A clinical evaluation of the long-term outcome of patients treated for bilateral fracture of the mandibular condyles

The object of the study was to present our experience of the treatment of bilateral condylar fractures between 1979 and 1995 and give the long-term outcome. The subjects were 61 patients, of whom 33 attended for review. There were 41 men and 20 women, age range 12-80 years (although nearly all the patients were between 17 and 32 years old). Thirty-one patients (51%) had bilateral fractures of the mandibular condyles alone, the remainder also having another mandibular fracture, usually at the parasymphysis. Over half the patients had been injured in falls. Only 8/122 fractures (7%) were intracapsular, 59 were of the condylar neck (48%), and the remaining 55 (45%) were subcondylar. Nearly half of the fractures were undisplaced. Thirty-nine patients (21%) were treated with wire intermaxillary fixation for a mean of 37 days, 13 (21%) were managed conservatively, and 9 (15%) with 10 fractured condyles were managed by open reduction and internal fixation (ORIF). The most common complaint after treatment was persistent limitation in mouth opening, which was significantly less in the ORIF group mean (SD) 44 mm (2 mm) than in the intermaxillary fixation group 28 mm (2 mm), P < 0.01. It is concluded that if either of the condyles is displaced ORIF is the most satisfactory method of treatment.

Photodynamic therapy of the ciliary body with tin ethyl etiopurpurin and tin octaethyl benzochlorin in pigmented rabbits

BACKGROUND AND OBJECTIVES

The authors used a pigmented rabbit model to investigate two photosensitizers, tin ethyl etiopurpurin (SnET2) and tin octaethyl benzochlorin (BNZ 203), to determine their potential for creating ciliary body injuries during photodynamic therapy (PDT).

MATERIALS AND METHODS

The biodistribution of SnET2 (n = 10) and BNZ 203 (n = 9) was studied by fluorescence microscopy using a low light detection system, based on charged-coupled device photography, with digital image processing at 1 and 24 hours after injection. PDT with SnET2 (n = 8; 664 +/- 7-nm light; 75 mW/cm2; 50 or 100 J/cm2; 1-mm spot size) and BNZ 203 (n = 6; 689 nm; 75 mW/cm2; 50 or 100 J/cm2; 1-mm spot size) was performed at 24 hours post-injection. The control subjects for SnET2 (n = 5) and BNZ 203 (n = 3) were given a maximal light dose (100 J/cm2).

RESULTS

Both photosensitizers demonstrated an intravascular distribution at 1 hour that shifted to a ciliary body distribution at 24 hours (SnET2 much greater than BNZ 203). In addition, the SnET2 demonstrated suborgan localization to the nonpigmented ciliary body epithelium. Both photosensitizing agents were able to produce selective injury to the rabbit ciliary body (SnET2 much greater than BNZ 203), with evidence of a small component of thermal damage (SnET2 greater than BNZ 203).

CONCLUSIONS

PDT with SnET2 or BNZ 203 can produce selective injury to the pigmented rabbit ciliary body. The nonpigmented ciliary body epithelium exhibits selective retention of SnET2. This finding warrants further investigation.

A global scale to measure the quality of the family environment

BACKGROUND

Simple, reliable measures of the quality of the environment in which a child was reared that can be used in clinical research and practice are lacking.

METHOD

The reliability and validity of a global scale to retrospectively appraise the quality of that environment were examined. Fifty-three clinicians from 4 centers in Australia and 1 in Hong Kong, People's Republic of China, used the scale to rate 7 case vignettes; 4 clinicians rated 20 medical records, and 49 rated 211 subjects after clinical interviews.

RESULTS

Interrater reliability (intraclass correlation coefficient) was 0.82 (time 1) and 0.84 (time 2) for case vignettes, 0.90 for medical records, and 0.89 for clinical interviews. Consistency in time was high (r = 0.91). Lower ratings, indicative of a less adequate environment, were associated with a clinical diagnosis of oppositional defiant or conduct disorder.

CONCLUSIONS

Our simple-to-use scale appears to measure reliably a relevant clinical construct and fills a gap among the instruments available. Ratings may be useful as a cost-effective index to consider in outcome studies, when examining response to treatment, or in other clinical research.

