Chronic sinusitis: a sequela of inferior turbinectomy

Inferior turbinectomy has generated a great deal of controversy among rhinologic surgeons. Proponents of partial and total inferior turbinectomy cite numerous studies of large numbers of patients with subjective relief of nasal obstruction after turbinectomy. Clinical studies critical of turbinectomy have focused on complications such as hemorrhage, crusting, adhesions, and atrophic rhinitis. Our study was undertaken to evaluate the incidence of chronic sinusitis post inferior turbinectomy. Postoperative evaluation by history, physical examination, and computerized tomography of the paranasal sinuses revealed that a significant number of patients who underwent inferior turbinectomy developed sinusitis. Patients evaluated in our clinic for nasal obstruction underwent a detailed history, physical examination along with nasal endoscopy and coronal computerized tomography of the paranasal sinuses. Those patients with nasal obstruction not responsive to medical treatment and without evidence of sinusitis underwent submucous resection and inferior turbinectomy. The incidence, cause, and possible prevention of post inferior turbinectomy sinusitis is discussed in this article.

The art and science of teaching rounds. A strategy for staff development

Teaching rounds can be a highly interactive, fluid process for developing staff nurses' critical thinking, assessment, and interpersonal skills. In this article, the authors describe how to conduct and evaluate teaching rounds using the example of Pain Management Teaching Rounds conducted by an advanced practice nurse on medical-surgical units of a large medical center. Qualitative and quantitative outcomes of the pain management rounds are discussed.

Endometrial cancer in patients undergoing diagnostic curettage

We made a retrospective review of in 2769 patients in whom curettage was performed. Of 1468 women under 50 years of age, only one (0.08%) had endometrial cancer. Of 834 patients presenting with postmenopausal bleeding 31, (3.7%) had endometrial cancer.

Thrombocytopenia with the HELLP syndrome. Report of two cases with reversal in normotensive and nonproteinuric gravidas

BACKGROUND

In the absence of hypertension and proteinuria, pregnant women with hemolysis, elevated liver enzymes and low platelet count (HELLP syndrome) present a diagnostic and therapeutic problem.

CASES

Two atypical cases occurred of HELLP syndrome diagnosed by hemolysis, elevated liver enzymes and low platelet count. The patients presented early in the third trimester with epigastric pain and lacked the usual signs of preeclampsia, such as hypertension and proteinuria. The patients were managed expectantly; during this time they became hypertensive, but the thrombocytopenia resolved.

CONCLUSION

Pregnant women with hemolysis, elevated liver enzymes and thrombocytopenia who do not have hypertension or proteinuria should undergo complete diagnostic evaluation. If other etiologies are ruled out, the patient should be managed as appropriate for severe preeclampsia complicated by the HELLP syndrome.

Scalp dysesthesia

BACKGROUND

Cutaneous dysesthesia syndrome is a disorder characterized by chronic cutaneous symptoms without objective findings. Patients complain of burning, stinging, or itching, which is often triggered or exacerbated by psychological or physical stress. These symptoms may be manifestations of an underlying psychiatric disorder or may represent a type of chronic pain syndrome.

OBSERVATIONS

Eleven women presented with chronic severe pain and/or pruritus of the scalp only without objective physical findings, a condition we term "scalp dysesthesia." Five women described pain, stinging, or burning only; 4 women complained of pain and pruritus; and 2 women reported pruritus only. The patients ranged in age from 36 to 70 years. The duration of symptoms ranged from 9 months to 7 years. Five women had physician-diagnosed psychiatric disorders, including dysthymic disorder, generalized anxiety, and somatization. Seven women reported that stress triggers or exacerbates their symptoms. Eight women experienced improvement or complete resolution of symptoms with treatment with low-dose doxepin hydrochloride or amitriptyline hydrochloride. One patient responded completely to treatment with sertraline and hydroxyzine hydrochloride but then experienced a relapse.

CONCLUSIONS

We describe 11 patients with a new syndrome that we term scalp dysesthesia. Of 11 patients, 9 benefited from treatment with low doses of antidepressants.

The potent lipid mitogen sphingosylphosphocholine activates the DNA binding activity of upstream stimulating factor (USF), a basic helix-loop-helix-zipper protein

We previously demonstrated that the sphingolipid, sphingosylphosphocholine (SPC) increased DNA binding activity of AP-1 proteins accompanying cellular proliferation. Herein, the effects of SPC on DNA binding activity and transcription of the basic, helix-loop-helix, leucine zipper (bHLH-ZIP) proteins Myc, Max, and USF were investigated because they regulate genes involved in mitogenesis. E-box (CACGTG) DNA binding proteins were detected by electrophoretic mobility shift assays in nuclear extracts from Swiss 3T3 fibroblasts. The slowest migrating complex (complex I) increased within 1-3 min after treatment with SPC, remained elevated for 10 min, and increased again after 12 h. Complexes I and II contained USF-1 and USF-2 proteins, and complex I migrated similarly to recombinant USF-1 protein/DNA complex. Treatment of nuclear extracts with alkaline phosphatase decreased these complexes suggesting USF might be a phosphoprotein, post-translationally modified by SPC. max and usf-1 mRNA levels were unaffected by SPC treatment. In contrast, c-myc mRNA was rapidly elevated, reached maximum levels at 0.5-1 h, and showed an additional increase after 12 h, just preceding S phase. Thus, certain bHLH-ZIP transcription factors may be involved in cell growth regulation by SPC.

