pericyte growth in vitro

Platelet-activating factor (PAF) is released from activated leukocytes and endothelial cells in sepsis, lung injury, and the adult respiratory distress syndrome. With these disorders, pulmonary hypertension develops, partly due to muscularization of the microvasculature by proliferation of pericytes. PAF may be a mediator of this process. Therefore, we examined the effects of PAF on in vitro growth of rat lung pericytes. Compared with control growth, semisynthetic PAF (10(-9) M) stimulated the 7-day mean growth of proliferating pericytes by 31% in medium with serum and 29% without serum and of previously growth-arrested pericytes by 12% with serum and 23% without serum. These effects were blocked by the PAF-receptor blocker CV-3988. PAF also increased [3H]thymidine incorporation into pericytes by 79%. Synthetic 16:0 PAF stimulated pericyte growth, but 18:0 PAF did not. PAF exposure did not induce apoptosis in pericytes. Thus PAF compounds, similar to those found in vivo, stimulate lung pericyte growth in vitro. PAF may act as a direct cytokine on cells involved in muscularization of the pulmonary vessel walls.

Prognostic value of the hyperdense middle cerebral artery sign and stroke scale score before ultraearly thrombolytic therapy

PURPOSE

To determine the relationship between the hyperdense middle cerebral artery sign (HMCAS) and neurologic deficit, as evidenced by the National Institutes of Health (NIH) stroke scale score, and to determine the relationship of the HMCAS and the NIH stroke scale score to arteriographic findings after thrombolytic therapy.

METHODS

Fifty-five patients with acute ischemic stroke were rated on the NIH stroke scale, were examined with CT, and were treated with intravenous alteplase within 90 minutes of symptom onset. Presence of the HMCAS was determined on the baseline CT scan by a neuroradiologist blinded to the patient's neurologic deficit. Patients with the HMCAS were compared with those without HMCAS with regard to baseline NIH stroke scale score, 2-hour NIH stroke scale score, findings at posttreatment arteriography, 3-month residual neurologic deficit, and 3-month ischemia volumes as evidenced on CT scans.

RESULTS

Eighteen patients (33%) had the HMCAS. These patients had a median baseline NIH stroke scale score of 19.5 compared with a median score of 10 for the patients lacking the HMCAS sign. At 3 months, one (6%) of the HMCAS-positive patients was completely improved neurologically compared with 17 (47%) of the HMCAS-negative patients. Restricting analysis to those patients with a stroke scale score of 10 or greater (n = 37), 18 HMCAS-positive patients showed less early neurologic improvement, were less likely to be completely improved at 3 months, and had larger infarcts compared with the 19 HMCAS-negative patients. Compared with the HMCAS-positive and HMCAS-negative patients with a stroke scale score of 10 or greater, patients with a stroke scale score of less than 10 had fewer occlusive changes of the internal carotid and middle cerebral arteries on posttreatment arteriograms and had a better neurologic recovery at 3 months.

CONCLUSION

The presence of the HMCAS on CT scans obtained within 90 minutes of stroke onset is associated with a major neurologic deficit, and in this study it predicted a poor clinical and radiologic outcome after intravenous thrombolytic therapy. However, a major neurologic deficit, defined as a stroke scale score of 10 or more, was better than a positive HMCAS as a predictor of poor neurologic outcome after thrombolytic therapy. Patients with a low stroke scale score (< 10) may benefit from ultraearly intravenous alteplase therapy.

Volumetric measurement of multifocal brain lesions. Implications for treatment trials of vascular dementia and multiple sclerosis

This pilot study examined the reproducibility of serial magnetic resonance (MR) measurements of brain, ventricular, sulcal, and lesion volumes in patients with ischemic brain disease using an image analysis protocol designed at the University of Cincinnati. Five patients with a clinical history of brain ischemia had two separate MR brain imaging studies using the standard clinical MR imaging protocol at the University of Cincinnati Medical Center. The MR images on both film and tape were digitized and then analyzed according to the standardized image analysis protocol. Based on tape data, variability in volume measurements between the two MR studies, as measured by the coefficient of variation, ranged from 1% for intracranial volume to 8% for ventricular volume. Variability based on film data was slightly greater, ranging from 2% for intracranial volume to 12% for lesion volume. As part of a multicenter treatment trial of vascular dementia, this method was then used to analyze MR films in 13 patients with vascular dementia who all had an MR study at baseline and at 1 year. The mean annual change in lesion volume was 4 +/- 5 cm3 (a 24% increase from the baseline lesion volume); in ventricular volume, 7 +/- 8 cm3 (a 10% increase from baseline); and in sulcal volume, 13 +/- 25 cm3 (a 5% increase from baseline). This method of image analysis, using MR film or tape-generated data, can provide reproducible serial measurements of brain, ventricular, sulcal, and ischemic lesion volumes. This method, if applied in randomized treatment trials of vascular dementia or multiple sclerosis, can be used to monitor disease progression and to evaluate the effectiveness of a given therapy.

Evaluation of predicted and measured energy requirements in burned children

OBJECTIVE

The energy predictions of nine calculations for pediatric patients were compared with measured resting energy expenditure (MREE) by means of indirect calorimetry to determine the optimal means of energy projection in the burn population younger than 3 years of age.

METHODOLOGY

Nutritional sufficiency and maintenance of preburn weight were factors in the confirmation of energy needs. Demographic factors were also studied: preburn weight, percent burn, percent third-degree burn, and age. Group 1 consisted of 24 patients younger than 3 years of age (range = 7 months to 2.6 years) with a percent burn of 30.6 +/- 2.0 and percent third-degree burn of 21.9 +/- 2.6. Group 2, consisting of 24 patients 5 to 10 years old matched by percent burn and percent third-degree burn, was included to determine whether differences between actual and projected needs were evident in older, prepubescent patients.

