A prospective longitudinal evaluation of pregnancy in the Marfan syndrome

OBJECTIVE

We undertook a prospective evaluation of the outcomes of pregnancy, both maternal and fetal, and the long-term impact of pregnancy on Marfan syndrome in a series of consecutive, unselected patients.

STUDY DESIGN

Forty-five pregnancies in 21 Marfan syndrome patients were prospectively observed in one institution between 1983 and 1992. During pregnancy, patients were monitored with serial echocardiograms and close attention to symptoms. Maternal and fetal outcomes were monitored with serial echocardiographic data were analyzed by least-squares regression. Eighteen of the patients were followed up for 15 months to 13 years after the completion of their last pregnancy for investigation of the long-term impact of pregnancy on the cardiovascular manifestations of Marfan syndrome.

RESULTS

Aortic dissection occurred in two patients, both with increased risk for dissection established before pregnancy. The incidence of obstetric complications otherwise did not exceed that in the general population. Echocardiographic data demonstrated little to no change in aortic root diameter throughout pregnancy in most patients. Long-term follow-up showed no apparent worsening of cardiovascular status attributable to pregnancy in comparison with a group of 18 women with Marfan syndrome who were of similar age, had a similar degree of disease severity, and underwent no pregnancies.

CONCLUSIONS

Patients with Marfan syndrome in whom cardiovascular involvement is minor and aortic root diameter is < 40 mm usually tolerate pregnancy well, with favorable maternal and fetal outcomes, and without subsequent evidence of aggravated aortic root dilatation over time.

Laparoscopic-assisted abdominal aortic aneurysm repair

Since the advent of laparoscopy, the sweeping changes seen in general surgery have not been paralleled in vascular surgery. There have been case reports of laparoscopic-assisted aortobifemoral bypass for occlusive disease. Because aneurysmal disease comprises the majority of aortic surgery, we pursued animal and cadaveric feasibility studies for laparoscopic-assisted abdominal aortic aneurysm (AAA) repair. We present a case report of the first clinical case performed under Institutional Review Board protocol using this technique. The patient was a 62-year-old male with a 6-cm infrarenal AAA. After obtaining a pneumoperitoneum, a modified fish retractor was used to exclude the bowel. Ten 11-mm ports provided access to laparoscopically dissect the neck of the aneurysm and the iliac vessels. Then, a 10-cm minilaparotomy was performed and standard vascular clamps were inserted via the port incisions. Standard aneurysmorraphy was performed with a polytetrafluoroethylene (PTFE) tube graft. Laparoscopy conferred three major benefits: better visualization of the aneurysm neck, less bowel manipulation, and avoidance of hypothermia. This case report illustrates the feasibility of laparoscopic-assisted aneurysm repair. Controlled human studies will define the role of laparoscopy in AAA surgery.

Patient education for low back pain in general practice

This comparative study of patient and general practitioner perceptions of patient education for low back pain (LBP) revealed significant differences in perspective. It suggests that although some general practitioners recognise the importance of patient education, they blame patients for its assumed failure as a management strategy. The patients in this study identified a range of reasons which explain their difficulties in following prevention advice which relate to not only limitations in themselves, but also to broader contextual factors over which they have little control. It is argued that both the inadequacy of current professional assumptions and the contextual factors that influence patients' prevention behaviours need to be acknowledged as a first step towards improving patient education for LBP in general practice.

General practitioner perceptions of low back pain patients

General practitioners' perceptions of low back pain (LBP) patients were investigated through a series of in-depth semi-structured interviews, as part of a wider study which also investigated patient perceptions. An exhaustive analysis of the interview transcripts revealed six principal ways in which GPs distinguished between different patients as a means of deciding how to treat them. This differentiation, on the basis of patient characteristics, is the major focus for the resulting discussion and conclusions, and is used as a way of exploring more effective strategies for the future.

T-cell clonality in synovial fluid from rheumatoid joints before and after culture in interleukin-2

T-cell receptor (TCR) gamma gene rearrangements which have been amplified in polymerase chain reactions (PCRs) and analysed by high resolution polyacrylamide gel electrophoresis have been used to investigate the clonal diversity of T-cells in joint effusions from 16 patients with rheumatoid arthritis, one with systemic lupus erythematosus and one with psoriatic arthropathy. Polyclonality was found in every case but an oligoclonal subset of dominant rearrangements was also demonstrated in all but the patient with psoriasis. Marked changes in the relative preponderance of the various clonotypes were observed in 29 of 48 paired tests from 12 cases before and after culture in media containing interleukin-2 (IL-2) showing that SF mononuclear cells cultured in vitro with IL-2 are not representative of those present in vivo.

