Prenatal sonographic diagnosis of skeletal dysplasias. A report of 47 cases

The purpose of this study was to evaluate the foetal sonographic efficiency for prenatal diagnosis of osteochondrodysplasias. Forty-seven prenatal and postnatal cases diagnosed between January 1993 and December 1998 in the referral sonographic centres of Strasbourg were studied. All cases were reviewed retrospectively and the prenatal ultrasound findings and diagnosis were compared to the postnatal or post-mortem diagnosis. Each case was studied by ultrasonographers, geneticists, radiologists, and foetopathologists. Final diagnosis was based on clinical examination, skeletal survey and molecular testing as deemed necessary. Routine screening and dating was the indication for foetal sonography in 72% (32/47) of our cases. The most likely time of diagnosis was between 16 and 24 weeks of gestation (17 out of 47 cases, 36%), which corresponds to the time of foetal anomaly sonographic scan in France. The other cluster of cases (12 among 47, 26%) was disclosed before 16 weeks of gestation. These results illustrate the importance of a detailed evaluation of the limbs during sonographic examinations of first and second trimesters of pregnancy. While the identification of skeletal dysplasias was relatively easy in our study, the ability to make an accurate specific antenatal diagnosis was more difficult. An accurate diagnosis was proposed in 28 of the 47 cases (60%). In 19% of the cases (9/47), the prenatal diagnosis was not accurate; in 21% of the cases (10/47), the prenatal diagnosis was imprecise. In 45 of the 47 cases (96%) prenatal foetal scan correctly predicted the prognosis.

Biliary stenting versus bypass surgery for the palliation of malignant distal bile duct obstruction: a meta-analysis

The objective of this analysis is to compare endoscopic stenting with surgical bypass in patients with unresectable, malignant, distal common bile duct obstruction using the technique of meta-analysis. The inclusion criteria for the studies were randomized patient assignment, publication in the English language, 20 or more patients per group, all patients followed up until death, and follow-up and complications reported in an equivalent way for both treatment arms. Data extraction was performed independently by 2 of the authors. The number of treatment failures, serious complications, requirement for additional treatment sessions, and 30-day mortality were extracted. Three existing trials met the inclusion criteria, all of which compared surgery with the use of plastic stents. There were no studies identified that used metallic expandable stents. For the rate of treatment failure and serious complications, the odds ratios (ORs) of the 3 trials were heterogeneous, and no summary ORs were calculated. More treatment sessions were required after stent placement than after surgery, and a common OR was estimated to be 7.23 (95% confidence interval [CI], 3.73 to 13.98). Thirty-day mortality was not significantly different (OR = 0.522; 95% CI, 0.263 to 1.036). Although surgical bypass required fewer additional treatment sessions, existing data do not allow a definitive conclusion on which treatment is preferable. A larger randomized controlled trial using newer metallic stents and proper quality-of-life instruments is required.

Distinct internalization of M2 muscarinic acetylcholine receptors confers selective and long-lasting desensitization of signaling to phospholipase C

Although M1-M4 muscarinic acetylcholine receptors (mAChRs) in HEK-293 cells internalize on agonist stimulation, only M1, M3, and M4 but not M2 mAChRs recycle to the plasma membrane. To investigate the functional consequences of this phenomenon, we compared desensitization and resensitization of M2 versus M4 mAChRs. Treatment with 1 mM carbachol for 1 h at 37 degrees C reduced numbers of cell surface M2 and M4 mAChRs by 40-50% and M2 and M4 mAChR-mediated inhibition of adenylyl cyclase, intracellular Ca2+ concentration ([Ca2+]i) increases, and phospholipase C (PLC) activation by 60-70%. Receptor-mediated inhibition of adenylyl cyclase and [Ca2+]i increases significantly resensitized within 3 h. However, M4 but not M2 mAChR-mediated PLC activation resensitized. At 16 degrees C, M2 mAChR-mediated [Ca2+]i increases and PLC stimulation desensitized to a similar extent as at 37 degrees C. However, at 16 degrees C, where M2 mAChR internalization is negligible, both M2 mAChR responses resensitized, demonstrating that M2 mAChR resensitization proceeds at the plasma membrane. Examination of M2 mAChR responses following inactivation of cell surface mAChRs by quinuclidinyl benzilate revealed substantial receptor reserve for coupling to [Ca2+]i increases but not to PLC. We conclude that M2 mAChR internalization induces long-lasting PLC desensitization predominantly because receptor loss is not compensated for by receptor recycling or receptor reserve.

