Patterns of remission in pemphigus vulgaris

BACKGROUND

The incidence of remissions in pemphigus is unclear because these are usually reported at a single point in the evolution of the disease. Thus it is uncertain whether treatment simply suppresses the manifestations of the disease and consequently must be continuously administered, or induces complete and long-lasting remissions that permit therapy to be discontinued.

OBJECTIVE

To answer this question, we investigated the incidence of remission in a long-term longitudinal study.

METHODS

The induction of complete and long-lasting remissions (lesion free with no systemic therapy for at least 6 months) was studied in 40 patients with pemphigus vulgaris treated conventionally and followed up for an average of 7.7 years by the same investigator.

RESULTS

Five (5%) of the patients died of the disease. Complete and long-lasting remissions were induced in 25%, 50%, and 75% of patients 2, 5, and 10 years, respectively, after diagnosis. Most of the remaining patients were in partial remission or had mild disease controlled with a small dose of steroids. The course of the disease followed different patterns, with some patients rapidly entering complete and long-lasting remissions, whereas others never entered into a complete remission. The induction of complete remission was related to the initial severity and extent of disease and to early response to treatment.

CONCLUSION

It is possible to eventually induce complete and durable remissions in most patients with pemphigus that permit systemic therapy to be safely discontinued without a flare in disease activity. The proportion of patients in whom this can be achieved increases steadily with time, and therapy can be discontinued in approximately 75% of patients after 10 years.

G-CSF receptor mutations in patients with severe congenital neutropenia do not abrogate Jak2 activation and stat1/stat3 translocation

Severe congenital neutropenia (SCN) is an inherited disorder of myelopoiesis, characterized by a maturation arrest at the stage of promyelocytes and myelocytes in bone marrow, and absence or low levels of mature neutrophil granulocytes in peripheral blood. Recently, studies of patients with SCN who subsequently developed acute myeloid leukemia (AML) revealed nonsense mutations in the cytoplasmic domain of the granulocyte colony-stimulating factor (G-CSF) receptor messenger RNA. We focused our interest on the G-CSF-mediated signaling cascade to examine the consequences of the observed point mutations for the nuclear translocation of the transcription factors Stat1 and Stat3. Expression vectors encoding for truncated G-CSF receptors were transfected in the murine fibroblast cell line C243 expressing a fusion protein consisting of the transcription factor Stat1 and Stat3, respectively, and the green fluorescent protein (GFP). Nuclear translocation of the GFP fusion proteins was examined after G-CSF stimulation of the transfected cells.

Preoperative intracavitary brachytherapy in early-stage cervical carcinoma

Local failure within the central pelvis is a common site of recurrence in patients with early stage cervical carcinoma who experience recurrence after radical hysterectomy and pelvic lymphadenectomy. To reduce the risk of local failure, the authors treated selected patients with early stage cervical carcinoma with a moderate dose (45 Gy) of preoperative intracavitary brachytherapy before radical hysterectomy and pelvic lymphadenectomy. Given the low risk of recurrence in patients with small (<2 cm) tumors, the authors included only patients with tumors 2 cm or more in size. Forty-three patients (37 with stage IB disease, six with stage IIA disease) were treated from 1986 through 1995. Forty-two completed intracavitary brachytherapy; intracavitary brachytherapy was stopped early in one patient secondary to a low-grade fever. Exploratory laparotomy and planned radical hysterectomy were performed 2 weeks later. Radical hysterectomy was aborted in patients found to have extrauterine disease. At a median follow-up of 45 months, only one local failure has been noted, which occurred in the patient unable to complete intracavitary brachytherapy as planned. The most significant factor correlated with poor outcome was nodal involvement (p < 0.0004). A trend to a better disease-free survival was seen in patients with no residual or only microscopically residual disease. No patients developed significant chronic bowel or bladder toxicity, including fistulae. The results suggest that preoperative intracavitary brachytherapy in selected patients with early stage cervical carcinoma is a promising approach and is associated with a high rate of local control without significant adverse sequelae. Further data is needed to determine whether this approach improves the long-term outcome of these patients.

Different types of acid-base changes at birth, fetal heart rate patterns, and infant outcome at 4 years of age

BACKGROUND

To study the relationship between different types of acidemia in umbilical artery blood at birth, fetal heart rate (FHR) patterns during labor, and infant long-term outcome.

