The effect of pregnancy on cyclosporine levels in renal allograft patients

OBJECTIVE

To assess the effects of pregnancy on cyclosporine levels in six renal allograft patients.

METHODS

Maternal demographic, laboratory, clinical, and perinatal outcome data were recorded in six pregnant women with previous renal allografts receiving cyclosporine immunosuppression. The cyclosporine and serum creatinine levels were measured before pregnancy, during each trimester, and postpartum.

RESULTS

The mean (standard deviation [SD]) maternal age was 29.1 (3.8) years. Parity ranged from 0 to 3. Mean serum creatinine levels tended to be lower during pregnancy than before or after, as did the mean cyclosporine levels. After adjusting for dose, five of six patients had declines in cyclosporine level during pregnancy. The mean (SD) gestational age at delivery was 37.5 (2.8) weeks with a mean (SD) birth weight of 2837 (538) g.

CONCLUSION

Pregnancy in patients with renal allografts can lead to a substantial decline in cyclosporine levels.

Caregivers' perceptions following gastrostomy in severely disabled children with feeding problems

Feeding difficulties are common in neurologically impaired children, often leading to great distress and frustration in the child and family. A gastrostomy may be advocated if oral intake is inadequate causing poor weight gain or when there is significant aspiration during feeding, or if feeding is very distressing. To find out if caregivers were happy with the outcome of gastrostomy (with fundoplication, when indicated), a 35-item questionnaire was developed and sent to 38 of them. Twenty-nine replies were received and appeared to be representative of the whole group. Coughing, choking, and vomiting improved in most cases. Weight gain improved in all in whom it had been a problem. In the majority, it became easier to give the children their medications although control of epilepsy was unchanged overall. Time spent feeding the child was reduced and many caregivers had more time to devote to other children and themselves. Only one parent regretted the operation. In children with severe disability and feeding problems, a gastrostomy (with fundoplication if there is significant reflux) can reduce symptoms of vomiting, coughing, and choking, help growth and improve quality of life in the child, when patients are properly selected.

Vaginal douching and adverse health effects: a meta-analysis

OBJECTIVES

The meta-analysis described here reviewed the current literature on adverse health effects of vaginal douching.

METHODS

Papers published in English from 1965 through 1995 were potentially eligible.

RESULTS

One third of White women and two thirds of Black women of reproductive age reported douching regularly. Analyses indicated that vaginal douching increases the overall risk of pelvic inflammatory disease by 73% and the risk of ectopic pregnancy by 76%. Frequent douching was shown to be highly associated with pelvic inflammatory disease and modestly associated with cervical cancer.

CONCLUSIONS

Current literature suggests that frequent douching increases the risk of pelvic inflammatory disease, ectopic pregnancy, and, possibly, cervical cancer.

Inflammatory bowel disease in infancy: an increasing problem?

Seven children with intractable diarrhoea of infancy seen between 1990 and 1993 developed endoscopically established inflammatory bowel disease unrelated to bacterial infection and not responsive to whole protein exclusion. Mouth ulcers were present in two patients, endoscopic upper-gastrointestinal-tract inflammation in two, villous atrophy in six, and chronic nonspecific colitis in all seven. There was considerable clinical and histological heterogeneity. All patients required parenteral nutrition. Steroid therapy was completely successful in only one child, while two underwent colectomy, and two died. Previously described cases other than those due to infection or milk intolerance have been rare and sporadic. The prevalence of inflammatory bowel disease in infancy is unknown but appears to be increasing.