Placental tissue enhances uterine relaxation by nitroglycerin

Nitroglycerin (TNG) has recently gained popularity in obstetric anesthesia for facilitating acute uterine relaxation in the treatment of obstetric emergencies such as retained placenta. Laboratory investigations, however, have consistently found the uterus insensitive to clinically used doses of TNG. We hypothesized that the presence of the placenta in the uterus may be important for TNG to be effective, because it has been present in most clinical reports and has generally been absent in laboratory investigations. Sections of near-term gravid rat uteri were mounted for isometric force recording. We studied spontaneous contractions and acetylcholine-induced sustained contractions both with and without the addition of minced placental tissue in close approximation to the uterine muscle. Phenylephrine-precontracted rings of thoracic aorta were studied as a positive control. Log dose-response curves for TNG, 10(-9) to 10(-5) M, were constructed for each tissue. Uterine muscle alone was resistant to all but the largest doses of TNG, both in spontaneous and sustained contraction models. The addition of placental tissue caused a marked increase in sensitivity, reducing spontaneous uterine contractions by 50% at log -5.92 M (95% confidence interval, -6.49, -5.05), which was comparable to the sensitivity in aorta. Nitric oxide (NO) inhibitors pyrogallol (a superoxide anion generator) and methylene blue (a guanylate cyclase inhibitor) completely blocked the effect of TNG in the presence of placenta. Placental tissue modestly increased the response of aorta to TNG, but not of uterine tissue to the NO-independent uterine relaxants MgSO4 and terbutaline.

IMPLICATIONS

Nitroglycerin can relax the human uterus during obstetric emergencies, but the drug has never been proven effective in the laboratory. This study shows that nitroglycerin can relax uterine contractions in the rat, provided that the placenta is adjacent to the uterus. The mechanism seems to be via the release of nitric oxide.

The role of protein kinase C in G1 and G2/M phases of the cell cycle (review)

The protein serine/threonine kinases--members of protein kinase C (PKC) family--are important components of the major signaling pathways regulating cell proliferation and differentiation. Recent studies implicate PKC in cell cycle control at two sites--during G1 to S progression and at G2 to M transition. Activation of PKC during G1 progression modulates the activity of the specific cyclin-dependent kinases (CDKs), which phosphorylate the retinoblastoma susceptibility gene product (RB). Phosphorylation of RB is a pivotal event in cell cycle progression leading to G1/S transition. PKC mediated enhancement or inhibition of CDK's activity and the RB phosphorylation state appear to be dependent on the precise timing of PKC activation during G1 and on the particular cell type. At G2/M transition, recent evidence suggests that PKC is involved in the regulation of CDC2 activity, although it is mostly implicated as a regulator of lamin B phosphorylation and the nuclear lamina disassembly.

Epidermal growth factor regulates protein kinase A activity in murine fibrosarcoma cells: differences between metastatic and nonmetastatic tumor cell variants

The interplay between cyclic AMP (cAMP)-dependent protein kinase A (PKA)- and p21ras-mediated signaling pathways is expected to determine further loss, maintenance, or modulation of differentiation and proliferation of a particular cell. Therefore, the relationship and nature of the cross-talk between these two major signaling systems are of utmost importance to the understanding of these processes in both normal and neoplastic cells. In view of their paramount physiological importance, one would expect the existence of a well-controlled bidirectional interaction between these pathways, which would be more appropriate and in agreement with basic principles of cellular homeostasis. However, based on the discovery that activated PKA may inhibit ras-mediated translocation of c-Raf-1 to the plasma membrane, it is generally accepted that the cross-talk between cAMP/PKA and p21ras-mediated signal transduction pathways is unilateral, i.e., that the activation of PKA regulates growth factor receptor protein tyrosine kinase-mediated signaling. To challenge the validity of a unilateral approach, we decided to test the possible existence of cross-talk of a bidirectional nature between the aforementioned signaling pathways at different stages of malignant differentiation. For that purpose, we investigated the nature of the cross-talk existing between a known receptor protein tyrosine kinase-epidermal growth factor receptor (EGFR) and PKA in highly metastatic and nonmetastatic cloned variants of a murine fibrosarcoma (T-10). Our study revealed the existence of principal differences in PKA activity between metastatic and nonmetastatic cloned fibrosarcoma variants that may be due to the differential expression and membrane translocation of the p21(Ki-ras) small mass G-protein. Most importantly, our experiments have demonstrated the existence of a novel character of interactions between EGFR and PKA, because the ligation of the EGFR by epidermal growth factor in the metastatic variant induced a high activity of PKA. These findings are of prime importance, because they reveal the existence of a new relationship between two major signal transduction pathways in mammalian cells, i.e., the existence of a bilateral interaction between the ras- and cAMP/PKA-mediated signal transduction pathways. Furthermore, the fact that two tumor cell variants originating in the same tumor and differing in their metastatic capacity differ as well in the nature of the cross-talk between major signal generation systems imposes new challenges for the future use of biological response modulators to cure cancer and restrict metastatic spread.

Urinary galactonate in patients with galactosemia: quantitation by nuclear magnetic resonance spectroscopy

Although numerous reports have appeared showing high levels of galactitol in the urine of patients with galactose-1-phosphate uridylyltransferase deficiency, little attention has been paid to measurement of urinary galactonate. Herein we explored the use of 1H and 13C nuclear magnetic resonance, which required only the concentration of urine without derivatization, to detect and quantitate urinary galactonate. We report that transferase deficient infants, as well as adults on galactose restricted diets excrete significant amounts of galactonate, whereas none is detected in the urine of normal subjects. Galactose-toxic infants were found to excrete large amounts of galactonate, which decreased when the lactose-free diet was instituted. We also found that normal individuals subjected to an oral galactose load also excrete high levels of galactonate for at least 4 h after galactose ingestion. Our data provide evidence that the first reaction in the oxidative pathway of galactose metabolism described in rat liver in 1966 is activated in patients with a variety of galactose-1-phosphate uridylyltransferase gene mutations even while on a lactose-restricted diet. In both patients and normal individuals, flux through the alternate galactonate pathway appears to be related to the body galactose burden.

