Successful pregnancy after hysteroscopic metroplasty

Congenital anomalies of the uterus have been estimated to affect 0.06-10% of women. Uterine septae account for approximately 80% to 90% of these anomalies and is also associated with the poorest reproductive outcome. Pregnancy loss in patients with a septate uterus has been reported to be as high as 90% after other causes for miscarriages have been excluded. We present here the first experience in Jamaica, of a successful pregnancy outcome after hysteroscopic metroplasty in a woman with a septate uterus and three previous miscarriages.

A modified Kleihauer technique for the quantification of foetomaternal haemorrhage

The Kleihauer technique, based on acid elution of maternal red cells, is the mostly widely used technique in the UK to screen for, and estimate the volume of, foetomaternal haemorrhage (FMH) and for determining the need for additional doses of anti-D immunoglobulin to prevent maternal alloimmunization. However, technicians often report difficulties in identifying and accurately counting maternal red cells in the blood film, leading to imprecision in the calculated FMH. In this report, we describe a simple modification of the standard Kleihauer technique, based on performing acid elution of only half of the film. Compared to the standard method, the modified technique showed improved accuracy and reduced interobserver variability across a range of simulated FMH volumes. There was a high degree of correlation between the new technique and FMH estimated by flow cytometry (r2 = 0.916, P < 0.001). Technicians found the new technique easy to incorporate into routine practice in a busy teaching hospital laboratory and were impressed by the relative ease of counting maternal ghost cells. The modified technique has been used routinely in our laboratory for 3 years, during which time our performance in the UK National External Quality Assurance Scheme for FMH has been uniformly satisfactory.

Lower prevalence of pre-morbid neurological illness in African-Caribbean than White psychotic patients in England

BACKGROUND

It has been suggested that the increased incidence of psychosis in African-Caribbeans living in England may be due to illnesses in which social stress plays an important aetiological role. If this is the case, the prevalence of factors associated with psychosis that predate illness onset such as obstetric complications, pre-morbid neurological illness and poor childhood social adjustment may be expected to be lower in African-Caribbean than Whites psychotic patients.

METHOD

Details of obstetric complications, pre-morbid neurological illness, and pre-morbid social adjustment were obtained for 337 psychotic patients by patient interview, interviews of mothers and chart review. The proportions of patients with each 'risk factor' in the African-Caribbean (N = 103) and White (N = 184) groups were compared using regression analysis; age, sex, social class, diagnosis and referral status were possible explanatory variables.

RESULTS

African-Caribbean patients were less likely to have suffered a pre-morbid neurological disorder than their White counterparts (odds ratio 0.19, 95% CI 0.06-0.61). There was no significant difference in pre-morbid social adjustment or obstetric complications between the two groups, though fewer obstetric complications were reported in the African-Caribbean group (21.5%) than the White group (30.9%).

CONCLUSIONS

African-Caribbean patients with psychosis have experienced less pre-morbid neurological illness.

Partially matched related donor peripheral blood progenitor cell transplantation in paediatric patients adding fludarabine and anti-lymphocyte gamma-globulin

Twenty-one paediatric patients (11 males and 10 females) received a CD34-selected partially matched related donor transplant for malignant (16 cases) and non-malignant conditions (five cases). The average cell dose was 11.13 x 10(6)/kg. Fifteen of 16 patients with malignant conditions and one with non-malignant disease received total body irradiation plus cyclophosphamide. Three of 5 patients with non-malignant conditions and one with leukaemia, received busulphan plus cyclophosphamide. One patient with Fanconi anaemia received 100 mg/kg of cyclophosphamide. Fludarabine (25 mg/m(2)/day for 5 days) was administered prior to all these regimens. Additionally, anti-lymphocyte gamma-globulin (12.5 mg/kg/day) was administered from day -2 to day +2. Three (15%) patients failed to achieve complete chimaerism (CC). These patients received a second cell infusion. Two of them achieved CC. In the third patient, the percentage of donor cells was increased. The likelihood for engraftment was not related to the cell dose received. Acute graft-versus-host disease (GVHD) occurred in nine patients but only one developed GVHD >grade II. Eight patients developed active viral infections, which resolved after treatment. Patients receiving cell doses higher than our average had a significantly faster CD3 and CD4 cell recovery and experienced a lower incidence of viral infections. After 480 +/- 255 days of median follow-up, 16/21 patients are alive and well and have CC. Three patients died of leukaemic relapse and a fourth from progression of his disease (adreno-leuko-dystrophy). We conclude that partially matched related donors are a feasible source of haemopoietic progenitor cells for transplantation for patients without matched familial or unrelated donors.