Progression of aortic dilatation and the benefit of long-term beta-adrenergic blockade in Marfan's syndrome

BACKGROUND

The aortic root enlarges progressively in Marfan's syndrome, and this enlargement is associated with aortic regurgitation and dissection. Long-term treatment with beta-adrenergic blockade, by reducing the impulse (i.e., the rate of pressure change in the aortic root) of left ventricular ejection and the heart rate, may protect the aortic root.

METHODS

We conducted an open-label, randomized trial of propranolol in adolescent and adult patients with classic Marfan's syndrome (32 treated and 38 untreated [control] patients). Aortic-root dimensions and clinical end points (aortic regurgitation, aortic dissection, cardiovascular surgery, congestive heart failure, and death) were monitored for an average of 9.3 years in the control group and 10.7 years in the treatment group. All 70 patients were included in the analysis according to the intention-to-treat principle.

RESULTS

The dose of propranolol was individualized; the mean (+/- SE) dose was 212 +/- 68 mg per day. The mean slope of the regression line for the aortic-root dimensions, which reflect the rate of dilatation, was significantly lower in the treatment group than in the control group (0.023 vs. 0.084 per year, P < 0.001). Clinical end points were reached in five patients in the treatment group and nine in the control group. The Kaplan-Meier survival curve for the treatment group differed significantly from that for the control group during the middle years of the trial and remained better for the treatment group throughout the study.

CONCLUSIONS

Prophylactic beta-adrenergic blockade is effective in slowing the rate of aortic dilatation and reducing the development of aortic complications in some patients with Marfan's syndrome.

Molecular cloning of the human mucosal lymphocyte integrin alpha E subunit. Unusual structure and restricted RNA distribution

The human mucosal lymphocyte-1 (HML-1) antigen is expressed on a subclass of T-lymphocytes known as intra-epithelial lymphocytes which are located between mucosal epithelial cells. The HML-1 complex is known to mediate adhesion of intra-epithelial T-lymphocytes to epithelial cell monolayers in vitro. We and others have shown that the HML-1 antigen is an integrin composed of the beta 7 subunit in association with a novel alpha subunit, alpha E. Here we report the cloning of the alpha E cDNA and its primary amino acid sequence. alpha E contained an inserted or I domain and was more homologous to the other I domain containing integrins than to the cleaved group of integrin alpha subunits. However, alpha E contained a unique extra domain of 55 amino acids located just NH2-terminal to the I domain without counterpart in other integrins. This extra domain contained a stretch of 18 consecutive charged residues and included a proteolytic cleavage site. Thus alpha E is the only I domain containing integrin alpha subunit that is also cleaved, and the cleavage site is distinct from that of members of the cleaved group of integrin alpha subunits. These structural features mark alpha E as an unusual member of the integrin family. High levels of alpha E and beta 7 mRNA were restricted to mucosal lymphocytes supporting the hypothesis that alpha E beta 7 plays a role in the localization or site-specific functions of intra-epithelial T-lymphocytes.

Effects of hormone replacement therapy in rheumatoid arthritis: a double blind placebo-controlled study

AIMS

To study the effects of ovarian hormone replacement therapy (HRT) on bone mineral density and disease activity in postmenopausal women with rheumatoid arthritis (RA).

METHOD

A placebo controlled double-blind study was carried out on 62 patients with RA, 22 on placebo and 40 on HRT (transdermal oestradiol patches twice weekly for 48 weeks plus norithisterone tablets when clinically indicated). Bone mineral density of spine, hip and wrist was measured at 0 and 48 weeks and clinical and laboratory measures of general well-being and disease activity at 0, 12, 24 and 48 weeks.

RESULTS

Thirteen of 22 (59%) of placebo and 31 of 40 (78%) of the HRT group completed 48 weeks in the study. At entry, bone mineral density (BMD) values in the lumbar spine and femoral neck were similar to those in age and sex matched controls in both treatment groups, whereas at the distal radius, BMD was significantly reduced to approximately 50% of control values (both p < 0.001 from controls). In the HRT group, spine BMD increased significantly by a median of +0.94% at 48 weeks (p = 0.024), but did not change significantly in the placebo group. BMD at the femoral neck and distal radius did not change in either group. In the HRT group, there was significant improvement in well being as assessed by the Nottingham Health Care Profile (p < 0.01) and in the articular index (p < 0.05). There were no significant changes in ESR or CRP in either group.