Congenital cholesteatoma and cholesterol granuloma of the temporal bone: role of magnetic resonance imaging

Magnetic resonance imaging (MRI) can be of significant benefit in characterizing expansile lesions of the petrous apex. MRI can be of particular help in distinguishing congenital cholesteatoma from cholesterol granuloma. Furthermore, with the advent of faster high-resolution scanning techniques, MRI can define precise spatial relationships of these masses with the middle and inner ear structures, internal carotid artery, jugular vein, and other structures of the skull base. MRI scanning is sensitive in detecting intracranial extension of these masses. MR angiography can provide additional information regarding the relationship of these masses with adjacent vascular structures and confirm patency of the adjacent vessels. In the postoperative period, MR scanning can help evaluate for complete removal, complication, recurrence, or formation of complicating granulation tissue.

Two cases of Townes-Brocks syndrome

Townes-Brocks syndrome (TBS) has been recognized as a dominant inherited syndrome. We report 2 cases of TBS. Case 1 was operated on for imperforate anus. Triphalangeal thumb and ear anomalies were remarkable. Deafness was diagnosed when the patient was 6 months old. Anomalies of the semicircular canals and the incus with inculomalleolar fusion were shown when the patient was 3.5 years old. During childhood, recurrent episodes of abdominal pain appeared. The diagnosis of hereditary angioneurotic edema (HANE) was made. HANE was familial as the father, the father's brother and the paternal grand mother were also affected. The parents of case 2, a female, are both mildly mentally retarded. This was the first pregnancy of the mother who had short stature. The child had an antepositioned anus, bifid right thumb, large toes, low set ears, microretrognathia and deafness. A (5, 16) translocation was observed in a child with TBS. At the breakpoint in 16q21.1, a gene coding for a transcription factor SALL1 has been identified and it was shown that mutations in the putative zinc finger of SALL1 cause TBS.

[Bone marrow cellularity in acute lymphoblastic leukemia of children]

The early response to therapy in childhood acute lymphoblastic leukemia (ALL) is typically assessed by bone marrow status. The clearance of blast cells in peripheral blood and bone marrow during induction therapy was analysed in 38 children (27 precursor-B-ALL and 11 precursor T-ALL) treated according to BFM90 or New York 93 protocols. Leukocyte count and peripheral blood smear taken at diagnosis, day 8, day 14 and day 33 as well as bone marrow cellularity and percentage of blasts on days: 0, 14, 33 were analysed. The number of blasts in bone marrow was correlated to bone marrow cellularity (Spearman's rho = 0.72, p = 0.001). Patients with T-ALL were more frequently resistant to steroids in vivo and reached remission later in comparison to precursor-B-ALL children (p = 0.019), however blasts reduction ratio was comparable in both lineages. Bone marrow cellularity on days 14 and 33 of induction therapy was similar.