Safety and efficacy outcome of mentor alpha-1 inflatable penile prosthesis implantation for impotence treatment

PURPOSE

We investigated safety and efficacy outcome pertaining to the Mentor Alpha-1, 3-piece inflatable penile prosthesis for impotence treatment.

MATERIALS AND METHODS

A 2-phase, multi-institutional, large scale retrospective study, with independently analyzed medical record (phase I) and questionnaire (phase II) data from consecutive eligible patients of 7 physician investigators was performed from March to October 1993.

RESULTS

In phase I there were no morbidities of any type in 394 of the 434 patients (90.8%) (mean age 61 years, range 24 to 88) who underwent Alpha-1 implantation (mean followup 22.2 months, range 0.67 to 44.5). The risk of prosthesis malfunction (fluid leak and auto-inflation) was 2.5%. No cylinder aneurysms were reported. A total of 93.1% of Alpha-1 devices was free from explantation (4.4%) or revision surgery (2.5%) for approximately 2 years from the original implant date. Kaplan-Meier actuarial analyses revealed that cumulative survival of the Alpha-1 prostheses at 12, 24 and 36 months was 98 +/- 1%, 93 +/- 2% and 85 +/- 7% until device malfunction, and 91 +/- 2% 83 +/- 4% and 75 +/- 7% until surgical intervention (revision or explantation). In phase II 89% of the men claimed fulfilled expectations with the Alpha-1 prosthesis as impotence treatment. Satisfaction responses 80% or greater were noted with regard to intercourse ability and confidence, and device rigidity and function. Implantation did not result in greater than 80% satisfaction in partner relationships or feelings (as judged by the patient), social or work confidence, or intercourse frequency. Factors adversely affecting satisfaction included partner feelings of dissatisfaction (as judged by the patient), specific physician investigators and need for explantation/revision surgery.

CONCLUSIONS

In 1 of the largest multi-institutional implant outcome studies thus far performed, safety and efficacy data concerning the Alpha-1 contemporary inflatable device were found markedly improved over earlier inflatable prostheses and now compare favorably with historical data from noninflatable rod type devices.

Social cognition in schizophrenia

The study of social cognition in schizophrenia may augment the understanding of clinical and behavioral manifestations of the disorder. In this article, the authors describe social cognition and differentiate it from nonsocial cognition. They garner evidence to support the role of social cognition in schizophrenia: Nonsocial information-processing models are limited to explain social dysfunction in schizophrenia, measures of social cognition may contribute greater variance to social functioning than measures of nonsocial cognition, task performance on nonsocial-cognitive measures may not parallel performance on social-cognitive tasks, and symptomatology may be best understood within a social-cognitive framework. They describe the potential implications of a social-cognitive model of schizophrenia for the etiology and development of the disorder.

Ischemic/reperfused myocardium can express recombinant protein following direct DNA or retroviral injection

A non-contracting scar following myocardial infarction can adversely affect ventricular topography and hemodynamic function. Gene transfer has the potential to prevent or alter such pathophysiological processes. Normal myocardium is a proven target for delivery of DNA or viral vectors but the potential for gene therapy in ischemic myocardium has not been evaluated. In an initial series of experiments, we determined whether the direct injection of reporter genes into hearts subjected to coronary artery occlusion followed by reperfusion could result in gene expression comparable to the levels observed in non-occluded normal hearts. Anesthetized rats were subjected to 15 min or 60 min of proximal coronary occlusion or sham operation. Luciferase gene under the control of the Rous sarcoma virus promoter was injected directly into the anterior left wall. At 1 week, high expression of luciferase was observed in both the ischemic/reperfused and non-ischemic tissue. Thus DNA transfer by direct injection is possible after ischemic injury and uptake and expression are not impaired. In a second series of experiments, myocardial infarcts in dogs were injected with a beta-galactosidase expressing retroviral vector. LNPOZ. Six to 11 days later frozen sections revealed macroscopically visible expression of beta-galactosidase activity. Not only can foreign genes be taken up by direct injection of DNA or retroviruses into ischemic/reperfused myocardium but they can be transcribed and the protein synthetic machinery of the injured cells can produce recombinant polypeptides that retain enzymatic activity. These results open the way for the investigation of gene therapy in models of ischemia.