METHODS

Case-control study of 48 infants with pure high base deficit (base deficit (BD) > or = 12 mmol/L and pCO2 < 8.0 kPa), 51 with mixed acidemia (BD > or = 12 mmol/L and pCO2 > or = 8.0 kPa), born at or after term, and controls matched for maternal age, parity, and gestational age at birth. FHR patterns during labor and the results of developmental screening at age 4 were compared between the groups.

RESULTS

Late decelerations were associated with pure high base deficit and complicated variable decelerations with mixed acidemia. Both types of acidemia were correlated with Apgar scores below 7 at 1 minute, and mixed acidemia with more admissions to the neonatal intensive care unit. Developmental screening at age 4 years showed no significant differences between infants with mixed acidemia or pure high base deficit and controls. Twelve infants with mixed acidemia and six controls had deficits in language/speech development.

CONCLUSIONS

Late decelerations may be an indicator of a metabolic component of acidemia and complicated variable decelerations an indicator of mixed acidemia. The higher rate of admissions to the neonatal intensive care unit in cases with mixed acidemia may suggest that a concomitant hypercapnia (resulting in lower pH) in metabolic acidemia at birth may be of importance for the outcome. A possible relation between acidemia at birth and deficits in speech/language development should be further evaluated.

Long term outcome after umbilical artery acidaemia at term birth: influence of gender and duration of fetal heart rate abnormalities

OBJECTIVE

To study the outcome after acidaemia at term birth, and the relation to gender and duration of pathological fetal heart rate changes.

DESIGN

Population based study of 154 infants with umbilical artery pH < 7.05 at term birth. Neonatal outcome and the result of developmental screening at age four years were compared with a control group with pH > 7.10. Fetal heart rate traces in infants with acidaemia were reviewed, and the relation between duration of fetal heart rate changes and outcome was analysed.

RESULTS

Of the 154 newborns with acidaemia at birth, 10 had encephalopathy, of which two died and two developed cerebral palsy. Nine of these 10 infants were boys, and eight had pH < 7.00. Male newborns (n = 39) more often had pronounced acidaemia (pH < 7.00) than females (n = 22). Although few infants had severe impairment, infants born with acidaemia significantly more often had speech problems at follow up than controls (19/102 versus 8/98; P = 0.03). In infants with acidaemia, duration of abnormal fetal heart rate changes was significantly associated with neonatal encephalopathy and speech problems at age four years.

CONCLUSIONS

Acidaemia at term birth was associated with neonatal encephalopathy and with speech problems at four years of age. Boys had more often pronounced acidaemia and a complicated course. A protracted abnormal fetal heart rate trace was associated with poor outcome.

Risk factors for acidemia at birth

OBJECTIVE

To identify risk factors for acidemia at birth.

METHODS

From September 1988 to December 1996, cord arterial blood pH was measured in 23,016 of 27,064 live-born infants (85.0%). Values below 7.05 were observed in 264 newborns (1.1%), of whom 14 born by cesarean delivery before labor and one triplet infant were excluded from the study. The remaining 249 newborns with acidemia and their mothers were compared with 249 unmatched controls with normal pH (the first infant with umbilical arterial pH above 7.10 born after each case). Multivariate logistic regression was used to adjust for potentially confounding variables.

RESULTS

Variables significantly and independently associated with acidemia at birth were labor with breech presentation (adjusted odds ratio [OR]2.9), oxytocin administration (OR 2.1), meperidine administration (OR 2.0), cord entanglement (OR 1.7), and male gender of the infant (OR 1.4). Clinical evidence of chorioamnionitis also was associated with acidemia, although after adjustment for prematurity, the association was not statistically significant (OR 3.9, 95% confidence interval 0.8, 19).

CONCLUSION

Labor with breech presentation, administration of oxytocin and meperidine, cord entanglement, and male gender are associated with an increased risk for insufficient fetomaternal gas exchange.

Maternal fever in term labour in relation to fetal tachycardia, cord artery acidaemia and neonatal infection

OBJECTIVE

To determine 1. whether maternal fever during term labour is associated with acidaemia at birth and neonatal infection and 2. whether fetal tachycardia precedes maternal fever and is associated with neonatal infection.