Quality of life in children with Crohn's disease

In a 10-week randomised cross-sectional study we used an 88-item questionnaire to assess the quality of life in 16 children (ages 8-17 years) with Crohn's disease and their families. The questionnaire covered six domains of health-related quality of life, including disease and its treatment, social, emotional, family, education, and future aspects. Crohn's disease affected education, with absenteeism in 12 and distraction during school work in six. Three children had had a home tutor, and five stated their need for one. Engaging in sports was a problem for eight children, mainly because of a lack of energy in five and the presence of a stoma in three children. Three children had missed every PE lesson in 1 year. Five children cited the social problem of being unable to stay over at friends' houses. Bullying concerned parents more than the children. Holiday difficulties included long distance traveling or lack of toilet facilities during school trips. Elemental diet was the preferred treatment, although the majority complained about the taste. Surgery was the most effective method of symptom control, though the resulting stoma was upsetting and restricted sports activities. Children on steroids had more depressive symptoms. Using the Rutter A Questionnaire, five children were designated "neurotic." Parents' views of the severity of symptoms significantly correlated with their children's views regarding rectal bleeding, poor growth, lack of energy, and poor appetite (p < 0.01). The main parental concerns were the side effects of medications and issues concerning their children's future, including schooling, job prospects, and marriage. The parents of 11 children cited problems with children's behaviour. The parents of seven cited disruption of work, and those of six named taking holidays. Crohn's disease in children, in addition to being a symptomatically disabling condition, has a great impact on the health-related quality of life of both sufferers and their parents. The questionnaire was a useful instrument, and with some adjustment it can be used again in large group studies.

Protective effects of extracellular acidosis and blockade of sodium/hydrogen ion exchange during recovery from metabolic inhibition in neuronal tissue culture

Acidosis is a universal response of tissue to ischemia. In the brain, severe acidosis has been linked to worsening of cerebral infarction. However, milder acidosis can have protective effects. As part of our investigations of the therapeutic window in our neuronal tissue culture model of ischemia, we investigated the effects of acidosis during recovery from brief simulated ischemia. Ischemic conditions were simulated in dissociated cortical cultures by metabolic inhibition with potassium cyanide to block oxidative metabolism and 2-deoxyglucose to block glycolysis. Lowering the extracellular pH (pH0) to 6.2 during metabolic inhibition had no effect on injury, as measured by lactate dehydrogenase release from cultures after 24 h of recovery. Lowering the pH0 during the first hour of recovery, in contrast, had profound protective effects. When the duration of metabolic inhibition was lengthened to 30 min, most of the protective effects of the NMDA receptor antagonist MK-801 were lost. However, the protective effects of acidosis were unchanged. This suggested that the protective effects of extracellular acidosis could be due to more than blockade of NMDA receptors. Intracellular acidosis might be responsible. To test this, recovery of intracellular pH (pH1) was slowed by incubation with blockers of Na+/H+ exchangers at normal pH0. The two compounds tested, dimethylamiloride and harmaline, had protective effects when present during recovery from metabolic inhibition. Measurements of pH1 confirmed that the blockers slowed recovery from intracellular acidosis; more rapid pH1 recovery was correlated with injury. The protective effects of acidosis could be reversed by brief incubation with the protonophore monensin, which rapidly normalized pH1. These results are the first demonstration of the protective effects of blocking Na+/H+ exchange in a model of cerebral ischemia. The protective effects of acidosis appear to arise either from suppressing pH-sensitive mechanisms of injury or from blocking sodium entry due to Na+/H+ exchange.

Resonant photoemission from complex cuprates and nickelates

Synchrotron-excited resonant-photoemission measurements at rare-earth 4d --> 4f and transition-metal 3p --> 3d thresholds have been carried out using a variety of complex cuprates and nickelates on stations 6.1 (grazing-incidence monochromator) and 6.2 (toroidal-grating monochromator) at the SRS CLRC Daresbury Laboratory. The systems studied are Nd(2)Ni(1 - x)Cu(x)O(4), La(2 - x)Sr(x)Ni(1- y)Fe(y)O(4 + delta) and Bi(2)Sr(2)Ca(1 - x)Y(x)Cu(2)O(8 + delta). A combination of EDC and constant-initial-state data is used to examine the 4f and 3d contributions to the valence-band density of states and their binding-energy positions relative to the Fermi energy. This allows the study of the valence states of the transition-metal ions and their modulation on doping. For La(2 - x)Sr(x)Ni(1 - y)Fe(y)O(4 + delta), this approach is used to infer a valence state of >/= 3.0 for Fe. In the case of Bi(2)Sr(2)Ca(1 - x)Y(x)Cu(2)O(8 + delta), the effect of Cu valence modulation on the 3p resonance is observed as x is varied. This is discussed in the light of controversy surrounding shifts in core-level photoemission with doping for this system.