Labour pain management in a parturient with an implanted intrathecal pump

PURPOSE

We report the peripartum anaesthetic management for vaginal delivery of a chronic pain patient with an implanted intrathecal pump. This is the first report describing labour analgesia in a patient with such a device. As intrathecal systems become more popular for the management of nonmalignant pain, this situation is likely to be encountered with increasing frequency in the future.

CLINICAL FEATURES

The patient was a nulliparous 23-yr-old with a history of chronic hereditary pancreatitis whose intractable pain had been managed with intrathecal morphine 3 mg.day-1 via an implantable pump for four years. Inadequate time between presentation and onset of labour prevented us from using this system. Intravenous patient controlled analgesia with fentanyl using a bolus of 25 micrograms and a lockout of five minutes was ineffective and epidural analgesia using bupivacaine was initiated and resulted in satisfactory analgesia.

CONCLUSION

The presence of an existing intrathecal delivery system does not preclude the use of supplemental epidural analgesia during labour.

Venous drainage of the inferolateral temporal lobe in relationship to transtemporal/transtentorial approaches to the cranial base

OBJECTIVE

Intimate to the application of lateral transtemporal approaches to the cranial base are the identification, manipulation, and/or the sacrifice of the venous anatomy of the inferolateral temporal lobe and the superior petrosal sinus and the transection of the tentorium. This study demonstrates the relationship and variability of the venous drainage of the lateral and inferior surfaces of the temporal lobe.

METHODS

Twenty-one specially prepared, injected cadaver specimens yielded 40 temporal lobes for examination. The venous systems in these specimens were traced from their origins on the temporal lobe (venous drainage complexes) to the transverse/petrosal sinuses, and the geometry of these venous complexes (venous configuration) was noted. The measurements of each complex's entry to the sinuses were noted.

RESULTS

Four distinct venous drainage complexes were identified: 1) the lateral complex, 2) the anteroinferior complex, 3) the medial-inferior complex, and 4) the posteroinferior complex. Three basic venous configurations were found: 1) the candelabra of veins uniting to form one large draining vein, 2) multiple independent draining veins, and 3) venous lakes running in the tentorium before entering the sinuses. The lateral complex, incorporating the classic "vein of Labbé," was present in 100% of the specimens. However, in the majority of cases, it did not represent the dominant venous drainage of the lateral and inferior surfaces of the temporal lobe.

CONCLUSION

An understanding of the complexity and diversity of the venous drainage complexes and their configurations is necessary to avoid venous complications during lateral cranial base surgery.

Inhibition of tumorigenicity in lung adenocarcinoma cells by c-erbB-2 antisense expression

The lung carcinoma cell line Calu3, which overexpresses the c-erbB-2 oncogene, was stably transfected with antisense (AS) cDNA constructs encompassing different regions of the c-erbB-2 gene. Transfected cells were analyzed for their tumorigenic properties in vitro and in nude mice. Two independent clones, AS F1 (low erbB-2 expressor) and AS B12 (high erbB-2 expressor), as well as the polyclonal Calu3/AS 5', were selected for these analyses. In Calu3/AS 5' transfected cells and in the AS F1 clone, c-erbB-2 RNA and protein levels were lower than those detected in the parental cell line and the AS B12 clone. Anchorage-independent growth and tumor take were also significantly reduced. Furthermore, cells derived from primary tumors of Calu3/AS 5', AS F1 and AS B12 lost the AS c-erbB-2 DNA insert but retained the gene for G418 resistance. Our results suggest that a correlation between c-erbB-2 overexpression and tumorigenicity may exist in the Calu3 lung carcinoma cell line.

Quantitative assessment of whole body galactose metabolism in galactosemic patients

We employed [1-13C] galactose in isotope kinetic studies to delineate whole body galactose metabolism in vivo in patients with galactose-1-phosphate uridyltransferase (GALT) deficiency. The data in three control and three adult galactosemic subjects, homozygous for the most common GALT gene defect, the Q188R mutation, and with absent RBC GALT activity, revealed an apparent endogenous galactose synthesis rate of 0.53-1.05 mg/kg per hour. Unlike normal children and adults who eliminated 3%-6% and 21%-47% of an intravenous bolus of [1-13C] galactose as 13CO, in expired air in 1 and 5 h respectively, classic galactosemic patients, either Q188R/Q188R or Q188R/unknown, released almost none in 1 h and 3%-6% in 5 h. In contrast, an African-American galactosemic variant patient with a S135L/S135L mutation and no residual RBC GALT activity oxidized [1-13C]galactose to 13CO2 at a rate comparable to control subjects. Individuals homozygous for the Duarte mutation, N314D/N314D and Q188R/ N314D. Q188R/+ and S135L/+ subjects also had normal breath test results. Not surprisingly, the Q188R/Q188R classic galactosemic patient cannot handle an acute galactose load, failing to match a control subject in the rapid conversion of [1-13C]galactose to [13C]glucose and 13CO2. However, classic patients synthesize substantial quantities of galactose de novo and on a lactose-free diet must oxidize comparable amounts of galactose to maintain steady-state levels of galactose and galactose metabolites such as galactose-1-phosphate, galactitol and galactonate. In vivo isotope kinetic analyses may allow us to understand better these aspects of galactose metabolism and, through the use of studies in variant galactosemics, perhaps allow us to begin to unravel the pathophysiology of galactosemia.