Hepatic resection of noncolorectal nonneuroendocrine metastases

Because hepatic resection is generally a safe procedure, the indications for resection of noncolorectal nonneuroendocrine (NCNNE) hepatic metastases have broadened. The prognostic features of NCNNE metastases treated surgically were reviewed to define better the value of resection. A retrospective review of patients undergoing liver resection for NCNNE metastases between 1978 and 1998 was undertaken. Thirty-seven patients were identified. Mean age was 56 years, with a median follow-up of 22 months. Primary tumor sites were grouped into gastrointestinal (GI) adenocarcinoma (small bowel, n = 4; pancreas, n = 2; esophagus, n = 1) and other (renal cell, n = 7; sarcoma, n = 7; melanoma, n = 5; adrenal, n = 3; unknown adenocarcinoma, n = 3; thyroid, n = 2; testicular, n = 1; ovarian, n = 1; breast, n = 1). All patients underwent surgery for cure. Metastases were synchronous in 14 patients. There was no surgical mortality. Overall 5-year survival rate was 45%. Five-year survival rates were better for patients with non-GI-origin metastases (60% v 0%; P =.01). Long-term survival was seen only in patients with non-GI-origin metastases. The extent of resection, presence of synchronous metastases, or disease-free interval from time of original disease to presentation with liver metastases were not predictive of outcome. We conclude that patients with NCNNE hepatic metastases can undergo liver resection with an expectation of prolonged survival. However, patients with liver metastases from GI primary tumors other than the colorectum are unlikely to show extended survival.

Hepatic resection of noncolorectal nonneuroendocrine metastases

Because hepatic resection is generally a safe procedure, the indications for resection of noncolorectal nonneuroendocrine (NCNNE) hepatic metastases have broadened. The prognostic features of NCNNE metastases treated surgically were reviewed to define better the value of resection. A retrospective review of patients undergoing liver resection for NCNNE metastases between 1978 and 1998 was undertaken. Thirty-seven patients were identified. Mean age was 56 years, with a median follow-up of 22 months. Primary tumor sites were grouped into gastrointestinal (GI) adenocarcinoma (small bowel, n = 4; pancreas, n = 2; esophagus, n = 1) and other (renal cell, n = 7; sarcoma, n = 7; melanoma, n = 5; adrenal, n = 3; unknown adenocarcinoma, n = 3; thyroid, n = 2; testicular, n = 1; ovarian, n = 1; breast, n = 1). All patients underwent surgery for cure. Metastases were synchronous in 14 patients. There was no surgical mortality. Overall 5-year survival rate was 45%. Five-year survival rates were better for patients with non-GI-origin metastases (60% v 0%; P =.01). Long-term survival was seen only in patients with non-GI-origin metastases. The extent of resection, presence of synchronous metastases, or disease-free interval from time of original disease to presentation with liver metastases were not predictive of outcome. We conclude that patients with NCNNE hepatic metastases can undergo liver resection with an expectation of prolonged survival. However, patients with liver metastases from GI primary tumors other than the colorectum are unlikely to show extended survival.

Prevalence and clinical outcome of hepatitis C infection in children who underwent cardiac surgery before the implementation of blood-donor screening

BACKGROUND AND METHODS

There are few data on the prevalence and clinical outcome of hepatitis C infection in children. We studied 458 children who underwent cardiac surgery in Munich, Germany, before 1991, when blood-donor screening for hepatitis C was introduced in Germany. Their mean age at first operation was 2.8 years; none of the children had received blood transfusions before or 'after cardiac surgery, and none of their mothers had antibodies to the hepatitis C virus (anti-HCV). We compared these patients with 458 control subjects matched for age and sex.

RESULTS

Sixty-seven (14.6 percent) of the 458 patients who had undergone cardiac surgery had anti-HCV, as compared with 3 (0.7 percent) of the control subjects (P<0.001). At a mean interval of 19.8 years after the first operation, 37 (55 percent) of the 67 patients who were positive for anti-HCV had detectable HCV RNA in their blood. The infection had cleared in the other 30 patients, as evidenced by negative results on three polymerase-chain-reaction analyses performed at six-month intervals. Only 1 of the 37 patients who were positive for HCV RNA had elevated levels of liver enzymes; that patient had severe right-sided congestive heart failure. Of the 17 patients who underwent liver biopsies, only 3 had histologic signs of progressive liver damage. These three patients had additional risk factors: two had congestive heart failure, and the third had also been infected with hepatitis B virus.