Manchester procedure vs. vaginal hysterectomy for uterine prolapse. A comparison

The Manchester procedure (MP) was compared with vaginal hysterectomy (VH) to determine whether any differences regarding patient demographics or operative or postoperative outcome could be found between the two techniques. A retrospective chart analysis was done comparing data from 88 consecutive MP to 105 randomly selected VH patients. All the operations were performed for uterine prolapse at Mount Sinai Hospital between 1984 and 1988. MP patients, when compared to VH patients, were more likely to be older and postmenopausal at the time of surgery and to have a private physician. MP patients were less likely to have significant medical illnesses than were VH patients. Statistically significant differences between MP and VH were found for operative time (100 vs 130 minutes, respectively) and blood loss (200 vs. 300 mL, respectively) (P < .001). This difference was not dependent on the performance of anterior or posterior repair. MP was associated with shorter operative time and less blood loss when compared to VH. This, coupled with apparently similar operative outcomes, suggests the use of MP as an alternative to VH in the absence of uterine pathology in appropriate candidates with uterine prolapse. Prospective, controlled, long-term studies comparing the operative results of these two procedures are needed.

Selenium and glutathione peroxidase status in paediatric health and gastrointestinal disease

To examine the effect of paediatric GI disease on selenium concentration in plasma and glutathione peroxidase activity in plasma and red cells, results in children with Crohn's disease (n = 39), cystic fibrosis (n = 14), intractable diarrhoea (n = 13), and biliary atresia (n = 10) were compared with those from 86 healthy children undergoing routine operations. In Crohn's disease, plasma selenium concentrations were rarely low, but glutathione peroxidase activity was increased in the plasma and reduced in the red cells. Selenium concentration and glutathione peroxidase activity increased with steroid treatment but decreased with a selenium-deficient elemental diet. Plasma selenium concentration was normal in children with cystic fibrosis but very low in severely malnourished children with biliary atresia and intractable diarrhoea. Selenium concentration and glutathione peroxidase activity should be monitored in children with severe malnutrition or requiring prolonged nutritional support. Supplementation is recommended in cases of severe selenium depletion.

Laparoscopic Pomeroy tubal ligation in a residency training program

STUDY OBJECTIVE

To evaluate the efficacy of the laparoscopic Pomeroy method of tubal ligation as a teaching tool during the initial acquisition of advanced laparoscopic skills by 14 residents in a 28-person, 4-year program.

DESIGN

A prospective, nonrandomized study.

SETTING

A metropolitan teaching hospital.

PATIENTS

Fifty-seven women who desired permanent sterilization, and 56 controls who underwent laparoscopic sterilization by standard coagulation. One refused entry and had standard sterilization by bipolar coagulation. In two women, both with several previous laparotomies, visualization of the pelvic organs was incomplete and the procedure was abandoned at the discretion of the surgeon. One had a minilaparotomy Pomeroy tubal ligation and the other was sterilized by standard two-puncture laparoscopic coagulation. One patient was excluded due to an incomplete data profile.

INTERVENTIONS

Laparoscopic sterilizations using the Pomeroy technique and standard coagulation were performed by gynecology residents with an attending physician present. First-year residents performed 36 (68%) of the 53 procedures.

MEASUREMENTS AND MAIN RESULTS

Operative times to teach this technique to house officers rotating on the gynecologic service were recorded by postgraduate year and stratified by the number of cases performed by each operator. The average operative times for residents in postgraduate years 1 through 4 were 18.6, 15.4, 21.7, and 14.8 minutes, respectively. These diminished with experience. A statistically longer time of 7.1 minutes was required to teach residents the Pomeroy technique compared with standard bipolar coagulation (p<0.0003).

CONCLUSION

Laparoscopic Pomeroy tubal ligation as a method to begin educating residents in advanced operative video-laparoscopy appears to have great potential.

The effect of placenta previa on blood loss in second-trimester pregnancy termination

OBJECTIVE

To determine whether placenta previa increases bleeding during second-trimester pregnancy termination.

METHODS

The records of 131 consecutive women undergoing elective pregnancy termination at 13-24 weeks' gestation were reviewed and divided into those with and without placenta previa based on an ultrasound examination before the procedure. These two groups were then compared for differences in maternal characteristics, estimated blood loss, operative time, infection, and hospital admission.

RESULTS

Twenty-three of 131 women (17.6%) had placenta previa. Sixty-seven percent of the previa patients smoked, versus 37% in the control group, a statistically significant difference. A statistical difference was noted with respect to placenta previa in intraoperative blood loss (P < .05), but not operative time, time to discharge, infection, hemorrhage, or other complications.