Melanotic neuroectodermal tumour of infancy: an immunohistochemical and ultrastructural study

Two cases of melanotic neuro-ectodermal tumour of infancy (MNTI)--a rare neoplasm arising in the first year of life--are reported, with the results of immunohistochemical and ultrastructural examination. The tumours consisted of a biphasic cell population in a fibrous stroma. The small, darkly staining cells comprising the first population stained positively for synaptophysin, showing them to be neuroblasts, and the large epithelioid cells comprising the second cell population stained positively with the antibodies HMB-45 and NKI-Beteb, showing them to be melanocytes. Ultrastructural examination of the second case confirmed the biphasic nature of the tumour cells, with secretory granules and neurofilaments in the neuroblastic population, and melanosomes in the epithelioid population. These results add to the evidence supporting the neural crest origin of MNTI and confirm its formation from two distinct cell lines. Both cases have responded to local excision, with no recurrence more than a year after initial treatment.

The role of autogenous primary rib grafts in treating fractures of the atrophic edentulous mandible

Fractures of the atrophic edentulous mandible are relatively uncommon representing less than 1% of all facial bone fractures seen at The Queen Victoria Hospital, East Grinstead. Only 35 patients have been treated for fractures of the atrophic edentulous mandible at this unit from a total of over 4000 facial bone fractures seen here between 1975 and 1994. All traditional treatment modalities have been utilised with varying degrees of success. A technique is presented whereby all displaced fractures of the atrophic edentulous mandible with a measured bony vertical dimension of less than 10 mm at the fracture site are managed with primary autogenous rib grafting. This reduces the risk for formation of pseudarthrosis and facilitates subsequent prosthetic rehabilitation.

Bilateral multifocal canalicular adenomas of buccal minor salivary glands: a case report

Although the incidence of multifocal epithelial tumours of the minor salivary glands is very low, canalicular adenoma not infrequently presents as a multifocal lesion, usually in the upper lip. We present an unusual case of bilateral multifocal canalicular adenomas of the buccal mucosa in a woman aged 75 years.

Adaptation of rabbit small intestinal brush-border membrane enzymes after extensive bowel resection

Short lengths of small intestine may be resected without significantly affecting the digestive and absorptive capacity; however, extensive resection produces varying degrees of malnutrition. This study was undertaken to define the adaptive changes in the remaining small intestine of two of the jejunal and ileal mucosal brush-border membrane enzymes after extensive small bowel resection in rabbits. Thirty adult New Zealand White rabbits underwent a 50% to 60% jejuno-ileal-enterectomy with end-to-end anastomosis. Maltase activity (UE/g protein) increased from 152 (preoperative) to 392 at 3 weeks in the proximal segment and from 85 to 259 in the distal segment; these levels decreased to 222 and 155 in the respective segments at 6 weeks. AOP activity (UE/g protein) increased from 154 (preoperative) to 171 in the proximal segment and 171 to 256 in the distal segment at 3 weeks, and was 131 and 288 in the respective segments at 6 weeks. This marked increase in the mucosal brush-border enzymatic activities at 3 weeks postoperatively was associated with a 28% increase in bowel length. By 6 weeks the enzyme levels had decreased slightly; however, there was a persistent 41% increase in bowel length over that immediately postoperation. The mucosal surface area increased from 295 mm2 immediately postoperation to 5,337 mm2 at 3 weeks and 7,635 mm2 at 6 weeks, a 250% increase. The authors conclude that there is an immediate compensatory increase in villus length as well as brush-border enzymatic expression in the remaining intestine that gradually declines as the small intestinal surface area continues to increase and the bowel lengthens with time.

The zinc coordination site of the bacteriophage Mu translational activator protein, Com

The bacteriophage Mu Com protein is a small "zinc finger-like" protein that binds a specific site in com-mom operon mRNA and activates translation of the mom open-reading-frame. Com contains six cysteine and five histidine residues that have the potential to form several alternative zinc-finger-like motifs. We have used oligonucleotide site-directed mutagenesis to individually alter each of these amino acids (Cys to Ser, and His to Asn or Gln) and tested the various forms of Com for their ability to function in vivo. We observed that mutation of any one of the four N-terminal cysteine residues (Cys-6, 9, 26 or 29) resulted in loss of Com activity. The Com protein requires zinc in order to fold into its functional tertiary structure, as demonstrated by characteristic 1H nuclear magnetic resonance (NMR) chemical shifts. 1H chemical shifts revert to random coil values in the presence of the metal chelator EDTA. The metal-binding specificity and thermal stability of Com also has been investigated using 1H NMR. We report the use of 113Cd NMR, 1H-113Cd heteronuclear spin-echo difference spectroscopy HSED and Zn extended X-ray absorption fine structure spectroscopy EXAFS to determine the zinc/protein stoichiometry as 1:1 and the ligand environment as tetrathiolate. Comparative NMR spectra of Com mutants C6S and C39S suggest position 6 is involved in zinc coordination, while position 39 is not metal-liganded. These studies indicate that the metal coordination, site of Com is a four-cysteine complex, involving residues 6, 9, 26 and 29.