DESIGN

Retrospective matched-pair case-control study.

SUBJECTS

Two hundred and forty-eight newborn infants whose mothers developed fever during term labour (cases) and 248 control infants. The women were matched for parity and duration of labour.

MAIN OUTCOME MEASURES

Cord artery acid-base status, Apgar scores, neonatal infections, and fetal heart rate before maternal fever.

RESULTS

Mean pH, as well as the rate of cord artery acidaemia at birth (pH < 7.10) was equal in cases and controls (in both groups 7.24% and 6%, respectively). Signs of septicaemia and/or pneumonia were identified in 17 case newborns (7%) and in one control (0.4%; OR 17.0, P < 0.001). Of 212 pairs with complete heart rate data, fetal tachycardia preceded maternal fever in 39 cases (18%) and in 16 controls (8%) (OR 2.6, P = 0.003). Tachycardia before maternal fever was not associated with increased neonatal infectious morbidity.

CONCLUSIONS

Maternal fever during term labour was associated with perinatal infection, but not with acidaemia at birth. Elevated fetal heart rate preceded maternal fever in a minority of cases and was not associated with perinatal infection.

Risk factors for fever in labor

OBJECTIVE

To identify risk factors for fever in labor.

METHODS

A retrospective case-control study was conducted. Maternal sublingual temperature was measured every 2-4 hours during labor in 3109 of 3860 consecutive term parturients presenting from September 1992 through December 1993. Women who had fever (at least one recorded temperature of 38C or more, n = 72) during labor were compared with those who remained afebrile (n = 3037). Furthermore, a matched-pair case-control study was conducted, involving 250 women at term who developed fever in labor and 250 controls matched for parity and duration of labor; all delivered between January 1989 and December 1993. A conditional multiple logistic regression analysis was used to identify independent risk factors for fever during labor.

RESULTS

In the case-control study, fever was associated with epidural analgesia, nulliparity, and a long duration of labor. These three variables were also related among themselves. However, multiple regression analysis showed that all three variables were independently associated with maternal temperature. In the matched-pair study, epidural analgesia, rupture of membranes longer than 24 hours, latency phase exceeding 8 hours, and a temperature in the upper normal range (37.5-37.9C) at admission were independent risk factors for developing fever in labor.

CONCLUSION

Epidural analgesia, duration of labor, and a long interval from rupture of membranes to delivery were independent risk factors for maternal fever in labor.

Blue Questionnaires and Blue Mood

The scores of 41 students on the Zung Self-rating Depression Scale were not affected by whether the questionnaire was printed on bright blue versus white paper.

Maternal health care program and markers for late fetal death

OBJECTIVE

To identify markers for late fetal death, a multicenter study was performed, based on routinely obtained data from maternal health care units.

MATERIAL AND METHODS

Prospectively recorded data were obtained from maternal health care units belonging to five delivery units. In all, 233 consecutive cases of singleton pregnancy involving late fetal death (> or = 28 weeks) were identified between 1983 and 1989. As a control for each case, the next consecutive mother giving birth to a live infant at the same delivery unit was selected, the sole matching criterium being parity.

RESULTS

After exclusion of pregnancies with lethal malformations or trauma, 205 cases remained for the statistical analysis. Two main subgroups were identified: mothers with placental abruption (n = 44), and pregnancies with no obvious reason for fetal death (n = 101). An increased risk for late fetal death was evident in expectant mothers > or = 40 years (10 vs 1; chi 2 = 7.6, p < 0.01), and in smokers where an association was seen to placental abruption. A significantly increased risk was also seen in women with medical treatment for essential hypertension (8 vs 1; chi 2 = 5.6, p < 0.05). On the other hand, we found no correlation between proteinuria, glucosuria, decreasing symphysis-fundal height, or changes in the Hb, on the one hand, and late fetal demise, on the other. There was no overrepresentation of post dated pregnancy (by ultrasound early in the second trimester) among the cases. Nor did post dated pregnancies (> or = 42 weeks) estimated from first day of last menstrual period (but not post dated by ultrasound) imply a higher rate of fetal death, as has been suggested in previous studies.