The effects of measles virus persistent infection on AP-1 transcription factor binding in neuroblastoma cells

Measles virus (MV) persistence in brain cells has broad effects on different cellular functions. We have previously shown that NS20Y clone, originally derived from C1300 neuroblastoma cells, persistently infected with MV (NS20Y/MS), displays constitutively elevated levels of c-fos and PKC mRNAs, implying MV-mediated effects on transcriptional regulation. Nonetheless, the mode by which virus affects the transcriptional machinery still remains obscure. In order to define this phenomenon, we studied the binding properties of major transcription factors (AP-1 and NFkappaB) in NS20Y/MS cells. Using electrophoretic mobility shift approach (EMSA) with the appropriate oligonucleotide probes, we have found that the persistent MV infection does not affect NFkappaB binding, while the AP-1 binding was significantly decreased. Similar inhibition was not observed in NS20Y cells acutely infected with MV. Anti-measles antibody-mediated restriction of viral gene expression restored AP-1 binding, thus suggesting that measles virus proteins may affect the components of the host transcriptional machinery.

Function of the c-Myc antagonist Mad1 during a molecular switch from proliferation to differentiation

Mad-Max heterodimers have been shown to antagonize Myc transforming activity by a mechanism requiring multiple protein-protein and protein-DNA interactions. However, the mechanism by which Mad functions in differentiation is unknown. Here, we present evidence that Mad functions by an active repression mechanism to antagonize the growth-promoting function(s) of Myc and bring about a transition from cellular proliferation to differentiation. We demonstrate that exogenously expressed c-Myc blocks inducer-mediated differentiation of murine erythroleukemia cells without disrupting the induction of endogenous Mad; rather, high levels of c-Myc prevent a heterocomplex switch from growth-promoting Myc-Max to growth-inhibitory Mad-Max. Cotransfection of a constitutive c-myc with a zinc-inducible mad1 results in clones expressing both genes, whereby a switch from proliferation to differentiation can be modulated. Whereas cells grown in N'N'-hexamethylene bisacetamide in the absence of zinc fail to differentiate, addition of zinc up-regulates Mad expression by severalfold and differentiation proceeds normally. Coimmunoprecipitation analysis reveals that Mad-Max complexes are in excess of Myc-Max in these cotransfectants. Moreover, we show that the Sin-binding, basic region, and leucine zipper motifs are required for Mad to function during a molecular switch from proliferation to differentiation.

Superiority of multi-orifice over single-orifice epidural catheters for labor analgesia and cesarean delivery

STUDY OBJECTIVE

To investigate whether a change from a single-orifice to multi-orifice catheter could reduce the incidence of inadequate epidural blocks requiring replacement of the epidural catheter in obstetric patients.

STUDY DESIGN

Prospective before-after cohort study.

SETTING

Obstetric unit at a university hospital.

PATIENTS

872 patients requesting epidural analgesia for vaginal delivery or cesarean section.

INTERVENTIONS

Patients received epidural analgesia via single-orifice (n = 433) or multi-orifice (n = 439) epidural catheters, depending on the month of the trial.

MEASUREMENTS AND MAIN RESULTS

Patient characteristics, obstetric procedure, anesthesiologist characteristics, and details of epidural placement did not differ significantly between the groups. The overall replacement rate was 14.3% in the single-orifice group versus 9.3% in the multi-orifice group (p = 0.032). There were no difference in the frequency of replacement for subarachnoid placement or migration, immediate intravascular placement, vascular migration, or absence of any block. Significantly fewer catheters were replaced in the multi-orifice group for inadequate analgesia, defined as unblocked segments or unilateral block (6.4% vs. 2.8%, p = 0.018). Paresthesias were less common in the multi-orifice group (22.4% vs. 31.5%, p = 0.003). There were no unrecognized subarachnoid or vascular catheter placements in either group.

CONCLUSIONS

The multi-orifice design offers significant advantages over the single-orifice type for obstetricepidural analgesia.

Umbilical cord androgens in infants of diabetic mothers

The aim was to measure umbilical cord testosterone and androstenedione and to explore possible relationships with fetal weight and insulin levels. Testosterone, androstenedione and insulin were measured at birth in venous umbilical blood in 12 infants of gestational diabetic mothers and in 12 control subjects. The mean concentrations of umbilical testosterone and androstenedione were not significantly different between the infants of the diabetic and control mothers. No significant correlation was found between maternal weight, fetal weight or insulin concentrations and androgen levels.

Hemophilus influenzae septic arthritis and pneumonia in an adult as the first presentation of multiple myeloma

We describe an apparently healthy woman who presented with monoarthritis of the right knee and a history of respiratory infection. The synovial fluid cultures grew beta lactamase-negative H. influenzae. Chest roentgenogram showed patchy densities throughout the right lung. Investigations for a predisposing factor for this H. influenzae infection revealed underlying multiple myeloma. As H. influenzae pyoarthrosis is extremely rare in adults, we suggest that an underlying systemic cause be sought in all such patients.