STATISTICAL ANALYSIS

Analysis of variance was used to ascertain the most reliable multiplier for MREE needed to maintain at least 95% of preburn weight at discharge while ensuring adequate nutrition. Multiple regression analysis was used to determine the relationship between energy requirement and body weight, percent burn, and age.

RESULTS

An additional 30% of MREE provided a consistent ratio of actual energy intake to required intake. MREE x 1.3 was used as a guide to study the existing calculations. For both groups, the four equations that predicted energy in healthy children most often underestimated MREE x 1.3, whereas the five formulas for children with burns tended to overpredict energy. Regression analysis yielded two new sets of equations using age, preburn weight, and percent burn (< 3 years = Mayes 1 [r2 = .71], 5 to 10 years = Mayes 3 [r2 = 70] or percent third-degree burn (< 3 years = Mayes 2 [r2 = .68], 5 to 10 years = Mayes 4 [r2 = .67]).

CONCLUSIONS

The application of a 30% factor to MREE is supported in burn patients younger than 10 years of age. Standard energy projections do not provide an accurate assessment of energy needs in the pediatric burn population; thus, two sets of equations that more closely predict energy needs are proposed.

Analysis of the dual discrimination ability of the two-port photorefractive joint transform correlator

An all-optical joint transform correlator featuring two operative correlation planes(ports) with complementary performance is presented. We present the theory of operation, derive the input-output characteristics, and demonstrate computer simulations and experimental results. The two-port joint transform correlator is based on simultaneous use of two photorefractive wave-mixing architectures. The first port uses two-beam coupling, and the second port uses four-wave mixing. The performance of the two ports depends on an experimentally controlled beam intensity ratio and the photorefractive coupling coefficient. With appropriate selection of these parameters, the first port is capable of high discrimination, while simultaneously the second offers a low discrimination output. Our results show that the two-beam coupling port can achieve peak-to-noise and signal-to-noise ratio values better than the phase-only correlator, whereas the four-wave-mixing port performs similarly to the classical joint transform correlator. This leads to a potential application in which the correlator could be set up so that in one port a general class is detected (interclass) and, in the other, the specific item in a class is detected (intraclass).

Nearly optimal correlations for shift-invariant associative memories

The optical implementation of the Hopfield algorithm in shift-invariant holographic associative memories is based on the use of correlators with matched filters. However, it is well known that such correlators have poor discrimination. We propose nearly optimal correlation designs for associative memories based on correlation filters that have maximum discrimination ability. These new designs avoid large cross-correlation-peak terms caused by a mismatch between partial input and the fully stored information in the filter. These solutions rely on whitened spectra of the stored and the recalled information.Computer simulations are made of eight different combinations.

[Pericardial hydatid cysts. Value of magnetic resonance imaging. Apropos of a clinical case]

Cardiac hydatic cysts are rare and represent 0.5 to 2% of all hydatic cysts in humans [1, 2]. They are usually found in the left or right ventricle, and exceptionally in the interventricular septum. An exclusively pericardia hydatic cyst is excessively rare. The case reported here emphasizes: That this hydatid cyst of the pericardium remained asymptomatic until rupture. The role of echocardiography as a diagnostic tool. The superiority of MRI to CT Scan in the establishment of a precise preoperative diagnosis.

Decreased platelet counts in infants of diabetic mothers

Infants of diabetic mothers (IDMs) have hematologic indices consistent with increased fetal erythropoiesis, presumably in response to chronic intrauterine hypoxemia. We hypothesized that increased erythropoiesis, as is evident from increased nucleated erythrocyte counts, would be accompanied by interrelated changes in thrombopoiesis and would correlate with maternal glycemic control during pregnancy. We compared absolute nucleated erythrocyte counts and platelet counts obtained in the first 24 hours of life in 32 term, nonasphyxiated IDMs with 47 controls. The IDM group had higher absolute nucleated erythrocyte counts (1.0 +/- 1.3 x 10(9)/L versus 0.4 +/- 0.7 x 10(9)/L; p < 0.05), and lower platelet counts (235 +/- 77 x 10(9)/L versus 348 +/- 79 x 10(9)/L; p < 0.001) than controls. Absolute nucleated erythrocyte counts correlated inversely with platelet counts (r = -0.28; p < 0.02). These neonatal hematologic measurements did not correlate with various parameters of maternal glycemic control. We conclude that in IDMs, increased erythropoiesis is accompanied by decreased platelet counts. These data are consistent with the theory of an erythropoietin-induced shift of fetal multipotent stem cell differentiation toward erythropoiesis at the expense of thrombopoiesis.

Photorefractive two-beam coupling optimal thresholding filter for additive signal-dependent noise reduction

Computer simulations of photorefractive thresholding filters for the reduction of artifact or dust noise demonstrate an increase in signal-to-noise ratio (SNR) of 70% to 95%, respectively, of that provided by the Wiener filter for inputs with a SNR of approximately 3. These simple, nearly optimal filters use a spectral thresholding profile that is proportional to the envelope of the noise spectrum. Alternative nonlinear filters with either 1/ν or constant thresholding profiles increase the SNR almost as much as the noise-envelope thresholding filter.

All-optical nonlinear joint Fourier transform correlator

We present the first all-optical nonlinear joint transform correlator based on a square-law receiver in the Fourier plane. Our device uses a photorefractive limiting quadratic processor. The compressional nonlinearity associated with the transfer function of the limiting quadratic processor enables the correlator to detect signals embedded in Gaussian and non-Gaussian noise. In the limiting region this device correlates the phase-only information of the input. This is the first time to our knowledge that photorefractives or real-time holography has been used in the correlation of the phase-only information. We demonstrate the operation of this device experimentally, and we evaluate its performance throughcomputer simulation for various forms of noise.