Oral squamous cell carcinoma arising in phenytoin-induced hyperplasia

A case is described of a squamous cell carcinoma arising in an area of phenytoin-induced gingival hyperplasia. Recent literature concerning the effects of phenytoin on the gingival tissues cites a possible mechanism of phenytoin-induced carcinogenesis.

1525 laparoscopic cholecystectomies without biliary injury: a single institution's experience

Laparoscopic Cholecystectomy (LC) has become the preferred treatment of gallbladder disease. The indications for LC remain unchanged from those for open cholecystectomy (OC). A total of 1525 patients underwent LC at Georgia Baptist Medical Center between December 1989 and December 1992. The procedure was completed in 1,492 patients (97.8%) and required conversion to OC in 33 patients (2.2%). Selective intraoperative cholangiography was used in 165 patients (10.8%). Overall morbidity was 4.06%, and there were four deaths not operatively related, for a 0.26% mortality rate. There have been no biliary ductal injuries. The average hospital stay was 0.82 days, with 37.4% of the patients going home as true outpatients and 44.5% going home on postop Day one. Most published series on LC report a small incidence of biliary injury. We feel that with meticulous dissection of the cystic duct and use of selective intraoperative cholangiography to define unsure anatomy, biliary injury can be minimized.

Malignant ameloblastoma revisited

A case of a malignant ameloblastoma in a 49-year old Sri Lankan woman with widespread pulmonary metastases is presented, the diagnosis confirmed by needle biopsy. The current histological classification of odontogenic carcinomas and the management of metastatic pulmonary deposits are discussed.

Laparoscopic diagnosis and treatment of Morgagni hernia

The application of new minimally invasive techniques in the diagnosis and treatment of surgically correctable diseases continues to produce impressive results. Herniae of the Foramen of Morgagni are unusual abdominal wall defects which have historically been difficult to diagnose. Interestingly, laparoscopy was utilized for the diagnosis and repair of three such herniae during a 5-month period. All of these repairs were performed by one primary author in conjunction with co-authors. In this report we will review this rare hernia and report our technique of repair. We believe that an aggressive approach to diagnostic laparoscopy may produce cost-effective solutions to old and new intraabdominal problems.

Tissue restricted gene expression assayed by direct DNA injection into cardiac and skeletal muscle

We have used direct injection of plasmid DNA into heart and tongue in vivo and transfection into cells in culture to determine (1) whether the pattern of reporter gene expression parallels the cell-type specific expression of endogenous genes, (2) whether the pattern of reporter gene expression approximates that of the same constructs transfected into myocardiocytes and myogenic cells in culture, (3) whether the expression patterns of promoters and enhancers that had been subtly altered by mutations are similar following transfection and direct DNA injection. We utilized reporter gene constructs derived from the two fiber-type specific human troponin C genes: the fast twitch gene (TnCf) and the slow twitch or cardiac gene (cTnC). The endogenous TnCf gene does not express in the heart and the plasmid DNA expresses neither in myocardium after injection nor in transfected cardiomyocytes. However injected TnCf does express vigorously in tongue muscle. Conversely, the endogenous cTnC gene does not express in fast twitch skeletal muscles like tongue and the plasmid DNA does not express in tongue after injection. However, injected cTnC does express in both injected myocardium and in transfected cardiomyocytes. With few discrepancies, various deletions and alterations of the promoters and enhancers of these genes that have previously been defined by transfection into permissive myogenic cells in culture gave parallel expression patterns after injection in myocardium and tongue. Thus we conclude that direct DNA injection appears to provide a method to verify the identities of important cis-acting regulatory regions that have been mapped in cells in culture.