CONCLUSION

Transdermal HRT was well tolerated, increased well being, reduced articular index and increased lumbar spine bone density over a one year period in postmenopausal women with RA. Although no laboratory evidence was found of a disease modifying effect, the symptomatic benefits and improvements in bone density indicate that HRT may be a valuable adjunct to conventional antirheumatic therapy in RA.

The spectrum of disease associated with a positive ANCA

This is a retrospective analysis of all patients with a raised titre of ANCA in a single centre over a two-year period. Sixty-five patients were identified and clinical data is presented for 58 of these-34 male and 24 female. The median age is 56 years (13-83). Fourteen patients had Wegener's granulomatosis, 14 microscopic polyarteritis nodosa and 30 had other diagnoses. The patients with unexpectedly positive results are discussed in detail. This study confirms the sensitivity of ANCA in Wegener's granulomatosis and microscopic polyarteritis nodosa but suggests that the test is not as specific as initially claimed.

Cyclosporine A induced colitis and acquired selective IgA deficiency in a patient with juvenile chronic arthritis

A 12-year-old girl with juvenile chronic arthritis was treated with cyclosporine A for recurrent uveitis. Two years later she presented with weight loss and diarrhea. Investigations suggested drug induced colitis. She improved after withdrawal of cyclosporine and her nonsteroidal antiinflammatory drug. Symptoms recurred on rechallenge with cyclosporine. She has developed a progressive selective IgA deficiency which persists despite cessation of cyclosporine.

Effectiveness of flushing on reducing lead and copper levels in school drinking water

Samples from drinking water fountains in 50 schools in New Jersey were collected at specific times during a typical school day and analyzed for lead, copper, pH, alkalinity, and hardness. First-draw lead and copper levels (medians 0.010 mg/l and 0.26 mg/l, respectively) decreased significantly after 10 min of flushing in the morning (medians 0.005 mg/l lead and 0.068 mg/l copper), but levels increased significantly by lunchtime (medians 0.007 mg/l lead and 0.12 mg/l copper) after normal use of fountains in the morning by students. Corrosive water, as defined by the aggressive index, contained significantly higher levels of lead and copper (medians 0.012 mg/l and 0.605 mg/l, respectively) than noncorrosive water (medians 0.005 mg/l and 0.03 mg/l, respectively).

Instrument comparison: corrected stellar scintillometer versus isoplanometer

The scintillation pattern from a single star can be utilized to provide information on the refractive turbulence along the line of sight. Instruments that provide refractive turbulence parameters are the isoplanometer and the stellar scintillometer. Attention is drawn to the fact that the National Oceanic and Atmospheric Administration theoretical treatment and implementation of the stellar scintillometer is incomplete. The theory is corrected for spectral effects and finite aperture. A comparison is made of simultaneously obtained isoplanometer values and stellar scintillometer-derived values for isoplanatic angle. The measurements are obtained from an electro-optical/meteorological experiment conducted at Pennsylvania State University in April and May 1986. An atmospheric drop-off model is used to extrapolate the scintillometer measurements beyond the heights probed. Agreement between the two instruments is significantly improved after the appropriate corrections are applied to the scintillometer data. These data were obtained during widely varying meteorological conditions that provided the opportunity for comparisons over a wide range of isoplanatic angles (3 to 14 µrad). Over the 5 days that data were obtained, relative percent departures of mean isoplanatic angles derived from the corrected stellar scintillometer are within 10% of the mean isoplanometer isoplanatic angle values. The uncorrected departures range from 16% to 24%.

Angular homeostasis. IX. Polygonal orbits with a moving target: implications for anomalous numbers of digits in congenital heart disease

This paper explores properties of discrete processes in which a pursuer seeks a target that is moving at constant velocity r that is a fixed proportion of the speed of the pursuer. The pursuer is subjected to proportional angular homeostasis, so chosen that the number of steps per circuit is small. The orbits relative to the target may assume any of four forms: polygons that reverse their sense an infinite number of times; or polygons that after a finite number of reversals ultimately come to have an integer numbers of sides; or have a rational numbers of sides; or have an irrational number of sides that densely fill an annulus. None of the polygons is regular. In the parameter space, the boundary line between the first of these sets and the other three has a somewhat bizarre pattern and may possibly be fractal, but no proof is forthcoming. Unlike the pattern with a stationary target, there may be a set or catchment of diverse values of the speed ratio, r, and the correction coefficient, b that all result in figures of some specified number, n, of sides (although with vertices in differing locations). Catchments have been found for only those polygons that have the winding number of 1. The implications are discussed that this property has for the genetic coding of biological traits that are countable. Some attention is also paid to the relevance of polygons with few sides to ontogenic growth when the correction coefficient is cyclically arc- or time-dependent.