A mouse model of galactose-1-phosphate uridyl transferase deficiency

Galactose-1-phosphate uridyl transferase (GALT) deficiency causes classical galactosemia in humans. Mice deficient in this enzyme were created by gene targeting. GALT-deficient mice develop biochemical features similar to those seen in humans with GALT deficiency, but fail to develop the pattern of acute toxicity seen in newborns with classical galactosemia. This study suggests that alternative routes of galactose metabolism are important in the pathogenesis of galactosemia.

c-Myc inactivation by mutant Max alters growth and morphology of NCI-H-630 colon cancer cells

The myc gene family has been implicated in multiple cell processes including proliferation, differentiation, tumorigenesis, and apoptosis. For its cellular growth promoting function, Myc must heterodimerize with Max. To study the effect of Myc inactivation on the growth and differentiation properties of epithelial tumor cells, we transfected the H-630 human colon cancer cell line with bm-max, a mutant Max protein in which DNA-binding activity has been abolished. Cells expressing high levels of bm-Max grow poorly, and the morphology of both colonies and single cells is altered. Moreover, increased bm-Max expression results in a prolonged G alpha/G1 phase accompanied by induced expression of p21 (WAF1/CIP1), elevated levels of alkaline phosphatase (ALP) activity, and accumulation of large fat granuli within the cells. These distinctive cell characteristics are associated with differentiation processes in numerous malignant cell lines. The results of this study support a model in which sequestering of endogenous Myc and Max proteins into "basic mutant" dimers lacking DNA-binding activity is sufficient both to inhibit proliferation and to induce changes in cell behavior consistent with differentiation.

Budd-Chiari syndrome complicating severe preeclampsia in a parturient with primary antiphospholipid syndrome

A 27-year-old primipara with severe preeclampsia and primary antiphospholipid syndrome developed right upper quadrant pain, massive ascites, HELLP syndrome, and disseminated intravascular coagulation shortly following vaginal delivery. Computed tomography and color Doppler studies were compatible with complete thrombosis of the right hepatic veins, the Budd-Chiari syndrome. Anticoagulation was initiated, along with supportive measures, and the patient recovered completely. Imaging studies 6 months later were normal. This case demonstrates that nearly fatal forms of venous thrombosis may complicate preeclampsia in women with antiphospholipid syndrome; Doppler studies of the hepatic vein are of value in establishing the diagnosis.

A multivariate model to predict the distance from the skin to the epidural space in an obstetric population

BACKGROUND AND OBJECTIVES

Several attempts to relate epidural space depth to individual patient parameters or details of technique have yielded modest correlations. An attempt has been made to construct a multivariate model to predict the depth from the skin of the epidural space with use of several such factors.

METHODS

The depth of the epidural space from the skin was measured in 263 obstetric patients by using calibrated needles. In 53 patients, the angle of insertion of the epidural needle was also measured, with protractors. For each patient, 14 descriptors of patient habitus and anesthetic technique were recorded. Multiple regression analysis was used to construct models incorporating combinations of these variables to predict the epidural space depth; the model balancing the highest correlation coefficient and greatest statistical significance was selected. The validity of the model was tested on the 53 patients in whom the angle of the needle had been measured but whose data have not been used to construct the model.

RESULTS

A model containing the seven variables present-weight, height, body mass index, age, parity, interspace, and patient position-yielded r = .689, < .0001. This model predicted the depth of the epidural space to within 8 mm and predicted the depth in the validation group well. Correction for the angle of insertion of the needle did not improve the predictive power of the model.

CONCLUSIONS

While this model is the best predictor of epidural space depth yet published, it is probably not sufficiently accurate to be clinically useful in confirming proper epidural catheter placement. Further work in this area is probably not justified.

Identification of in vivo target RNA sequences bound by thymidylate synthase

We developed an immunoprecipitation-RNA-random PCR (rPCR) method to isolate cellular RNA sequences that bind to the folate-dependent enzyme thymidylate synthase (TS). Using this approach, nine different cellular RNAs that formed a ribonucleoprotein (RNP) complex with thymidylate synthase (TS) in human colon cancer cells were identified. RNA binding experiments revealed that seven of these RNAs bound TS with relatively high affinity (IC50 values ranging from 1.5 to 6 nM). One of the RNAs was shown to encode the interferon (IFN)-induced 15 kDa protein. Western immunoblot analyses demonstrated that the level of IFN-induced 15 kDa protein was significantly decreased in human colon cancer H630-R10 cells compared with parent H630 cells. While the level of IFN-induced 15 kDa mRNA expression was the same in parent and TS-overexpressing cell lines, the level of IFN-induced 15 kDa RNA bound to TS in the form of a RNP complex was markedly higher in H630-R10 cells relative to parent H630 cells. These studies begin to define a number of cellular target RNA sequences with which TS interacts and suggest that these TS protein-cellular RNA interactions may have a biological role.

Gestational diabetes mellitus and hypertension in pregnancy: hemodynamics and diurnal arterial pressure profile

We characterised the 24-h arterial pressure (AP) profile and the left ventricular (LV) structures and functions in pregnant women with pregnancy-induced hypertension (PIH) or gestational diabetes mellitus (GDM). Thirty pregnant women after 20 weeks' gestation--(10 normotensive; 10 with PIH; and 10 with GDM)--were investigated haemodynamically using 24-h AP monitoring and Doppler echocardiography for determination of LV structures and functions, both systolic and diastolic. The PIH women had significantly higher AP determinations throughout the 24 h, with no change in the diurnal variation, ie, nocturnal decline and early morning peaks. The LV mass was greater in PIH and GDM than in the normotensive women, despite normal AP in GDM. The increased LV mass in GDM was mainly due to LV dilatation and not to increased thickness of its walls. In PIH, the increase in AP was due to peripheral vasoconstriction, while cardiac output was preserved. The LV systolic functions did not differ among the three groups. However, a slight reduction in the myocardial contractility was found in PIH and GDM. The LV relaxation was significantly impaired in both PIH and GDM. Thus, GDM and PIH, although differing in their 24-h AP profile, are characterised by LV hypertrophy and reduction in diastolic function.