Comparative responses of genetically lean and fat chickens to lysine, arginine and non-essential amino acid supply. I. Growth and body composition

1. Three experiments were performed to study the effects of amino acid imbalance on the growth of genetically lean (LL) or fat (FL) male chickens from 28 to 42 d of age. In experiment 1, five concentrations of digestible lysine were compared (4.75, 6.75, 7.75, 8.75 and 9.75 g/kg). In experiment 2, four concentrations of digestible arginine were compared (6.53, 7.69, 8.84 and 10.0 g/kg). In experiment 3, three diets were compared: a high-protein diet (189 g CP/kg), a low-protein diet containing added essential amino acids (EAA) (144 g CP/kg) and this low-protein diet supplemented with 40 g/kg of non-essential amino acids (NEAA) (glutamic acid+aspartic acid). 2. LL birds exhibited a lower growth rate than the FL when the diet was deficient in either lysine or arginine. Plotting weight gain against lysine or arginine intake suggested that most of this effect was caused by variations in food intake. 3. When protein gains (body or total proteins) were plotted against lysine or arginine intake, LL chickens appeared more efficient than FL chickens. 4. Similar growth rates, although slightly lower in FL, were obtained with low- and high-protein diets. However, NEAA supplementation of the low-protein diet reduced adiposity of LL and did not modify that of FL. Increasing crude protein content (all amino acids) was more effective than NEAA supplementation in decreasing the adiposity of both lines.

Photorefractive phase-conjugate technique for measuring surface granularity

A self-aligned photorefractive autocorrelator is implemented for the real-time use of second-order statistics for texture analysis. We demonstrate the measurement of the length scale of the granularity of a rough surface.

The 1994 Clinical Research Award. A prospective clinical study of the polysomnographic stages of sleep after burn injury

Although subjective evidence suggests that patients with burns are deprived of sleep, previous clinical studies have been limited to observational data and have not to date included electroencephalographic or polysomnographic recordings. The purpose of this study was to characterize the sleep pattern of patients suffering from thermal injury. Biweekly 24-hour polysomnographic measurements (electromyography, electrooculography, and electroencephalography) were performed with 12 leads. This measuring permitted continuous recording of intrinsic electrical activity in skeletal muscles via chin electrodes, eye movement via outer canthal electrodes, and brain wave activity with the other bipolar electrodes. Determinations were obtained on 11 patients with thermal injuries for a total of 43 24-hour periods. The patients had a mean age of 8.31 +/- 1.5 years (range 1.4 to 16 years), a mean total body surface area burn of 55.1% +/- 16.5% (range 17.5% to 90.5%), and a mean full-thickness burn of 48.5% +/- 8.1% (range 10.5% to 90.5%). Although mean total sleep time was seemingly adequate (625.1 +/- 31.6 min/patient/24 hrs), large aberrations in sleep stage distribution were noted. Significant decreases in stage 3 + 4 and in rapid eye movement (deep sleep) and increases in stages 1 and 2 (light sleep) were noted, suggesting a cycling back to stages 1 or 2 after disruption of sleep. Overall, in 43 runs 40% of the subjects were completely lacking stage 3 + 4, and 19% were missing rapid eye movement during an entire 24-hour run.(ABSTRACT TRUNCATED AT 250 WORDS)

Phase-coding technique for one-way image transmission through aberrating media

We propose and demonstrate one-way image transmission through an aberrating medium. In contrast to previous techniques, which usually use exact phase compensation for correcting phase distortion, our technique uses the phase- or amplitude-coded form of the exact phase. This technique allows us to utilize a wide variety of spatial light modulators for image correction in one-way image transmission through aberrating media.

Glycemic thresholds for spontaneous abortion and congenital malformations in insulin-dependent diabetes mellitus

OBJECTIVE

To test the hypothesis that women with insulin-dependent (type I) diabetes have a threshold of glycemic control in early pregnancy for increased risks of spontaneous abortion and congenital malformations.

METHODS

Receiver-operating characteristic (ROC) curves were formed for the occurrence of abortion and malformations as a function of the median first-trimester preprandial blood glucose concentration and the first measured glycohemoglobin concentration in pregnant women with type I diabetes.

RESULTS

Fifty-two of the 215 women (24%) who enrolled before 9 weeks' gestation had spontaneous abortions. Six percent of the women enrolled before 14 weeks had infants with major congenital malformations. Thresholds for an increased risk of abortion and malformations were a median first-trimester blood glucose concentration of 120-130 mg/dL or an initial glycohemoglobin concentration of 12-13% (6.2-7.5 standard deviations above the normal mean).

CONCLUSIONS

Type I diabetic women with initial glycohemoglobin concentrations in pregnancy above 12% or median first-trimester preprandial glucose concentrations above 120 mg/dL have an increased risk of abortion and malformations. Below these glycemic thresholds, the risks are comparable to those in nondiabetic women.

Real-time holographic frequency-division demultiplexing: theoretical aspects

The multiplicative and low-band-pass filtering characteristics of real-time holograms in photorefractive media are proposed for use for frequency-division demultiplexing. Several aspects of the frequencydivision demultiplexer are discussed and derived. These aspects are baseband demodulation of optical images, demultiplexing limits, heterodyne cross talk, and nonlinear cross-talk effects that are due to second- and high-order nonlinearities. The nonlinear cross talk is calculated in two different approaches. Both approaches indicate that nonlinear effects enhance the performance of this demultiplexer.

Impact of metabolic control of diabetes during pregnancy on neonatal hypocalcemia: a randomized study

OBJECTIVE

To test the hypothesis that strict control of diabetes during pregnancy can reduce the risk for neonatal hypocalcemia in infants of diabetic mothers.