A review of intensity modulated radiation therapy: incorporating a report on the seventh education workshop of the ACPSEM--ACT/NSW branch. Australasian College of Physical Scientists and Engineers in Medicine

Intensity modulated radiation therapy (IMRT) is an evolving treatment technique that has become a clinical treatment option in several radiotherapy centres around the world. In August 2001 the ACT/NSW branch of the ACPSEM held its seventh education workshop, the subject was IMRT. This review considers the current use of IMRT and reports on the proceedings of the workshop. The workshop provided some of the theory behind IMRT, discussion of the practical issues associated with IMRT, and also involved presentations from Australian centres that had clinically implemented IMRT. The main topics of discussion were patient selection, plan assessment, multi-disciplinary approach, quality assurance and delivery of IMRT. Key points that were emphasised were the need for a balanced multi-disciplinary approach to IMRT, in both the establishment and maintenance of an IMRT program; the importance of the accuracy of the final dose distribution as compared to the minor in-field fluctuations of individual beams; and that IMRT is an emerging treatment technique, undergoing continuing development and refinement.

Design of high essential amino acid proteins: two design strategies for improving protease resistance of the nutritious MB-1 protein

Protein design is currently used for the creation of new proteins with desirable traits. In our lab, we focus on the synthesis of proteins with high essential amino acid content having potential applications in animal nutrition. One of the limitations we face in this endeavour is achieving stable proteins despite a highly biased amino acid content. We report here the synthesis and characterisation of two mutants derived from our MB-1 designer protein. The first mutant contains a disulphide bridge designed to cross-link remote segments of the polypeptide chain. The second one is a Tyr62-Trp mutant, where position 62 is buried in the core of the protein. Both mutants were found to be largely helical as per design, and based on thermal denaturation experiments, were substantially more stable than the MB-1 parent molecule. Enhancement of conformational stability in MB-1Trp translated into an impressive improvement of its ability to resist proteolytic degradation. Furthermore, digestion experiments intended to model degradation of proteins in a cow's rumen revealed that MB-1Trp's resistance to degradation compared to that of cytochrome c. Design strategies used for these mutants are discussed with regards to their applicability in creating efficient nutritional proteins.

The point-of-referral barrier--a factor in the success of telehealth

A feasibility study was carried out to test the hypothesis that, for an effective telehealth service, a full-time coordinator is required to act as a single point of contact for consultation requests. By shifting the responsibility for telepaediatrics from the referrer to the provider, the telehealth process becomes equally (or more) attractive as the conventional alternative. Preliminary results showed that, within six months, telepaediatric activity increased to an average of 8 h per month. Not only did certain health services become more accessible to children and their families in remote areas of Queensland, but significant savings were also made. At least 12 patient transfers were avoided to and from the tertiary facility, with an estimated minimum saving of $18,000 to the health-care provider.

Reliability of the vertical spinal creep response measured in sitting (asymptomatic and low-back pain subjects)

Vertical spinal creep (or change in stature) has been used as an index of spinal loading, yet reliability of the testing protocol has not been fully examined. This study investigated the reliability of a vertical spinal creep response in 10 asymptomatic and five low-back pain subjects. Each subject performed the 25-min testing protocol, which consisted of three phases (5-min preload, 10-min loaded and 10-min unloaded), at the same time on two separate days. Good reliabilities in vertical spinal creep response between two days of testing were demonstrated for both asymptomatic and low-back pain subjects.

Improving dementia care through community linkages: a multi-site demonstration project

The purpose of the multi-site project was to develop and implement a model for dementia care which improved linkages of caregivers to community services. Key components of the model included a single point of informational contact, provider education, case-finding, caregiver education and support, internal linkages, and linkages with community services. The model was implemented at six medical centers. Outcome measures included caregiver, provider, and community agency satisfaction. Caregivers reported high satisfaction with information provided to them about community resources. Primary care providers reported that dementia services had improved from one year earlier. Community agencies reported high satisfaction with the dementia program initiatives.