Sugar nucleotide concentrations in red blood cells of patients on protein- and lactose-limited diets: effect of galactose supplementation

Uridine diphosphate (UDP) galactose, a pivotal compound in the metabolism of galactose, is the obligate donor of galactose in the formation of complex glycoconjugates. The cellular UDPgalactose concentration has been thought to be maintained by the interconversion of UDPglucose and UDPgalactose by UDPgalactose-4-epimerase. However, recent findings of lower average red blood cell (RBC) UDPgalactose concentrations in galactose-1-phosphate uridyltransferase-deficient patients suggest that other factors play a role in determining its concentration. To test the hypothesis that the amount of galactose traversing the Leloir pathway contributes to the cellular UDPgalactose pool, we determined RBC UDPgalactose in patients with maple syrup urine disease (MSUD), phenylketonuria (PKU), and other metabolic diseases who were treated with a low-protein, and consequently, low-lactose diet. Six patients with MSUD were also supplemented with 19 g galactose/d and their UDPhexose concentrations were measured at intervals. We show that young patients with MSUD or PKU have decreased average RBC UDPgalactose concentrations when compared with similarly aged healthy subjects. Galactose supplementation of MSUD patients significantly increased their UDPgalactose concentrations in both RBCs and white blood cells (WBCs) from 29.5 +/- 1.5 to 42.3 +/- 5.8 nmol/g hemoglobin and from 69.0 +/- 7.5 to 193.0 +/- 49.0 nmol/g protein, respectively. Discontinuation of supplementation was associated with a return to basal values in RBCs and a reattainment of the pretreatment ratio of UDPglucose to UDPgalactose in WBCs. These observations demonstrate that dietary galactose is a factor in establishing the steady state concentrations of the uridine sugar nucleotides and imply that galactose metabolism modulates the achievement of an epimerase-mediated equilibrium.

Reproductive outcome after expectant management of ectopic pregnancy

OBJECTIVE

To study fertility rates following expectant management of clinically stable ectopic pregnancies.

STUDY DESIGN

Twenty of 33 patients with laparoscopically confirmed aborting tubal pregnancies managed expectantly were followed for a period of 1-5 years (mean 2.7 years). Excluded were the patients not desiring pregnancy, and patients with known impediments to fertility, such as age > 40 years and previous infertility, as well as patients lost to follow-up.

RESULTS

Successful pregnancies occurred in 16 patients (80%); one patient (5%) had a repeat ectopic pregnancy.

CONCLUSIONS

Expectant management is associated with a favorable reproduction outcome.

Retroperitoneal abscess after normal delivery. A report of two cases

BACKGROUND

Retroperitoneal abscess is a rare complication of normal labor and delivery, and no apparent etiology is evident.

CASES

We report on two patient who presented with back and leg pain soon after normal deliveries. While the condition was initially clinically misdiagnosed, ultrasonography and computed tomography demonstrated retroperitoneal collections and aided in guided percutaneous drainage. After a protracted course of antibiotic treatment and daily irrigation, the collections resolved.

CONCLUSION

Ultrasonography and computed tomography were invaluable in the diagnosis and guided drainage of rare psoas abscesses complicating delivery.

The outcome of pregnancy in an immigrant Ethiopian population in Israel

To study the assumption that obstetric risk factors would change over time in an immigrant Ethiopian population, a retrospective study of the records of singleton births among the Ethiopian immigrants between 1981-88 was undertaken and compared to a similar study of the general population. The Ethiopian immigrants were characterized by pregnancies at age extremes, a greater incidence of preeclampsia and premature deliveries, and a lower incidence of premature rupture of membranes. There was over time an increase in maternal weight gain among the Ethiopians as well as an increase in the incidence of preeclampsia and perinatal mortality.

Complementary organ expression of IL-1 vs. IL-6 and CSF-1 activities in normal and LPS-injected mice

The specific expression of pro-inflammatory cytokines may affect the functioning of organs in different ways. The results of specific cytokine bioassays used in this study show a distinct pattern of tissue expression of IL-1 IL-6 and CSF-1. Cytokine activity was assessed in conditioned media (CM) and lysates (LYS), obtained from different organs of control or lipopolysaccharides (LPS)-injected mice; LPS representing a potent inflammatory stimulus. Low constitutive levels of IL-1 could be demonstrated only in CM/LYS from organs with lymphoreticular function, such as the liver, spleen, intestine and lungs. On the other hand, IL-6 and CSF-1 were mainly detected in the CM (and not in lysates) of organs, such as the heart, kidneys, muscle and brain. LPS injection basically resulted in an accentuated form of the constitutive pattern. CSF-1 displays a similar pattern of expression to that of IL-6, best detected in CM after LPS stimulation. Thus, a mirror-image relationship emerges between the patterns of IL-1 and IL-6/CSF-1 expression in two groups of organs: those with lymphoreticular function, which manifest high IL-1 and low IL-6/CSF-1 activity, as compared to organs characterized by highly specialized and potentially vulnerable functions (such as the heart, brain, muscle and kidney), which exhibit high IL-6/CSF-1 and low IL-1 activity. Due to their defensive functions, lymphoreticular organs, which are in charge of the 'gates of entry' to the body, mount extensive IL-1-mediated inflammatory responses, even at the cost of possible tissue-damage. On the other hand, the more vulnerable internal organs mount IL-6/CSF-1-mediated responses which are milder and bear less potential for tissue damage. The distinct patterns of expression of pro-inflammatory cytokines in different organs, at steady state or under inflammatory conditions, may shed light on tissue characteristic homeostatic and defence mechanisms.