CONCLUSION

In the present material, there was no sign of systematic error in the evaluation of data routinely obtained from the antenatal clinics and maternity units. Apart from placental abruption in smokers, a high maternal age, and medical treatment for essential hypertension, deviating data were recorded as often among controls as among cases. No correlation was evident between a post date pregnancy and fetal demise. A short symphysis-fundal height was recorded as often among controls as among cases and the even distribution of fetal birthweight in case pregnancies around the standard curve for the normal population is noteworthy.

No relation between maternal weight gain and stillbirth

BACKGROUND

To evaluate the relationship between stillbirth in singleton pregnancy (> or = 28 weeks gestation) and maternal weight (weight gain) from 24 completed weeks.

METHODS

All fetal deaths (n = 210) at five delivery units during seven years in southern Sweden were analysed. To each case a control mother was selected, the only matching criteria being parity and place of delivery. Regression analysis was used for comparison of body weight gain in cases and controls.

RESULTS

Mothers experiencing stillbirth had a significantly lower mean body weight at 24 weeks gestation than control mothers (63.5 kg vs 67.3 kg; t = 2.4, p < 0.05). No significant difference between cases and controls was found in mean weight gain during pregnancy from 24 completed gestational weeks to delivery, even when the last three measurements before delivery for cases and controls were compared separately.

CONCLUSION

There is no difference in body weight gain between mothers with stillbirth and mothers giving birth to a live infant.

Intermittent versus continuous electronic monitoring in labour: a randomised study

OBJECTIVE

To compare the efficacy in detecting signs of fetal hypoxia in labour of intermittent (I-group) versus continuous (C-group) electronic fetal monitoring in women with low or moderate risk factors for fetal distress.

DESIGN

A prospective, randomised study.

SETTING

A tertiary referral centre.

SUBJECTS

Four thousand and forty-four parturients at low risk for obstetric complications with a reactive fetal heart rate admission test at arrival in labour. During the study period (October 5 1989 to May 31 1991), 5647 women were delivered in the labour ward. Of these, 1178 women (20.9%) were excluded because of high risk factors in pregnancy or at admission for labour, including women undergoing elective caesarean section. Of the remaining 4469 women 4044 (90.5%) were randomised to either intermittent (n = 2015) or continuous monitoring (n = 2029) during the first stage of labour.

METHODS

In the C-group the fetal heart rate was recorded continuously with electronic fetal monitoring during the first stage of labour. In the I-group the fetal heart rate was recorded with electronic fetal monitoring for 10 to 30 min every 2 to 2.5 h during the first stage of labour, and the fetal heart rate was auscultated every 15 to 30 min in between recording periods. If complications occurred, recording was changed to continuous. In the second stage of labour all the women were monitored continuously. Umbilical cord artery acid-base status was assessed at birth.

MAIN OUTCOME MEASURES

Duration of electronic fetal monitoring, rates of abnormal fetal heart rate patterns, caesarean section for fetal distress, acidosis in umbilical cord arterial blood at birth, Apgar scores of less than 7 at 1 or 5 min, and referrals to the neonatal intensive care unit.

RESULTS

There were no significant differences between the study groups in the incidence of ominous fetal heart rate recordings: 6.3% (I-group) versus 6.6% (C-group), or the interval from arrival to first detected abnormal fetal heart rate, although the number of suspicious fetal heart rate patterns was higher in the C-group (28.6%) than in the I-group (24.6%). In the I-group electronic fetal monitoring was performed for (median monitoring time) 38.8% of the first stage of labour as compared with 78.6% in the C-group. The incidence of caesarean section for fetal distress was similarly low in both groups: 1.2% versus 1.0%. There were no significant differences in the immediate neonatal outcome in terms of umbilical artery pH, Apgar scores, or admissions to the neonatal care unit.

CONCLUSIONS

Intermittent use of electronic fetal monitoring at regular intervals (with stethoscopic auscultation in between) appears to be as safe as continuous electronic fetal monitoring in low risk labours.