Use of inverse PCR to amplify and sequence breakpoints of HPRT deletion and translocation mutations

Deletion and translocation mutations have been shown to play a significant role in the genesis of many cancers. The hprt gene located at Xq26 is a frequently used marker gene in human mutational studies. In an attempt to better understand potential mutational mechanisms involved in deletions and translocations, inverse PCR (IPCR) methods to amplify and sequence the breakpoints of hprt mutants classified as translocations and large deletions were developed. IPCR involves the digestion of DNA with a restriction enzyme, circularization of the fragments produced, and PCR amplification around the circle with primers oriented in a direction opposite to that of conventional PCR. The use of this technique allows amplification into an unknown region, in this case through the hprt breakpoint into the unknown joined sequence. Through the use of this procedure, two translocation, one inversion, and two external deletion hprt breakpoint sequences were isolated and sequenced. The isolated IPCR products range in size from 0.4 to 1.8 kb, and were amplified from circles ranging in size from 0.6 to 7.7 kb. We have shown that inverse PCR is useful to sequence translocation and large deletion mutant breakpoints in the hprt gene.

Fatty acid, amino acid, and trace mineral analyses of five weaning foods from Jos, Nigeria

Five plant-based weaning foods (WF) (Dietrend, Jot-M, Soy, Ang, and Vic-T) locally prepared in Jos, Nigeria were analyzed by gas-liquid chromatography, reverse-phase high performance liquid chromatography, and atomic emission spectrometry with inductively coupled plasma to determine their fatty acid (FA), amino acid, and trace mineral contents, respectively. Results of these direct analyses were compared to expected values derived from food composition tables prepared by the United States Department of Agriculture (USDA). Additionally, results were compared against recommended nutrient values, using breast milk as the standard for FA content and recommended dietary allowances (RDA) for amino acid and mineral contents. The overall nutritional value of the five WF varied considerably and the quantities of particular nutrients determined by direct analysis differed markedly from those estimated using USDA food tables. Comparison of WF fatty acid composition relative to the RDA recommendations and a human milk standard revealed a much higher proportion of both linoleic (35-55 wt%) and alpha-linolenic acids (1%-7 wt%) relative to human milk lipids (11%-12% and 0.8%-0.9% wt, respectively); however, the WF were devoid of arachidonic acid and docosahexaenoic acid. Soy contained the highest amounts of linoleic acid (59.7 mg/g) and alpha-linolenic acid (7.46 mg/g) compared to the other four WF (10.2-41.0 and 0.35-3.18 mg/g, respectively). The linoleic acid/alpha-linolenic acid ratio was within the recommended range (5:1 to 10:1) in only Jot-M (10:1) and Soy (8:1). Dietrend, Vic-T and Ang, contained linoleic/alpha-linolenic ratios of 12:1, 29:1, and 82:1, respectively. The Soy weaning food would provide the most protein (24.3 g/day), based on an estimated daily intake of 65 g of weaning food by a normal six-month-old infant, compared to Jot-M (11.9 g/day), Dietrend (11.7 g/day), Ang (8.07 g/day), and Vic-T (7.26 g/day). The protein RDA for children up to 1 year of age is 13-14 g/day. Comparison of the mineral contents of the WF to the RDAs for various minerals indicated that all five would provide suboptimal amounts of calcium (16 to 250 mg/day) and zinc (1.42 to 3.56 mg/day) compared to respective RDAs of 400 mg/day and 5 mg/day. These data show that the Soy weaning food is an excellent source of linoleic acid and alpha-linolenic acid, as well as being a good source of high quality protein. Jot-M and Dietrend provide useful amounts of the essential FA; however, it is advisable to reevaluate the composition of Ang and Vic-T to find ways to improve the linoleic/alpha-linolenic ratio of each and increase their total protein content. These results document the shortcomings of using published food composition tables based on foods in America when devising weaning foods based on ingredients in another part of the world.

Adolescent versus adult responses to vertical spinal loading

This study compared the vertical spinal creep response between adolescent and adult males. Thirty healthy male subjects, 15 adolescents (aged 12 to 16 years) and 15 adults (aged 30 to 57 years) were measured. Spinal creep was measured continuously over 25 min under loaded and unloaded conditions using a seated stadiometer that controlled spinal posture. Both adolescent and adult subjects showed significant increase in vertical spinal creep with time but the magnitude of vertical spinal creep was significantly greater in adolescent than in the adult subjects.

Cardiac rhabdomyoma in infancy. A case report

We describe a case of rhabdomyoma of the heart in a newborn infant and present an overview of current knowledge about the natural history of these lesions, with implications for management. This is the only case of its kind seen at this hospital.

Prospective analysis of endoscopic vein harvesting

BACKGROUND

Utilization of bridging vein harvesting (BVH) of saphenous vein grafts (SVG) for coronary artery bypass grafting (CABG) results in large wounds with great potential for pain and infection. Endoscopic vein harvesting (EVH) may significantly reduce the morbidity associated with SVG harvesting.