METHODS

One hundred thirty-seven pregnant women with insulin-dependent diabetes enrolled before 9 weeks' gestation were randomized to one of two treatment groups. In 68 subjects, the goals were fasting blood glucose level less than 4.44 mmol/L (80 mg/dL) and 1.5-hour postprandial blood glucose level less than 6.66 mmol/L (120 mg/dL) (strict control), whereas in 69 the goals were fasting blood glucose level less than 5.55 mmol/L (100 mg/dL) and 1.5-hour post-prandial glucose level less than 7.77 mmol/L (140 mg/dL) (customary control).

RESULTS

Infants in the strict control group had a significantly lower rate of hypocalcemia (mean calcium less than 8.0 mg/dL in term infants and less than 7.0 mg/dL in preterm infants) than infants in the customary control group (17.6 versus 31.9%; P < .05). Using logistic regression analysis and after adjusting for the effects of gestational age, asphyxia, and White class on hypocalcemia, the difference between groups remained significant. The lowest infant serum calcium concentration correlated significantly with maternal glycohemoglobin A1 concentration at delivery (P = .03), gestational age (P = .0001), and the lowest serum magnesium concentration (P = .0001).

CONCLUSION

Strict management of diabetes in pregnancy is associated with a reduction in the rate of neonatal hypocalcemia.

Photorefractive mixing of amplitude-modulated signals

We analyze the circumstances under which a real-time hologram written with amplitude-modulated beams behaves as a linear mixer. We calculate nonlinear correction terms that can be used to analyze the linearity of a variety of photorefractive time-integrative devices.

Real-time holographic baseband frequency demodulator

The multiplicative and low-bandpass filtering characteristics of real-time holograms in photorefractive media are used as a basis for a baseband frequency demodulator by means of holographic homodyne detection. We experimentally demonstrate the demodulation of spatial bandpass signals in the kilohertz regime and homodyne detection in the gigahertz regime.

Poor glycemic control and antepartum obstetric complications in women with insulin-dependent diabetes

OBJECTIVE

The purpose of this study was to test the hypothesis that the rate of complications of pregnancy in women with insulin-dependent diabetes is higher than in nondiabetic women and is associated with poor glycemic control and microvascular disease.

METHOD

Women who enrolled in a multidisciplinary program of diabetes in pregnancy prior to 20 weeks' gestation were included in the study and matched 1:2 by age, race and parity to a control group of nondiabetic women. Complications of pregnancy were retrospectively analyzed and compared between groups. The association of complications with glycemic control and microvascular disease was analyzed within the diabetic group.

RESULT

Women with diabetes had significantly higher rates of pregnancy-induced hypertension (PIH), polyhydramnios, pyelonephritis, preterm delivery and meconium-stained amniotic fluid. Poor glycemic control, particularly during the first and second trimesters of pregnancy, was associated with all complications, except pyelonephritis. Microvascular disease was associated with PIH and preterm delivery prior to 34 weeks.

CONCLUSION

Women with insulin-dependent diabetes are at high risk for complications of pregnancy. Glycemic control during the first and second trimesters may affect events later in pregnancy.

Evaluation of latex allergy in patients with meningomyelocele

Seventy-six patients with meningomyelocele were evaluated for latex sensitivity by medical history and epicutaneous skin testing. Four different latex glove extracts, two nonlatex glove extracts, cornstarch, selected inhalant antigens, and negative and positive controls were used for skin testing. Forty-nine patients (64.5%) were skin test positive to latex extracts (latex-positive group). Twenty-four patients (49%) of the latex-positive group and none of the latex-negative group had histories of immediate reactions to latex products (P less than .001). The latex-positive group had a higher mean number of surgical procedures, 12.67 +/- 11.27, compared with 6.89 +/- 6.55 (P less than .001) in the latex-negative group. Twenty-three of the latex-positive patients (47%) used latex products daily compared to seven patients (26%) in the latex-negative group (P = .073). Twenty latex-positive patients (41%) had atopy compared with five patients (19%) of the latex negative group (P = .041). There was no significant difference between the two groups in age, sex, daily catheterization, or positive skin tests to cornstarch. All 76 patients tested negative to the nonlatex glove extracts. Ten control subjects tested negative for all latex and nonlatex glove extracts.

The value of urodynamic studies in infants less than 1 year old with congenital spinal dysraphism

The role and timing of urodynamic studies in infants with congenital spinal dysraphism are controversial. We reviewed 64 consecutive infants with a mean followup of 28 months who underwent video urodynamic study when they were less than 1 year old (50 of the 64 patients were less than 3 months old). A previously reported video urodynamic "hostility score" from 0 (best) to 10 (worst) was given to each study and compared with the outcome of the upper urinary tract and subsequent urodynamic studies. A larger fraction of these children with high hostility scores (5 or greater) had upper tract deterioration (39%) compared to those with low hostility scores (9%). Moreover, 6 of 14 patients in the low hostility group who underwent repeat video urodynamic studies after age 1 year had high hostility lower urinary tracts. We conclude that urodynamic studies during and after the first year of life are useful in the appropriate urological evaluation and management of infants with spinal dysraphism.

Primary non-Hodgkin lymphoma of the vulva

We report a rare case of non-Hodgkin lymphoma located in the vulva. The diagnosis was supported by the cytological anomalies in material obtained by fine needle aspiration. The tumor was removed with wide excision, and the patient was alive and in good health ten months after surgery.