Infections and antibiotic prophylaxis in reconstructive vascular surgery

In 98 patients undergoing elective vascular surgery, specimens for bacterial cultures were obtained from urine, ischaemic ulcers, incisional wounds and the implanted grafts. Wound and graft infections were registered and compared with the results of these cultures and suspected risk factors in an attempt to find the source of infections. Antibiotic prophylaxis with cefuroxime was given for 24 h beginning at the start of surgery. Patients with ischaemic ulcers also received "spread prophylaxis", directed against isolated bacteria, for ten days. Three cases of graft infection and twelve cases of wound infection occurred. Positive postoperative cultures from wounds did not correlate with pre- or peroperative cultures. Peroperative cultures revealed small numbers of staphylococcus epidermidis in eleven patients, and none of them developed graft infection. Ischaemic ulcers, diabetes or re-do procedures were not accompanied by a significantly increased frequency of wound or graft infection, although each of three patients with graft infection had one of these risk factors. Bacteria, sensitive to cefuroxime, were found in one graft infection, six wound infections, and in two patients with urosepsis, whereas cefuroxime resistant organisms were isolated from one graft infection and three infected wounds. One of the three graft infections was probably caused by bacteria originating from the patient's ischaemic ulcer. In the other two patients the source of bacteria could not be determined. Cefuroxime seems to be an adequate alternative for prophylaxis of vascular graft infection, but in some patients with bacteriuria or indwelling catheters, a one day regimen may be too short.

Rates and risks of diethylstilbestrol-related clear-cell adenocarcinoma of the vagina and cervix. An update

We reviewed 519 cases of clear-cell adenocarcinoma of the vagina and cervix identified by the Registry for Research on Hormonal Transplacental Carcinogenesis of the University of Chicago through June 30, 1985. In 60 percent of all cases the patient's mother had received diethylstilbestrol during pregnancy. An additional 12 percent of all mothers had been treated with another hormone or with an unidentified medication. Ninety-one percent of the cases in diethylstilbestrol-exposed women were diagnosed when the patient was between the ages of 15 and 27. The median age at diagnosis was 19.0 years. The risk that clear-cell adenocarcinoma will develop in an exposed female from birth through age 34 is 1 case per 1000 women. The temporal pattern of occurrence of clear-cell adenocarcinoma corresponds closely with that of the use of diethylstilbestrol for pregnancy support in the United States. The rarity of this tumor among exposed women suggests that diethylstilbestrol is not a complete carcinogen and that some other factor is also involved in the pathogenesis of clear-cell adenocarcinoma of the vagina and cervix.

[Treatment of alcohol-dependent patients in Rostock]

In the first part of the paper is reported on differential-therapeutic experiences in the hospital treatment of 307 alcoholics with disulfiram R, Lithium R and Apomorphine R as monotherapy as well as in combined application. Our investigations show that neither lithium R nor apomorphine R have ascertained advantages to the monotherapy with Disulfiram R. An improvement of the still unsatisfactory number of success is to be achieved in the first place by an optimization of the after-care by means of a close sociotherapeutic and if necessary psychotherapeutic care, possibly in special outpatient departments. In the second part of the paper is reported on first experiences.

[Lipoprotein lipase activity in healthy subjects and patients with metabolic disorders]

The activity of the post-heparin-lipase as well as of the cholesterol and triglyceride levels of test persons with normal weight and obese test persons of different age groups was established: 1. In normal persons (males and females) in mature age (30-45 years) a decrease of the enzyme activity takes place which is connected with an increase of the triglyceride content. Above all in older females a repeated increase of the post-heparin-lipase activity was observed, which positively correlates with the triglyceride level. While the decreases of the enzyme activity in mature age may be connected with processes of ageing, a repeated increase of the enzyme activity in older persons is perhaps induced by the increase of the triglyceride level. 2. Obese persons show higher enzyme activities in all age groups examined. Also in obese persons in mature age a decrease of the activity of post-heparin-lipase is to be established. The ageing development of the enzyme activity of the post-heparin-lipase is similar to that of normal persons, takes place, however, at a higher level. 3. The cholesterol and triglyceride levels of the obese persons examined were on an average higher than those of normal persons of the same age group. A dependence of age of these parameters was not observed in the adipose patients.

Nuclear chromatin determination in amniotic fluid cells for prenatal sex prediction in the macaque

Amniotic fluid cells obtained after the ninetieth day of gestation in the macaque were analyzed for nuclear chromatin. The technique proved reliable for the prediction of fetal sex.