Parathyroid hormone (PTH) secretion: stimulation of PTH secretion by a peptide derived from the adenosine diphosphate-ribosylation factor

Using preparations of dispersed bovine parathyroid cells, we have investigated the effect of a 16-residue synthetic peptide, ARF-16, which corresponds to the N-terminus of the ADP-ribosylation factor, on the secretion of PTH. We find it to be a very effective secretagogue for PTH secretion, acting in a dose- and time-dependent manner. At concentrations in the range of 15-25 microM, the ARF peptide stimulated PTH secretion to a greater degree than low extracellular calcium, and at 25 microM was more effective than isoproterenol. The stimulatory effect of ARF was not dependent on the extracellular calcium concentration over the range of 0.5-3 mM. Upon testing other synthetic peptides of similar size we found no effect on PTH secretion, indicating that the ARF-16 effect is specific. In an attempt to define the structural elements of ARF that are required for activity, we tested several analogs of ARF with amino acids deleted from the N- and C-terminus. Deletion of the 2 N-terminal residues yielded a peptide with substantially reduced activity. Further deletions from the N-terminus yielded an inactive peptide. Similarly, a peptide with deletions of 3 residues from the C-terminus was inactive. Thus, the activity of ARF-16 requires both the N- and C-terminal sequence, suggesting that the 16-residue peptide is the minimal sequence required for full activity. Measurements of cAMP concentrations indicate that the stimulatory effect is not mediated via this second messenger. The ARF peptide does not alter intracellular calcium, suggesting that its effect is not mediated by calcium. Although cells incubated with ARF are vigorously stimulated to secrete PTH, this effect is reversible, as demonstrated by washing cells free of ARF, whereupon PTH secretion returns to basal levels. These results indicate that the peptide is not entering the cells, but is effecting secretion through a low affinity interaction at the cell surface. Other experiments, in which the capacity for ARF stimulation was abolished after a brief exposure of the cells to trypsin, support this conclusion. Characteristics of the ARF stimulatory effect, such as dose dependency and reversibility, lead us to conclude that the peptide is probably acting on the regulated secretory pathway. As the effect is not dependent on extracellular calcium levels and is not mediated via cAMP, we believe that this peptide will be a useful additional tool for future studies of the mechanisms of PTH secretion.

An institutional review of the management of choledocholithiasis in 1616 patients undergoing laparoscopic cholecystectomy

At Georgia Baptist Medical Center, 1616 patients underwent laparoscopic cholecystectomy between December 1989 and December 1992; and 103 perioperative endoscopic retrograde cholangiopancreatography (ERCP) procedures were performed, 79 preoperative and 24 postoperative. Endoscopic sphincterotomy with stone extraction was performed in 49 patients (4.7%). Normal ERCP was noted in 46 patients (44%), four patients failed stone extraction preoperatively, and two patients failed extraction postoperatively (5.7%). Four patients had small stones (< 2 mm) managed expectantly without sphincterotomy. Ten laparoscopic common bile duct explorations and eight open common bile duct explorations were performed without retained stones after these procedures. The incidence of detected choledocholithiasis requiring intervention was 4.4 per cent, which is significantly lower than the published incidence of 8 to 15 per cent. It is assumed that a higher percentage of stones may have been detected with liberal or routine use of cholangiography. The clinical significance of these potentially missed stones have not been manifest in our series to date. The authors believe that although improved patient selection may lower the percentage of normal ERCP, this combination of minimally invasive techniques provides a satisfactory approach to choledocholithiasis.

Meralgia paresthetica: a complication of laparoscopic herniorrhaphy

Laparoscopic herniorrhaphy is a new and presently evolving technique applied to the repair of inguinal defects. Many different authors have described various methods by which this can be achieved. Some of these include the transabdominal preperitoneal approach, the plug technique, the intraperitoneal onlay of mesh, and the extraperitoneal approach. The authors have performed 252 laparoscopic hernia repairs utilizing a form of the transabdominal preperitoneal procedure that is referred to as the "transperitoneal anatomic approach." The development of new procedures or the modification of existing procedures can create new problems or alter the pattern of traditional complications. These problems must be thoroughly evaluated and reported if repetition of these errors is to be avoided. Five cases of meralgia paresthetica are reported that resulted from staple entrapment of the lateral femoral cutaneous nerve during laparoscopic herniorrhaphy. An understanding of the preperitoneal inguinal anatomy and precise placement of staples will allow avoidance of this complication.