Birth trauma in insulin-dependent diabetic pregnancies

Infants of insulin-dependent diabetic mothers are considered to be at high risk for birth trauma, presumably due to macrosomia. With current management of diabetes in pregnancy, including strict glycemic control, the rate and the severity of macrosomia should be decreased. The frequent use of ultrasound to assess fetal growth and weight and the use of cesarean delivery in case of fetal macrosomia should further decrease the risk for birth trauma in these infants. We therefore undertook this study to test the null hypothesis that with current management, insulin-dependent diabetic mothers have a rate of birth trauma similar to that of infants of nondiabetic mothers (normal glucose challenge test at 28 weeks' gestation) matched for gestational age at birth, presence or absence of labor, delivery method (vaginal versus cesarean), and race. We studied 118 insulin-dependent diabetic mothers (White classes B-RT) and 354 control subjects (three matches for each insulin-dependent diabetic mother). The rate of birth trauma was 3.4% in insulin-dependent diabetic mothers, not significantly different from controls (2.5%). Logistic regression analysis in which birth trauma was the dependent variable and diabetes, race, presence or absence of labor, mode of delivery (vaginal versus cesarean), infant weight, and infant head circumference were independent variables revealed that only vaginal delivery was a significant risk factor for birth trauma in infants in both groups (p = 0.01). Most frequently observed birth traumas were brachial plexus injury, facial nerve injury, and cephalohematoma. Of the three infants with brachial plexus injury (insulin-dependent diabetic mothers, two; controls, one), two were delivered with use of midforceps.(ABSTRACT TRUNCATED AT 250 WORDS)

Binary phase-only filter associative memory

An associative memory is implemented by using a binary phase-only filter as the memory element in a two-focal-length (2-f) correlator architecture. A sharp autocorrelation peak, combined with the 2-f architecture, allows the noise to be separated adequately from the signal such that a simple plane mirror can be used in the correlation plane instead of a nonlinearity.

Progression of diabetic retinopathy in pregnancy: association with hypertension in pregnancy

OBJECTIVE

To test the hypothesis that women with insulin-dependent diabetes and chronic or pregnancy-induced hypertensive disorders are at increased risk for developing retinopathic complications during pregnancy.

STUDY DESIGN

One hundred fifty-four women with insulin-dependent diabetes were prospectively followed in an intensive program of diabetes in pregnancy. Ophthalmologic evaluations were obtained through pregnancy and at 6 to 12 weeks post partum, and findings were graded by a standard scale. Association of retinopathic progression with risk factors was tested with chi 2 and multiple logistic regression analysis.

RESULTS

Fifty-one women had progression of retinopathy during pregnancy; postpartum regression was observed in 13 women. Changes in glycemic control early in pregnancy, chronic hypertension, and pregnancy-induced hypertension were significantly associated with progression of retinopathy.

CONCLUSION

Women with insulin-dependent diabetes who have hypertensive disorders in pregnancy are at increased risk for progression of retinopathy.

Cooling effects and comfort of four cooling blanket temperatures in humans with fever

Adult patients with fever (N = 89) were randomized into four blanket temperature groups: 7.2, 12.8, 18.3, and 23.9 degrees C. With their extremities protected, subjects were given acetaminophen and placed between two cooling blankets. There were no differences in the mean time (in minutes) to cool to a body temperature of 38.9 degrees C among groups. Although there were no differences in mean time for shivering, a trend of less shivering was apparent with warmer blanket temperatures. Few patients shivered (n = 17). There were no differences in the mean time (in minutes) for afterfall among the groups. The mean amount of afterfall for the 7.2 degrees C group (1.04 degrees C, SD = 0.50) was significantly greater than the 23.9 degrees C group (0.68 degrees C, SD = 0.47). Comfort scores significantly improved with warmer blanket temperatures. Thus, warmer blanket temperatures provided similar rates of cooling as the colder temperatures, yet were perceived to be more comfortable by the patient.

Factors associated with career longevity in residency-trained emergency physicians

STUDY OBJECTIVE

To test the hypothesis that residency-trained emergency physicians who left the practice of emergency medicine do not differ significantly from those who continue to practice.

DESIGN

A retrospective cohort study using a mailed questionnaire.

TYPE OF PARTICIPANTS

Eight hundred fifty-eight emergency medicine residency graduates from 1978 through 1982.

METHODS

A mailed questionnaire was used to obtain data from the study population. Individuals who did not respond to the first mailing were sent a second survey six weeks later. A sample of 10% of nonrespondents was contacted by telephone and compared with respondents on five variables. Respondents were divided into physicians who continued to practice emergency medicine and those who had elected to leave the specialty. The variables used to compare the two groups included personal and professional demographics, career satisfaction, and satisfaction with training. chi 2, Fisher's exact t-test, and logistic regression were used to analyze the data with an a priori level of significance set at .05.

MEASUREMENTS AND MAIN RESULTS

There were 539 complete responses for a response rate of 62.8%. No statistical differences between responders and nonresponders were identified. The ten-year survival rate of respondents was 84.9%. Those who left emergency medicine were less likely to be board certified in emergency medicine (P less than .001), were more likely to be board certified in another field (P = .001), were less likely to work with residents during their emergency medicine practice (P = .009), and were more likely to report an annual gross income of less than $100,000 per year (P less than .001). Emergency physicians who have left the field were less likely to report being satisfied or very satisfied with their initial choice of emergency medicine as a specialty (P = .001). There was no difference in satisfaction with the quality of emergency medicine residency training (P = .183).

CONCLUSION

Career longevity of residency-trained emergency physicians has been greater than early predictions. Interactions with residents, higher income, satisfaction with training decision, and board certification in emergency medicine are variables associated with a higher retention rate.

Neonatal hematocrit and maternal glycemic control in insulin-dependent diabetes

We hypothesized that in infants of diabetic women neonatal hematocrit would correlate with third-trimester maternal glycemic control. Neonatal hematocrit correlated with the maternal total glycosylated hemoglobin level at delivery (r = 0.36; p less than 0.05) but not at 36 weeks of gestation in 32 mother-infant pairs. Improved maternal glycemic control during late gestation may decrease the incidence of neonatal polycythemia.