CONCLUSION

Second-trimester pregnancy terminations in the presence of placenta previa are associated with a higher estimated blood loss, but no apparent increase in abortion-related infection, postoperative transfusion requirements, hysterectomy, or other complications.

Dietary intake and nutritional treatment in childhood Crohn's disease

Dietary intake was assessed in 24 children with active Crohn's disease. Seventeen of the children were sex and height matched with healthy siblings of other patients. The mean energy intake was 1,764 KJ/day (420 kcal/day) lower in patients during relapse than controls (p < 0.05). All 24 children entered a randomised controlled trial of high-dose steroids compared to an elemental diet. The elemental diet was well tolerated orally in most cases; only one patient required nasogastric administration. There was a similar improvement in disease activity and duration of remission in both groups regardless of the site of disease. Subsequent growth velocity was significantly better in the group treated with the elemental diet despite a greater and more sustained increase in energy intake in the group treated with steroids. Reintroduction of specific foods in the elemental diet group initially caused symptoms in three children but were subsequently tolerated. During remission, there was no significant difference in energy intake, but vegetables were consumed significantly less frequently (p < 0.01) and confectionery significantly more frequently (p < 0.05) when patients were compared with their own siblings.

Insulin like growth factor-I, insulin like growth factor binding protein-1, and insulin in childhood Crohn's disease

Twenty nine children with Crohn's disease were studied before and after treatment with steroids or an elemental diet to assess the effect of disease activity and treatment on serum insulin like growth factor I (IGF-I), insulin like growth factor binding protein (IGFBP-1), and insulin concentrations. The median serum IGF-I concentration was lower in patients with active disease than in matched controls, and lower in stunted than well grown patients, but insulin and IGFBP-1 concentrations were not significantly different between any group. After four weeks of either treatment there was an increase in the median serum IGF-I concentration; this was greater in the steroid group than the elemental diet group. The median serum insulin concentration increased and median serum IGFBP-1 concentration decreased in the steroid treated group but not in the elemental diet group. These changes were accompanied by a greater and more sustained increase in energy intake in the steroid group. Despite this the median height velocity SD score was greater in the elemental diet group than in the steroid group.

Operating room personnel morbidity from carbon dioxide laser use during preceptored surgery

OBJECTIVE

To determine the extent of laser-induced morbidity away from the operative site during the preceptor phase of laser credentialing in our institution.

METHODS

All laser surgeries performed from June 1, 1990 through May 31, 1991 and preceptored by one of the authors (MB) were included in the study. All of the surgeries were performed by a resident or attending physician seeking laser privileges in our institution. During that time, 141 such cases were performed.

RESULTS

In 13 of 141 cases (9%), there were injuries unrelated to the surgical procedure itself to either the patient or operating personnel. There were nine accidents associated with laser use during 42 laparotomy procedures (21%) and four accidents at the time of 44 vulvar surgeries (9%). There were no accidents during laparoscopic or colposcopic surgery of the vagina or cervix.

CONCLUSIONS

Despite extensive training requirements before use of the CO2 laser, accidents did occur. Operating room safety requirements should be a high priority to minimize morbidity. We report our experience with intraoperative morbidity caused by surgeons' errors and present recommendations to limit further complications.

Cryptosporidium, chronic diarrhoea and the proximal small intestinal mucosa

The association between Cryptosporidium, chronic diarrhoea and a proximal small intestinal mucosal enteropathy was reviewed over a six and a half year period. One hundred and twenty three children with cryptosporidiosis and no clinical evidence of immune deficiency were identified. 50% of children excreting only Cryptosporidium had chronic diarrhoea. Most cases (63%) of chronic diarrhoea occurred in the first two years of life. A mild to moderate enteropathy was present in all nine children undergoing a small intestinal biopsy and seven showed the presence of Cryptosporidium adhering to villous epithelium. All patients eventually recovered spontaneously. Cryptosporidium is a cause of chronic diarrhoea and a proximal small intestinal mucosal enteropathy in children without immune deficiency. Screening for the parasite should be part of the investigative procedures in children with chronic diarrhoea.