Basic mutant Max reverses a c-Myc block to differentiation

Murine erythroleukemia (MEL) cells overexpressing a transfected c-myc gene are blocked in their ability to undergo inducer-mediated differentiation, whereas overexpression of a transfected max gene mutated within the basic region (bm-max) accelerates differentiation. Based on these findings, we cotransfected MEL cells with plasmids which express human c-Myc constitutively and bm-Max in a zinc-inducible manner. Competition of endogenous proteins for binding to bm-Max can be considered negligible in cells expressing such high constitutive levels of c-Myc. Thus, this system provides a cell culture model for studying Myc:Max complex formation and its effect on erythroid differentiation. Clones expressing high levels of c-Myc and low levels of bm-Max are blocked in their ability to undergo N,N'-hexamethylene bisacetamide (HMBA)-mediated differentiation, presumably due to a preponderance of growth-promoting Myc:Max complexes. However, increased expression of bm-Max, in these clones, allows differentiation to occur by decreasing the levels of functional Myc:Max complexes. Although the exogenously expressed c-Myc and bm-Max associate in vivo, the basic region mutation in bm-Max abolishes the binding of Myc:bm-Max complexes to the specific E-box consensus sequence. We demonstrate that this sequestering of c-Myc by bm-Max reverses the c-Myc block to differentiation.

In vivo oxidation of [13C]galactose in patients with galactose-1-phosphate uridyltransferase deficiency

We developed an intravenous and oral [13C]galactose breath test for the in vivo study of galactose metabolism. Following an intravenous bolus of 7 mg/kg of [1-13C]galactose in the fasting state, normal children and adults eliminated 3-6% and 21-47% of the bolus as 13CO2 in expired air collected over 1 and 5 h, respectively. Comparable fractional elimination was seen when the dose was given orally. Patients with galactosemia who have barely detectable or absent galactose-1-phosphate uridyltransferase (GALT) activity in erythrocytes and are homoallelic for the Q188R gene mutation, when given a 7 mg/kg intravenous bolus had barely detectable 13CO2 in air samples in the first hour, but eventually eliminated as much as 3.6% of the dose in 5 h. A galactosemia/Duarte (Q188R/N314D) compound heterozygote and a homozygous Duarte subject, as well as a subject with one normal allele and one Q188R allele, showed normal in vivo oxidation. An assessment of whole body galactose metabolism can be made with this procedure. Further use of this in vivo modality in patients with different genetic backgrounds should increase our understanding of genotype-phenotype relationships in hereditary galactosemia.

Bridging the professions: an integrated and interdisciplinary approach to teaching health care ethics

In 1993, the authors introduced an interdisciplinary course in health care ethics at the University of British Columbia. They were motivated by two convictions: (1) an interdisciplinary approach to health care decision making is best; and (2) every significant health care decision has an ethical component. They wanted to encourage students from the various health care disciplines to participate in interdisciplinary decision making in their future practices by giving them an opportunity to study health care ethics together during their training. The authors give detailed descriptions of the objectives, format, curriculum, and evaluation of this innovative course in the hope that other educators who may want to develop similar courses can learn from their experience.

Endogenous synthesis of galactose in normal men and patients with hereditary galactosaemia

Despite restricted ingestion of lactose, patients with galactose-1-phosphate uridyltransferase deficiency have raised concentrations of galactose metabolites in blood and urine. Endogenous production of galactose may underlie this phenomenon. Using isotopically labelled galactose in a continuous intravenous infusion, we employed the steady-state flux method to calculate endogenous galactose production rate in three normal men and three patients with classic galactosaemia. We found that galactosaemic patients and normal subjects synthesise gram quantities of galactose per day. The rate of synthesis ranged from 0.53-1.05 mg/kg per h. Endogenous production of galactose may be an important factor in the pathogenesis of the complications of the brain and ovary, and could explain the persistent elevation of galactose metabolites in patients despite dietary restriction of galactose.

Expression of c-myc and c-ras oncogenes in the neoplastic and non-neoplastic cells of Hodgkin's disease

The oncogenes c-myc and c-ras are known to elicit a cooperative tumorigenicity. In this study we investigated their role in the pathogenesis of Hodgkin's disease. The expression of these oncogenes was determined in Hodgkin's disease patients by avidin-biotin peroxidase complex immunohistochemical staining and was compared to their expression in patients with non-Hodgkin's lymphomas and inflammatory reactive lymph nodes. Of 29 examined patients with different histological types of Hodgkin's disease, 21 (72.4%) showed an elevated expression of c-myc and 28 (96.5%) of c-ras. Although this expression was marked especially in the neoplastic Reed-Sternberg cells, it was also noted in the numerous reactive cells present in the involved lymph nodes. By contrast, a much lower frequency of increased expression of these oncogenes was recorded in 19 patients with different grades of non-Hodgkin's lymphoma and in 29 patients with inflammatory reactive lymph nodes. The elevated expression of c-myc and c-ras in the neoplastic Reed-Sternberg cells may reflect an oncogenic event that directly activates these genes. However, their increased expression in the surrounding non-neoplastic cells probably results from signal transduction induced by certain growth-promoting factors possibly released by the Reed-Sternberg cells and that act paracrinally to stimulate the proliferation of the neighboring cells. Furthermore, the continuous c-ras elevation may impair the normal cell cycle control and thereby promote mutagenesis and overt malignancy.