The prognostic value of nutritional and inflammatory indices in patients with burns

The Prognostic Inflammatory and Nutritional Index (PINI = [alpha 1-acid glycoprotein x C-reactive protein] divided by [albumin x prealbumin]) has been proposed as a means of predicting morbidity or mortality in hospitalized patients. This study compared the efficacy of the PINI versus its individual determinants as potential prognostic indicators of infection or death in patients with burns. Laboratory data from postburn days 7 to 10 were evaluated in a series of 60 patients who had a mean total body surface area (TBSA) burn of 44.7% (range 10% to 81%) and a mean age of 18.9 years (range, 0.5 to 71 years). Survivors had a mean TBSA burn of 42.9%, whereas patients who subsequently died had a mean TBSA burn of 51.8% (not significant). Percent third-degree burn and alpha 1-acid glycoprotein were likewise not related to the mortality rate. We found the PINI to be associated with death (p less than 0.0003), as were the variables C-reactive protein (p less than 0.0002), prealbumin (p less than 0.0001), and albumin (p less than 0.03). Thirty-six patients had infectious complications that were statistically related to percent burn (p less than 0.02), percent third-degree burn (p less than 0.003), alpha 1-acid glycoprotein (p less than 0.05), prealbumin (p less than 0.0009), and the PINI (p less than 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic anemia in pregnant ewes: maternal and fetal effects

To examine maternal and fetal responses to a sustained reduction in maternal hematocrit during days 110-138 of ovine gestation, 22 ewes and their singleton fetuses were instrumented. By repetitive exchange transfusions, the hematocrit in 12 ewes was decreased from 28.1 +/- 0.8 (baseline, day 110) to 14.0 +/- 0.7% (day 117) and maintained at that level. Anemic ewes demonstrated a transient increase in heart rate from 99 +/- 4 to 116 +/- 4 beats/min and a sustained increase in cardiac output from 117 +/- 8 to 153 +/- 11 ml.min-1.kg-1 compared with control animals. Uterine blood flow steadily increased in control animals from 868 +/- 100 (day 110) to 1,410 +/- 177 ml/min (day 138) but failed to increase in the anemic ewes. Uterine oxygen delivery fell from 83 +/- 10 to 39 +/- 4 ml/min with production of anemia and remained low in the anemic ewes. Arterial PO2 and oxygen content in the fetuses of anemic ewes fell transiently below control values (19.9 +/- 0.8 vs. 23.4 +/- 1.0 mmHg and 5.3 +/- 0.3 vs. 6.8 +/- 0.4 ml/dl, respectively) but did not persist. Fetal weights at 138 days gestation were lower in the anemic group (2,596 +/- 329 vs. 4,313 +/- 132 g). We conclude that chronic maternal anemia results in a decreased uterine blood flow as well as decreased uterine oxygen delivery. The fetus responds with decreased growth but does not develop sustained hypoxia or acidosis.

Pre-conception management of insulin-dependent diabetes: improvement of pregnancy outcome

Poor glycemic control in early pregnancy in insulin-dependent diabetes is associated with an increased risk for spontaneous abortions and congenital malformations. Strict glycemic control from the initial stages of embryogenesis is one of the major goals of management in these pregnancies. We hypothesized that insulin-dependent diabetic patients attending a pre-conception program would have improved glycemic control compared with insulin-dependent diabetic patients who enrolled after conception and would have better pregnancy outcome, with fewer spontaneous abortions and fewer major malformations. Ninety-nine pregnant insulin-dependent diabetic patients were recruited before reaching 9 weeks' gestation and were followed prospectively throughout pregnancy. Twenty-eight had attended a pre-conception clinic to optimize glycemic control (study group) and 71 had enrolled after conception (control group). Early glycemic control was significantly better in the study group: Glycohemoglobin values at the first prenatal visit and at 9 and 14 weeks' gestation were significantly lower than in the control group. The rate of spontaneous abortion was significantly lower in the study group (7%) than in the controls (24%). There was one major malformation in the control group and none in the study group. We conclude that patients with insulin-dependent diabetes attending a pre-conception program have a decreased rate of early pregnancy loss compared with those receiving prenatal care early in pregnancy.

[Hydatid cyst of the right ventricle]

A 35 years old women has had palpitations for the last six months on auscultation she has a mid systolic clic. The echocardiogram shows a typical aspect of right ventricular hydatid cyst. The right and left catheterization confirms the diagnosis. A thoracic scan is done to rule out other localisations. The patient is successfully operated. The authors emphasized the importance of an echocardiogram in a visceral or secondary localisation of echinococcosis.

Noise reduction using adaptive spatial filtering in photorefractive two-beam coupling

We present an optical signal-processing technique for additive noise reduction that uses the noisy signal and a Gaussian reference beam to produce an adaptive Wiener filter. We experimentally demonstrate an improvement from 1 to 8 in the signal-to-noise ratio by using nonlinear gain in two-beam coupling in barium titanate to transmit 50% of the signal and 6% of the noise.

Hypertension during pregnancy in insulin-dependent diabetic women

Insulin-dependent diabetic patients are at increased risk for hypertensive disorders of pregnancy. This study was designed to study prospectively the rate of pregnancy-induced hypertension (PIH) in 175 insulin-dependent diabetic pregnancies (88 White classes B-C, 87 classes D-RT). Pregnancy-induced hypertension was defined as two or more occurrences after 20 weeks' gestation of a mean arterial pressure (MAP) of 105 mmHg or greater or an increase of 20 mmHg or greater from the baseline MAP. The rate of PIH in the diabetic population was 15.4% and was significantly associated with nulliparity, poor glycemic control in the first and second trimesters, and advanced White class. Neonatal outcome was not significantly altered in the presence of PIH. We speculate that improved glycemic control throughout pregnancy might reduce the rate of this complication in diabetic patients.