Reassessment of lead exposure in New Jersey using GIS technology

In order to prevent children's exposure to lead, a variety of sources must be controlled. The New Jersey Department of Environmental Protection and Energy (NJDEPE) is using its Geographic Information System to identify areas within Newark, East Orange, and Irvington, New Jersey, where there may be greater environmental exposure to lead. Sensitive populations are identified through the U.S. Bureau of the Census information. Blood screening data provided by the New Jersey Department of Health (NJDOH) provide reported patterns of elevated blood lead in the study area. Comparisons of these spatial patterns will assist the NJDEPE in its soil sampling activities and lead exposure research, will provide information for public education, and will provide valuable information on sections of the study area where further screening and public education may be needed.

Twin studies of Alzheimer disease: II. Some predictions under a genetic model

The twin method for investigating genetic and environmental causes of disease has been applied mostly in early-onset illnesses. Analysis of late-onset disorders requires reexamination of common assumptions about the relation between genetic causes and the degree of concordance expected. This paper considers Alzheimer disease (AD) as an example of a late-onset disorder with putative genetic factors. For argument it employs the strong hypothesis that AD is an autosomal dominant trait with age-dependent expression, as described by a previously published parametric model. That model encompasses 2 principal variants of disease: a rare form with onset in middle life, and a more common late-onset type which is nonetheless eventually fully penetrant. The present work then specifies the probability that, when a given member of a twin pair (the proband) is affected, an identical or fraternal co-twin also shows the disease. Such probability is expressed as a function of the age at onset of the proband and the current age of the pair. Even under strong working assumptions regarding genetic influence, the expected proportion of identical co-twins actually affected with AD will not exceed 40% until the subjects are about 80 years old. Therefore, except in very old subjects, modest twin concordance is a feeble argument against genetic causes, or in favor of exclusively environmental ones. In this sense the interpretation of results of twin studies in AD and other late-onset disorders differs substantially from studies of diseases with early onset.

Threshold model in the genetics of age-dependent disease in twins: I. General principles as applied to Alzheimer disease

In the context of the etiology and pathogenesis of Alzheimer disease (AD), we discuss assumptions under which categorical data on the phenotypes of twin pairs may be used to estimate standardized characteristics (correlation and the critical threshold) for an age-dependent multinomial process. Important topics include Erlangian, gamma, and Poisson processes, tetrachoric and trichoric functions, and degrees of freedom and how they relate to estimation from both an abstract and a practical standpoint. Under plausible assumptions about the age-dependence of a heritable trait, it is possible to generate sufficient degrees of freedom to test the genetic model and to explore age-dependence and the impact of environmental factors that may influence it systematically. Though general in scope, the model is focused on data from twin pairs. The statistical strategy is briefly outlined, but its properties are not examined in detail.

Angular homeostasis. VIII. Pursuit of a slowly moving target in a plane: relevance to lateralization in cardiovascular ontogeny

We explore the pursuit in a plane of a target moving at constant slow speed in a straight line. Two models of the pursuit are given. In the continuous case, the pursuer is moving at constant speed and is subject to proportionate angular homeostasis with correction constant b. In the discrete version movement occurs at a constant speed in a sequence of straight line segments of constant length (called the step size, s) the end of the segments being called the vertices. The pattern considered is not the absolute position of the pursuer, but its distance and orientation relative to the target. Both the transients and the asymptotic orbit are addressed. A key quantity is r, the speed of the target expressed as a fraction of that of the pursuer. If the speed of the pursuer is defined as unity, r is also the ratio of the speeds. There exists a critical speed fraction, R(b,s), a function of b and s, that defines what the term slow designates. R(b,s), which has to be found numerically, has the following property. For r less than R(b,s), the asymptotic path is a simple closed curve. In the discrete case the vertices converge to a simple closed curve. The larger r, the more the path (or in the discrete analogue its set of vertices) departs from a circle, and the more eccentric the target is with respect to it. Interest centers on two issues. First we address the transient patterns of the path, notably whether or not the sense of any particular path (clockwise or counterclockwise) is the same throughout, or changes at some stage.(ABSTRACT TRUNCATED AT 250 WORDS)