Effect of glucose and galactose loading in normal subjects on red and white blood cell uridine diphosphate sugars

In order to test the assumption that red blood cell (RBC) uridine diphosphate galactose content is regulated in part by dietary galactose and to help comprehend factors influencing RBC and white blood cell (WBC) uridine diphosphate hexose concentrations in vivo, oral loading studies were performed with 50 g of galactose or 75 g of glucose in normal adults. While elevations of blood glucose did not influence RBC or WBC UDPhexose levels, increased blood galactose concentrations caused transient increases in both RBC and WBC UDPgalactose. In both RBC and WBC, the UDPgalactose-4-epimerase was rate limiting. In comparison to RBC, WBC had larger changes in UDPgalactose levels, synthesized additional UDPglucose through the action of UDPglucose pyrophosphorylase and began to restore the equilibrium ratio between UDPglucose and UDPgalactose concentrations while the plasma galactose level was still increasing. Thus, galactose ingestion alters the steady-state levels of UDPhexoses in circulating cells. The modulation of UDPglucose and UDPgalactose concentrations, occurring after the presentation of galactose to cells, as a result of the combined actions of GALT and UDPgalactose-4-epimerase, may be important in determining rates of synthesis of complex glycoconjugates.

Comparison of erythrocyte uridine sugar nucleotide levels in normals, classic galactosemics, and patients with other metabolic disorders

By limiting galactosylation mechanisms, a cellular deficiency of the uridine sugar nucleotide, UDPgalactose, has been implicated as a cause of the long-term complications seen in patients with classic galactosemia despite dietary treatment. As a result, great interest has been generated in the accurate assessment of UDPgalactose, as well as UDPglucose, from which UDPgalactose may be derived by the function of a ubiquitous, active UDPgalactose-4-epimerase. Since several series of values for the concentration of these compounds in red blood cells (RBCs) of galactosemics have been flawed by the use of methods subsequently shown to be unsuitable, we have quantified erythrocyte UDPgalactose and UDPglucose levels by an accurate high-performance liquid chromatography (HPLC) assay in 116 normals, 76 galactosemics, and 39 patients with other metabolic disorders. These large groups have permitted the evaluation of age, diet, and genotype as influential factors in the steady-state RBC levels of the sugar nucleotides. The data show that age is an important determinant of RBC levels, with children younger than 10 years having higher values than individuals older than 10 years. Mean UDPgalactose levels in galactosemic children younger than 10 years and those older than 10 years were 30% and 18% lower, respectively, than levels in comparable normals. Although the mean differences were highly significant, there was considerable overlap of individual values. There was no difference in UDPglucose levels between galactosemics and normals.(ABSTRACT TRUNCATED AT 250 WORDS)

DNA binding properties of the zinc-bound and zinc-free HIV nucleocapsid protein: supercoiled DNA unwinding and DNA-protein cleavable complex formation

The HIV nucleocapsid (NC) protein contains, as those of other retroviruses, two Cys-His arrays which function as zinc finger binding domains. The nucleic acid binding properties of retroviral NC have been previously demonstrated. In this study, we characterized the DNA binding ability of the zinc-bound and zinc-free forms of HIV NC. We found that in addition to binding single-stranded DNA, both forms bind and unwind supercoiled plasmid DNA. The binding ability of the zinc-bound form was higher than the zinc-free form. In addition we showed the formation of NC protein-DNA cleavable complex which is the result of a presumably covalent bond formed between the protein and the phosphate moiety of the DNA backbone. The NC unwinding activity and the protein-DNA cleavable complex formation resembles the first step of the relaxing mechanism of DNA topoisomerase. Our results shed light on the possibility of a novel physiological function for the HIV NC protein in the viral life cycle.

Defective galactosylation in galactosemia: is low cell UDPgalactose an explanation?

There is circumstantial evidence that defective galactosylation of complex glycoconjugates exists in tissues from galactosemic patients. Whether this is an etiologic factor in the long-term complications of the disorder is not known. Also not evident is the basis for the impaired galactosylation. The hypothesis that abnormally low cellular uridine diphosphate galactose (UDPgal) content is responsible has not been established. There is a tendency for galactosemic red cell UDPgal to be in the low normal range with a high uridine diphosphate glucose to UDP-gal ratio. This may reflect an inability of red cell UDPgal-4'-epimerase to maintain a normal ratio and consequently higher levels of UDPgal. In the more complex white blood cells and cultured fibroblasts, the UDPgal content and the uridine diphosphate glucose to UDPgal ratio of galactosemics are normal. Therefore, defective galactosylation observed in galactosemic fibroblasts must result from a defect in the transfer of galactose from UDPgal to these moieties.

Galactosemia unsolved

Classic galactosemia is an enigmatic disorder that presents the challenge of unraveling the basis of the long-term complications of mental disability, speech defects, ovarian failure and neurologic syndromes which occur despite a galactose-restricted diet. A complete understanding of the pathobiochemistry and molecular genetics, and evaluation of the present theories for the poor long-term outcome, continuous intoxication, critical metabolite depletion and in utero damage is needed in order to design new therapeutic strategies. Answering this urgent question of how to treat galactosemic patients mandates enhanced clinical and basic research efforts.

Evaluation of breast stimulation for induction of labor in women with a prior cesarean section and in grandmultiparas

BACKGROUND

Information on the efficacy of breast stimulation for inducing labor in grandmultiparas and in women with a previous cesarean section with or without premature rupture of membranes is limited.

METHODS

Retrospective study of labor data from 135 women of grand multiparity or those with a previous section with or without premature rupture of the membranes in whom labor was induced by breast stimulation.

RESULTS

The success rate in achieving vaginal delivery was 84%. The duration of breast stimulation, length of labor, vaginal delivery rate, and Apgar score did not differ significantly among the four groups studied.

CONCLUSION

Breast stimulation in grandmultiparas and in women with a previous cesarean section is efficacious and safe.