Effects of chronic instrumentation on fetal growth

Chronically-instrumented fetal sheep are a commonly used animal model for the study of fetal growth and metabolism. In the current study, we wanted to test the hypothesis that instrumentation alone would alter fetal growth patterns. Thirty-two animals in three groups were used: (i) non-instrumented animals (n = 10); (ii) instrumented with catheters in the maternal and fetal femoral artery and vein and electromagnetic flow probes on the main uterine arteries (n = 10): (iii) animals instrumented as group 2, but with the addition of a doppler flow probe on the common umbilical artery and a common umbilical vein catheter (n = 12). Animals in group 2 and 3 were monitored until 137 to 140 days of gestation, at which time they were sacrificed for fetal morphometric measurements. Instrumentation significantly (P less than 0.05) decreased fetal body weight, length, and thymus weights. Liver-to-body ratios increased (P less than 0.05) in both surgically-instrumented groups. The addition of the umbilical artery doppler flow probe and an umbilical venous catheter did not lead to any further alterations in fetal growth. The current study demonstrates that surgical instrumentation alone can lead to significant alterations in fetal growth.

Minor congenital malformations in infants of insulin-dependent diabetic women: association with poor glycemic control

A prospective study of 171 insulin-dependent diabetic pregnant women was undertaken to establish the relationship of glycemic control with minor congenital malformations. Each live-born infant was assessed systematically by two independent examiners using a standardized checklist. There were 32 infants with minor congenital malformations (18.7%). There were significant differences in mean glycohemoglobin A1 between the group with minor congenital malformations and the group without congenital malformations at 12, 16, and 20 weeks, but not at 8 or 24 weeks. Logistic regression analysis showed that maternal age, race, gravidity, White class, duration of diabetes, maternal vasculopathy, and cigarette smoking were not significant variables correlated with minor congenital malformations. Because glycohemoglobin levels from 12-20 weeks are believed to reflect glycemic control from approximately 6-20 weeks, we conclude that poor glycemic control during late embryogenesis and early fetal development is associated with an increased risk of minor congenital malformations. We speculate that improvement of glycemic control during this period should decrease the risk of minor congenital malformations.

Postnatal surge in serum calcitonin concentrations: no contribution to neonatal hypocalcemia in infants of diabetic mothers

It has been suggested that hypercalcitoninemia may contribute to neonatal hypocalcemia in infants of diabetic mothers (IDM). Because the role of calcitonin (CT) in Ca metabolism in humans is questionable, we hypothesized that serum CT peaks similarly after birth in IDM and controls and that serum Ca concentrations do not correlate with serum CT. Forty-seven term IDM (White classes B-RT) were compared with 31 controls. Controls were born after normal pregnancies, labors, and deliveries. Blood samples (cord and 24 h) were analyzed for Ca, Mg, parathyroid hormone (PTH), and CT. Repeated measures analysis showed increasing serum Mg, PTH, and CT, and decreasing Ca over time. The incidence of hypocalcemia was significantly higher in the diabetic group (p less than 0.01) and the incidence of hypomagnesemia was borderline significantly higher (p less than 0.06). There were no differences in cord or 24-h serum concentrations of CT between groups. In multiple regression analysis, serum Ca and PTH were correlated (p less than 0.02, R2 = 0.33), but not serum Ca and CT; the increase in serum PTH in relation to serum Ca at the nadir (24 h) correlated directly with serum Mg concentrations (R2 = 0.31, p less than 0.05). Thus, serum CT increases after birth irrespective of the rate of decrease of serum Ca in both IDM and controls; high CT concentrations observed after birth (as compared with adult norms) do not seem to play a role in the pathogenesis of neonatal hypocalcemia in IDM; and responsiveness of parathyroid gland at birth is adversely affected by hypomagnesemia, which supports the theory of functional hypoparathyroidism in Mg deficiency.

High infectious morbidity in pregnant women with insulin-dependent diabetes: an understated complication

Patients with insulin-dependent diabetes are prone to infection, possibly related to poor metabolic control. Relative immune deficiency exists in pregnancy. We hypothesized that pregnant patients with insulin-dependent diabetes are at an increased risk for infection and that infection is related to poor glycemic control. We matched 65 pregnant women with insulin-dependent diabetes to 65 nondiabetic pregnant controls. At least one episode of infection before delivery occurred in 83% of the women with insulin-dependent diabetes (26% in control group). The rate of postpartum infection was five times higher in the group with insulin-dependent diabetes and they were susceptible to more kinds of infections. Although there was no overall difference among the indices of glycemic control, hemoglobin A1 obtained before the infection was higher than during infection. We conclude that a high rate of infection exists in pregnant women with diabetes; infection and poor glycemic control may be associated, but it is unclear whether improvement in metabolic control will reduce this high infection rate.

Histopathology of spontaneous abortion in diabetic pregnancies

This study reviewed the histopathology of endometrial curettings following spontaneous abortion in diabetics and controls. The two groups did not differ significantly for an array of histologic features. The relationships between histopathology and diabetic White class, diabetic nephropathy or retinopathy, first trimester hemoglobin A1 percentage, and first trimester serum magnesium level were studied. The only significant correlation found was between diabetic retinopathy and decidual congestion with the presence of venous fibrin.