An infarcted Warthin's tumour presenting with facial weakness

It is rare for benign salivary gland neoplasms to cause facial nerve weakness. We present such a case occurring in a 70-year-old patient with an infarcted Warthin's tumour and review the benign causes of facial nerve impairment.

Cryptogenic constrictive bronchiolitis. A clinicopathologic study

Four women with a chronic respiratory illness characterized by chronic cough, dyspnea, mild to severe physiologic abnormalities, relatively normal chest radiographs, and lack of response to bronchodilators or prednisone were identified and prospectively evaluated. Constrictive bronchiolitis, defined as concentric narrowing of the bronchiolar lumen, mural scarring, smooth muscle hyperplasia, and mucus stasis, was the major histologic finding on open lung biopsy in all cases. Each presented with an illness clinically distinct from asthma, connective tissue disorders, occupational or environmental lung disease, bronchiectasis, diffuse panbronchiolitis, cystic fibrosis, and emphysema. None of the patients smoked cigarettes. None had clinical evidence of a recent viral lower respiratory tract infection. The physical examinations were normal except for rales heard on chest examination in two patients. Chest radiographs showed increased bronchovascular markings in three patients. Lung function was normal in one patient, two of the patients had a reduced diffusing capacity associated with moderate hypoxemia and an obstructive ventilatory defect, and one patient exhibited a mixture of restrictive and obstructive defects. None have experienced significant progression of their disease over 1 to 5 yr of follow-up. However, complete return to normal function did not occur. We hypothesize that patients with the constellation of findings described represent a distinct and definable clinicopathologic entity and further clarifies the spectrum of "small airways disease." Establishing the diagnosis appears important for prognostic and possibly therapeutic reasons.

Laparoscopic herniorrhaphy without pneumoperitoneum

To study the feasibility of gasless laparoscopy using the Laparolift device (Origin Medsystems), appropriate animal studies were carried out using a porcine model. After preliminary success in the laboratory, a petition was made to the institutional review boards of our hospitals. A laparoscopic herniorrhaphy was performed successfully in a consenting male patient with a right indirect inguinal hernia. To further delineate the role of mechanical planar lifting in surgical procedures, further investigation appears safe and is warranted.

A novel Yes-related kinase, Yrk, is expressed at elevated levels in neural and hematopoietic tissues

While screening a chicken kidney cDNA library for the normal homolog of the yes oncogene, we isolated a clone that encodes a novel non-receptor type protein tyrosine kinase of the Src family. We named this gene product Yrk (York), as an acronym for Yes-related kinase. As predicted from the cDNA sequence, the Yrk protein consists of 536 amino acids and has all the canonical features of a Src kinase. At the amino terminus it contains a myristylation signal, followed by a unique domain, SH3 and SH2 motifs, an ATP binding site, a kinase region and a carboxy-terminal sequence with a potential regulatory tyrosine at position 530. The sequence of the Yrk protein showed 79% identity with human Fyn and 72% identity with chicken Yes. To eliminate the possibility that the Yrk protein is an avian homolog of mammalian Fyn, we isolated and sequenced the chicken fyn cDNA. The sequence data together with Southern and Northern blot analyses showed that the chicken yrk gene is distinct from the chicken fyn gene. Antibodies generated against the unique domain of the yrk protein expressed in bacteria precipitated a 60-kDa protein that was active in an immune complex kinase assay and was phosphorylated on tyrosine. Expression of the Yrk protein in adult chicken tissues was elevated in cerebellum and spleen. Relatively high levels of Yrk were also found in lung and skin.

Is laparoscopic herniorrhaphy an effective alternative to open hernia repair?

While the inguinal approach to hernia repair remains the standard of care, laparoscopic hernia repair techniques are rapidly evolving. The first 102 laparoscopic hernia repairs were reviewed. Reported herein are the types of hernias repaired, length of hospital stay, early recurrence rate, complications, and assessment of postoperative pain. The long-term recurrence rate has yet to be determined. From these results, it is felt that in select patients, laparoscopic hernia repair is an effective surgical alternative in the treatment of inguinal hernia.