The value of proximal small intestinal biopsy in the differential diagnosis of chronic diarrhoea

The value of proximal intestinal mucosal biopsy was reviewed in 381 children presenting with chronic diarrhoea over an eight year period. An enteropathy was detected in 44% of cases and was more frequently seen in those aged less than 6 months. A diagnosis was established in 91% of cases. The most common diagnosis was the postenteritis syndrome where the presence of an enteropathy indicated those requiring treatment with a cows' milk free diet. Other conditions where a biopsy facilitated diagnosis or treatment included giardiasis, enteropathogenic Escheriichia coli, crytosporidiosis, autoimmune enteropathy, and microvillous atrophy. Coeliac disease was considered in 55% of children and established in 8%, clearly identifying those requiring a gluten free diet. This also emphasises the important role of the biopsy procedure in the exclusion of specific diseases. Proximal small intestinal mucosal biopsy is an essential investigation in children with chronic diarrhoea in whom an enteropathy is suspected.

Whole body protein turnover in childhood Crohn's disease

In order to investigate the effects of treatment on protein metabolism in childhood Crohn's disease whole body protein turnover was measured using a primed constant intravenous infusion of L-[1-13C]leucine and mass spectrometry in 10 children with active disease. Mean rates of protein synthesis and breakdown markedly decreased after treatment with steroids (four) or an elemental diet (six). This suggests that protein synthesis and breakdown are increased during active Crohn's disease in children and are reduced after induction of remission regardless of the type of treatment.

Incarcerated hernia after laparoscopic sterilization. A case report

Small bowel incarceration after laparoscopic procedures is rare. Such a complication occurred after an elective laparoscopic sterilization in a 36-year-old woman.

Protein-losing enteropathy in an infant with a lymphangiomyoma

A 3-month-old girl with intractable diarrhoea had protein-losing enteropathy secondary to a lymphangiomyoma. This is the first reported case of lymphangiomyoma in an infant. As enteral feeds were not tolerated, she was maintained on parenteral nutrition for 2 months. Pancreatic enzyme supplementation produced a rapid clinical improvement and normalization of serum albumin level. Weaning was subsequently tolerated and the vitamin, mineral, and trace element deficiencies improved. Subsequent recurrence was associated with normal pancreatic function and has proved refractory to treatment.

[Distribution and ecology of the ephemeropterans of Tunisia (1). (Insecta, Ephemeroptera)]

The study of 51 localities distributed throughout most of Tunisia has permitted the first establishment of a faunistic inventory of 11 species of Ephemeropterans (excluding Baetidae). 7 of these are newly recorded for Tunisia and one is new for North Africa. Species distributions depend essentially on chemical parameters (salinity, Cl-, Ca++, etc.) and on conductivity. Increases in the ionic concentration of the water quickly cause large decreases in population diversity, as is seen in eastern, central and southern waters. In Kroumirie, in the North West, the waters are less mineralized and so support a richer fauna. The species Caenis luctuosa possesses by far the greatest range of ecological tolerance. It is the most abundant and most frequent throughout the region, being followed by Ecdyonurus rothschildi. Distributional maps are established and the species' biogeographies and periods of flight are studied.

The specificity of auxin transport in intact pea seedlings (Pisum sativum L.)

When eight (14)C-labelled auxin and non-auxin compounds were applied to the apical buds of intact dwarf pea seedlings (Pisum sativum L.), only [1-(14)C]indoleacetic acid ([(14)C]IAA) and α-[1-(14)C] naphthaleneacetic acid ([(14)C]NAA) underwent appreciable basipetal transport during the first 24 h; over a longer period (72 h) considerable basipetal transport of the auxin [1-(14)C]2,4-dichlorophenoxyacetic acid ([(14)C]2,4-D) also occurred, but at a very much lower velocity (ca. 1.4-2.2 mm·h(-1)). The movement of 2,4-D possessed many of the characteristics of a typical auxin transport. During uptake and transport IAA and NAA were extensively metabolised to the corresponding aspartates, and to ethanol-insoluble/NaOH-soluble compounds; little metabolism of 2,4-D was observed. None of the non-auxin compounds applied (sorbose, sucrose, leucine, adenine and kinetin) underwent appreciable basipetal transport from the apical bud. All but sorbose were extensively metabolised by the apical tissues. Little metabolism of sorbose itself was detected.The results suggest that the long-distance basipetal auxin transport system from the apical bud of intact plants is specific for auxins; the specificity may result from the affinity of auxins for specific transport sites.