METHODS

A prospective database of 200 matched patients receiving EVH and BVH was compared. The patients all underwent CABG done over a period of 4 months (April to August 2000). Patients were excluded if they had prior vein harvesting.

RESULTS

The EVH and BVH group included 100 patients each with similar demographics. The patients in the EVH group had significantly fewer wound complications, mean days to ambulation, and total length of stay (P <0.05). There was no difference in harvest time or vein injuries.

CONCLUSION

Endoscopic vein harvesting results in significantly fewer wound complications, decrease in days to ambulation, and the total length of stay. EVH is superior to BVH in patients undergoing CABG.

Senior health professional's perceptions of variations in medical practice: a qualitative and quantitative study

Following the introduction of the UK General Medical Council's regulations on the handling of poor medical performance, an interview and survey study was carried out among senior health professionals in the National Health Service (NHS). The aims of the study were to explore the respondents' perceptions of poor medical performance and to seek their experience of handling poorly performing doctors. Sixteen interviews were held face to face, followed by 28 telephone interviews. Subsequently, using similar questions to those in the interview schedule, a survey was carried out among senior health professionals across the NHS. Interview results identified a number of barriers to resolving poor performance, such as the unwillingness of some doctors to seek advice and the protective culture which prevented complaints being made against doctors. Survey respondents had high standards by which they judged poor performance, but they were more hesitant about considering poor consultation skills as being of the same significance as poor technical skills. However, problems with communication skills were the most frequently reported type of poor performance. The new arrangements for handling NHS doctors whose performance is perceived to be poor have much to do to overcome the barriers to effective action expressed by the respondents in this study.

Cardiovascular disease risk factors and diet of Fulani pastoralists of northern Nigeria

BACKGROUND

The Fulani of northern Nigeria are seminomadic pastoralists who consume a diet rich in saturated fats, do not use tobacco, are lean, and have an active lifestyle. Little is known about their serum lipid profiles and corresponding risk of cardiovascular disease.

OBJECTIVE

We measured serum lipid, homocysteine, folate, and vitamin B-12 concentrations in Fulani men and women and assessed the nutrient content of their diet.

DESIGN

Blood samples from 42 men (18-64 y old) and 79 women (15-77 y old) living in the Jos Plateau of Nigeria were analyzed for cholesterol (total, HDL, and LDL), triacylglycerol, homocysteine, folate, and vitamin B-12 serum concentrations. Body composition was determined by bioelectrical impedance analysis. Dietary information was obtained with use of a 7-d dietary recall and a food-frequency questionnaire. Results were compared with US referent ranges.

RESULTS

The mean energy content of the Fulani diet was relatively low (men, 6980 kJ; women, 6213 kJ) and the mean protein content was high (men, 20% of energy; women, 16% of energy). Nearly one-half of energy was provided by fat, and one-half of that was derived from saturated fatty acids. The diet provided marginal to adequate amounts of vitamins B-12, B-6, and C but only one-third of the US recommended dietary allowance for folate. The mean total cholesterol, HDL-cholesterol, and triacylglycerol concentrations of Fulani adults were within the referent ranges; the mean LDL-cholesterol concentration of Fulani adults below the range; and the mean serum homocysteine concentration of Fulani men above the range. Homocysteine and folate concentrations were inversely correlated for both men and women.

CONCLUSIONS

Despite a diet high in saturated fat, Fulani adults have a lipid profile indicative of a low risk of cardiovascular disease. This finding is likely due to their high activity level and their low total energy intake.

An investigation of condom use by frequency of sex

OBJECTIVES

To examine the association between condom use and frequency of sex across sexual partner types.

METHODS

Data were collected from African American drug users residing in Washington, DC. Participants were asked to provide the first name of the last three partners with whom they had had vaginal sex, to define the type of relationship, the number of times they had had vaginal sex in the last 30 days with each partner, and whether they had used a condom during their last sexual encounter with each partner. Condom use was examined by frequency of sex in the past 30 days controlling for partner type.

RESULTS

Frequency of sexual encounters varied by partner type. The largest number of sexual encounters was with casual partners, followed by commercial and primary partners, respectively. Within partner types, participants had sex most frequently with primary partners. Condom use was lowest within primary partner relationships. Regardless of partner type, condom use varied consistently depending on the frequency of sex with the same partner.

CONCLUSIONS

Condom use is related to the frequency of sex between partners when partner type is controlled. The association between frequency of sex and condom use is independent of partner type, suggesting that partner type may become less influential in determining condom use as the frequency of sex increases. This finding suggests that contextual factors determining condom use go beyond partner type designations and include other relationship variables.