CONCLUSIONS

Children who had undergone cardiac surgery in Germany before the implementation of blood-donor screening for hepatitis C had a substantial risk of acquiring the infection. However, after about 20 years, the virus had spontaneously cleared in many patients. The clinical course in those still infected seems more benign than would be expected in people infected as adults.

Role of US in the detection, characterization, and staging of cholangiocarcinoma

Cholangiocarcinoma is a rare tumor with a broad range of pathologic and clinical manifestations that demonstrates a myriad of imaging findings. Recent experience indicates that a more definitive role is possible for ultrasonography (US) in the evaluation of cholangiocarcinoma. Dilatation of the intrahepatic bile ducts is the most frequently seen US abnormality in patients with ductal cholangiocarcinoma. Klatskin tumors classically manifest as segmental dilatation and nonunion of the right and left ducts at the porta hepatis. Papillary and nodular ductal cholangiocarcinoma are relatively easy to see at US: Papillary tumors resemble polypoid intraluminal masses, whereas nodular cholangiocarcinoma manifests as a discrete smooth mass with associated mural thickening. Infiltrating ductal cholangiocarcinoma at the porta hepatis is the most common subtype but is the most difficult to appreciate at US. Peripheral cholangiocarcinoma may be either nodular or infiltrating at US: The nodular form predominates and appears as a solitary mass with a distinct right lobe predilection, whereas the infiltrative form is rare and manifests as a diffusely abnormal liver echotexture. In capable hands, modern high-resolution US equipment with color Doppler imaging capability is highly sensitive in the detection, characterization, and determination of the potential for resectability of cholangiocarcinoma. Thus, use of US may obviate more invasive procedures in some patients and help identify those patients for whom further investigation would be contributory.

[Massive feto-maternal transfusion. Report of 3 cases with review of the literature]

Massive feto maternal hemorrhage is rare. Early diagnosis is important because massive feto-maternal hemorrhage has a poor prognosis. The clinical manifestations of transplacental hemorrhage are related not only to the size of the hemorrhage but also to the time at which the hemorrhage occurs. In women who are candidates for Rh immune prophylaxis, massive feto maternal hemorrhage may be detected by Kleihauer test and we suggest that 10 micrograms dose of immune globin should be administered for each estimated ml of Rh positive blood given, to prevent an immunization Disappearance of fetal cells by Kleihauer test or appearance residual antibody suggests the adequacy of therapy. Three cases of massive fetomaternal hemorrhage (more than 225 ml) are presented here. Two mothers was Rh negative and they are delivered of rhésus positive children, which necessitated the administration of large volume of anti D. One of the cases shows the possibility of association between choriocarcinoma and positive kleihauer test.

Routine prenatal care in Europe: the comparative experience of nine departments of gynaecology and obstetrics in eight different countries

OBJECTIVE

The aim of this study was to compare routine prenatal care in nine European obstetrics and gynaecology departments.

STUDY DESIGN

A survey was performed between October 1992 and November 1993 by means of a questionnaire. The questionnaire comprised 118 questions covering clinical examinations and investigations systematically performed during the pregnancy.

RESULTS

The survey revealed a certain number of differences between the types of prenatal care performed by each department. Thus, one notices differences to do the serological testing (toxoplasmosis, AIDS and hepatitis B) at the first visit and in the practice of vaginal examination, systematic ultrasound examination or cardiotocography.

CONCLUSION

The differences observed in the prenatal care furnished are only a reflection of our uncertainties concerning the validity of the various tests used to monitor pregnancies. At a time when financial restrictions impose choices, we consider an evaluation of the efficacy and cost of prenatal care to be essential.

[Prenatal and neonatal management of digestive tract duplications. Diagnostic difficulties and therapeutic implications]

OBJECTIVE

To insist on the difficulty of the antenatal diagnosis of digestive duplications, to show the importance of a complete malformative screening, and the need for immediate management at birth.