Early neonatal predictors of neonatal hypocalcemia in infants of diabetic mothers: an epidemiologic study

Prematurity, neonatal asphyxia, hypomagnesemia, and advanced maternal diabetes are traditional risk factors for hypocalcemia in infants of diabetic mothers (IDMs). The aim of this study was to determine the relative contribution of these factors separately and combined in a cohort of diabetic pregnancies managed prospectively in the recent 9 years and to find accurate predictors of neonatal hypocalcemia in infants of diabetic mothers. We hypothesized that these factors plus low cord blood calcium (Ca) concentration allow prediction of IDMs who develop neonatal hypocalcemia. We studied 186 IDMs (White class B-RT); gestational age (GA, weeks) was by last menstrual period, confirmed +/- 2 weeks by Ballard score. The goals of glycemic control were: preprandial blood glucose less than 100 mg/dl and 90-minute postprandial blood glucose less than 140 mg/dl. Apgar scores, and cord, 24-, 48- and 72-hour serum calcium (Ca) (mg/dl) and magnesium (Mg; mg/dl) were determined. In univariate analysis, lowest serum Ca correlated with cord blood Ca (r = 0.48, p less than 0.001), GA (r = 0.37, p less than 0.001), and 1-minute Apgar score (r = 0.18, p = 0.09), but did not correlate with cord Mg or with advanced White class. In multiple regression, cord Ca and GA were dominant effects and other variables became insignificant. Lowest Ca (mg/dl) was predicted as follows: lowest Ca = 34.05 - 3.22 (Ca cord) - 0.84 (GA) + 0.10 (GA) (Ca cord). This equation predicts neonatal hypocalcemia (lowest Ca less than 8 mg/dl) with a sensitivity of 72% and a specificity of 75%. Thus, GA and cord Ca allow determination of IDMs at risk for neonatal hypocalcemia.

Base changes at position 792 of Escherichia coli 16S rRNA affect assembly of 70S ribosomes

To investigate the function of base 792 of 16S rRNA in 30S ribosomes of Escherichia coli, the wild-type (adenine) residue was changed to guanine, cytosine, or uracil by oligonucleotide-directed mutagenesis. Each base change conferred a unique phenotype on the cells. Cells containing plasmid pKK3535 with G792 or T792 showed no difference in generation time in LB broth containing ampicillin, whereas cells with C792 exhibited a 20% increase in generation time in this medium. To study the effect on cell growth of a homogeneous population of mutant ribosomes, the mutations were cloned into the 16S rRNA gene on pKK3535 carrying a spectinomycin-resistance marker (thymine at position 1192), and the cells were grown with spectinomycin. Cells containing G792 or C792 showed 16% and 56% increases in generation time, respectively, and a concomitant decrease in 35S assimilation into proteins. Cells with T792 did not grow in spectinomycin-containing medium. Maxicell analyses indicated decreasing ability to form 70S ribosomes from 30S subunits containing guanine, cytosine, or uracil at position 792 in 16S rRNA. It appeared that C792-containing 30S ribosomes had lost the ability to bind initiation factor 3.

Spontaneous abortions in repeat diabetic pregnancies: a relationship with glycemic control

In previous studies, we reported a high rate of spontaneous abortions in insulin-dependent diabetic pregnancies. Abortions were associated with poor first-trimester glycemic control. We hypothesized that improvement of glycemic control from one pregnancy to the other would improve fetal outcome and that deterioration of glycemic control would increase the likelihood of abortion. We studied prospectively 43 insulin-dependent diabetic women (White class B-RF) with two consecutive pregnancies, recruited before 9 weeks' gestation. Preprandial and 90-minute postprandial blood glucose concentrations were measured at each weekly visit. Glycohemoglobin A1 was measured at 9 weeks' gestation. Twenty women had two successful pregnancies and 15 had an abortion followed by a successful pregnancy (abortion-no abortion); the sample sizes for other sequences (no abortion-abortion, N = 5; and abortion-abortion, N = 3) were too small to allow for analysis. Glycohemoglobin A1 concentrations were stable in the sequence no abortion-no abortion (9.7 +/- 0.5 versus 9.8 +/- 0.4%, mean +/- SEM; not significant), whereas in the sequence abortion-no abortion, there was a significant decrease in glycohemoglobin A1 values from the nonsuccessful to the successful pregnancy (10.7 +/- 0.6 versus 9.3 +/- 0.4%; P = .01). Similarly, in the sequence abortion-no abortion, there was a significant decrease in mean postprandial blood glucose from first to second pregnancy (166 +/- 13 versus 135 +/- 11 mg/dL; P = .04), whereas in the sequence no abortion-no abortion, mean postprandial blood glucose did not change significantly (160 +/- 14 versus 144 +/- 11 mg/dL; not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

Major malformations in infants of IDDM women. Vasculopathy and early first-trimester poor glycemic control

From animal and in vitro studies, it has been suggested that high environmental glucose, ketone, or insulin concentrations and low glucose or insulin concentrations may be etiologic factors for congenital malformations (CMs) in infants of diabetic mothers (IDMs). Transplacental passage of antibody-bound insulin has been demonstrated in humans. Controversy exists regarding the pathophysiology of CMs in human insulin-dependent diabetes mellitus (IDDM) pregnancies. We hypothesized that CMs in IDMs are associated with maternal vasculopathy, poor first-trimester glycemic control (i.e., hyper- and/or hypoglycemia), advanced White class, and high insulin requirements. We studied 165 first pregnancies of women with IDDM from 1978 to 1986. The goals of glucose control were a fasting blood glucose of less than 100 mg/dl and a 90-min postprandial blood glucose of less than 140 mg/dl. Insulin requirements, body weight, and pre- and postprandial blood glucose were recorded at weekly clinic visits. Maternal blood HbA1 was measured on entry and every 4 wk to confirm that adequate glycemic control was achieved. Women who enrolled in the project were interviewed during gestation by a geneticist/dysmorphologist who obtained genetic and environmental histories using a standard questionnaire. All live-born infants and stillbirths were examined. Each live-born infant was assessed systematically by two independent examiners, a neonatologist and a geneticist/dysmorphologist; examination with standardized checklists was performed in the newborn nursery as soon after birth as was practical. In first pregnancies in the study, there were 13 IDMs with major CMs (7.9%).(ABSTRACT TRUNCATED AT 250 WORDS)