Reduction of HIV transmission during laparoscopic procedures

Laparoscopic surgery has recently been encouraged as an alternative to open procedures in patients infected with the human immunodeficiency virus (HIV). The laparoscopic technique reduces exposure to blood products and sharp instruments; however, it exposes the surgical team to the HIV-infected patient in a manner not encountered during open procedures. The evacuation of the pneumoperitoneum during laparoscopic procedures releases aerosolized HIV-infected blood and peritoneal fluid into the operative suite. Evacuation of the penumoperitoneum into a closed system and appropriate precautions during instrument changes will diminish the exposure of the surgical team to aerosolized HIV-infected blood and peritoneal fluid.

Impact of socioeconomic status on hospital use in New York City

This DataWatch examines the potential impact of socioeconomic differences on rates of hospitalization, based on patterns of hospital use in New York City in 1988. The research suggests that lack of timely and effective outpatient care may lead to higher hospitalization rates in low-income areas. For certain conditions identified as ambulatory care sensitive, hospitalization rates were higher in low-income areas than they were in higher-income areas where appropriate outpatient care was more readily available. Further study is needed to determine the relative impact of various economic, structural, and cultural factors that affect access to care.

Dysphoric distress in childbearing women

Previous research on depression in childbearing women has focused on the presence or absence of clinical depression. Little attention has been paid to the distress caused by the presence of depressive symptoms in the absence of the full syndrome of clinical depression. A convenience sample of 202 healthy, married, primigravid women who were free of psychiatric symptoms were assessed at 10 to 14 weeks and 30 to 32 weeks of pregnancy and at 1 to 2 weeks and 14 weeks post partum. Depression symptoms were measured by using the Schedule of Affective Disorders and Schizophrenia, the standardized clinical interview for research and depression of The National Institute of Mental Health. Data from the Schedule of Affective Disorders and Schizophrenia indicated that only 5% of the women met criteria for clinical depression but approximately 50% of the sample reported clinical levels of three or more depressive symptoms. Anger, fatigue, psychic anxiety, and worry were the most frequently endorsed symptoms at each assessment point. The implications of these findings for symptom management and health promotion for childbearing women are discussed.

Alternative management of choledocholithiasis

This paper is presented to clarify the role of ERCP in conjunction with laparoscopic cholecystectomy. As the field of surgery moves more toward less invasive procedures, our management schemata may also need revision. With the popularity of laparoscopic cholecystectomy came a large increase in the number of patients treated with cholelithiasis, and therefore an increase in patients with choledocholithiasis. The authors believe that treatment options exist to avoid open common bile duct procedure in most cases.

Copepods associated with a perirectal abscess and copepod pseudo-outbreaks in stools for ova and parasite examinations

We observed copepods, an intermediate host for several human parasites, in material obtained from a perirectal abscess of a 22-year-old man with Crohn's disease. We subsequently noted copepod "outbreaks" in stool specimens submitted for ova and parasite examination. Copepods in the hospital tap water supply were the source for one "outbreak".

James Mackenzie Lecture 1991. Second among equals

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Com, the phage Mu mom translational activator, is a zinc-binding protein that binds specifically to its cognate mRNA

Bacteriophage Mu controls an unusual DNA-modification function encoded by the mom gene, which is located in an operon that consists of two overlapping genes. The com gene, located proximal to the 5' end of the common mRNA transcript, encodes a polypeptide of 62 amino acids that is required for translation of mom. Analysis of the derived amino acid sequence reveals that Com contains zinc-binding finger motifs, suggesting that Com may be a zinc-activated regulatory protein. Atomic absorption analysis showed that there is about one zinc bound per molecule of Com. We have subcloned the com gene into an expression vector and thus have overproduced and purified the Com protein. By gel retardation analysis with various 32P-labeled RNAs (made by in vitro transcription with T7 RNA polymerase), we show that Com binds specifically to com-mom mRNA. A single C----U substitution mutation, located 26 nucleotides upstream from the mom translation start codon, abolishes Com binding. The nature of the Com target sequence was deduced from in vitro footprinting analyses. The results are consistent with the existence of a complex stem-loop structure within the overlap of the com-mom open-reading-frames. Com binding to its target site results in the destabilization of a proposed translation-inhibitor stem-loop (TIS) to expose the Shine-Dalgarno sequence and mom translation initiation codon. This suggests that Com interaction with a specific site on its cognate mRNA alters the mRNA secondary structure to activate translation of mom.