MATERIAL AND METHODS

A cystic duplication of the tongue, a duplication, abdomino-thoracic transdiaphragmatic, and a duplication of the small bowel are described and compared with cases previously reported in th literature.

RESULTS

Antenatal evacuation puncture of a duplication of the tongue must be reserved for exceptional situations. Foregut duplications are often associated with other malformations. The duplication of the small intestine can exceptionally expose to a mechanical complication, mostly during the postnatal period, which may require emergency surgery.

CONCLUSION

Duplications of the alimentary tract should be detectable on prenatal ultrasound examination. A complete antenatal malformative screening is required and in utero transfer is warranted because emergency surgery may be required.

[Clinical importance of fetal pulse oximetry. II. Comparative predictive values of oximetry and scalp pH. Multicenter study]

OBJECTIVE

To compare the predictive value of intrapartum fetal pulse oximetry to that of fetal blood analysis for an abnormal neonatal outcome in case of abnormal fetal heart rate (FHR).

STUDY DESIGN

A prospective multicenter observational study, from June 1994 to November 1995. Fetal oxygen saturation was continuously recorded using a Nellcor N-400 fetal pulse oximeter in case of abnormal FHR during labor. Simultaneous readings of fetal oxygen saturation and fetal blood analysis obtained before birth, i.e. either at full dilatation, or before cesarean section when indicated, were compared with the neonatal status. The criteria for an abnormal neonatal outcome were 1) an umbilical arterial blood pH < or = 7.15 and 2) a combined variable including: 5 min. Apgar score < or = 7, umbilical arterial pH < or = 7.15, secondary respiratory distress, transfer in a neonatal care unit, or neonatal death.

RESULTS

At a 7.20 threshold for fetal scalp pH, and 30% for fetal oxygen saturation (i.e. the tenth centile in the study population), the predictive value of fetal pulse oximetry was similar to that of fetal blood analysis for an arterial umbilical pH < or = 7.15, and for an abnormal neonatal outcome (positive predictive value 56% vs 55%, negative predictive value 81% vs 82%, sensitivity 29% vs 35%, and specificity 93% vs 91% respectively). The receiver operating curve showed similar performance of either technique for cut-off values < or = 7.20 for fetal blood pH and < or = 30% for fetal oxygen saturation, whereas fetal pulse oximetry became superior at higher thresholds.

CONCLUSION

The predictive value of intrapartum fetal pulse oximetry can be favorably compared with that of fetal blood analysis. Randomized controlled management trials can now be performed to assess potential clinical benefits of this new tool.

Temperature calibration under ultrafast MAS conditions

For conventional fast magic-angle spinning (MAS) frequencies (</=15 kHz), there is a known heating of the sample due to the friction between the rotor and the bearing gas. At the recently achievable ultrafast MAS frequencies of up to 35 kHz, a more dramatic heating effect is expected. Using the 119Sn NMR signal of the chemical shift thermometer Sm2Sn2O7, this frictional heating effect is quantified, and a calibration of the sample temperature under ultrafast MAS conditions is described. An empirical expression is given which allows the determination of the sample temperature as a function of the bearing gas temperature and the spinning frequency. Copyright 1999 Academic Press.

Relation between hospital surgical volume and outcome for pancreatic resection for neoplasm in a publicly funded health care system

BACKGROUND

Recent studies from the United States have shown that institutions with higher numbers of pancreatic resection procedures for neoplasm have lower mortality rates associated with this procedure. However, minimal work has been done to assess whether the results of similar volume-outcome studies within a publicly financed health care system would differ from those obtained in a mixed public-private health care system.

METHODS

A population-based retrospective analysis was used to examine pancreatic resection for neoplasm in Ontario for the period 1988/89 to 1994/95. Outcomes examined included in-hospital case fatality rate and mean length of stay in hospital. For each hospital, total procedure volume for the study period was defined as low (fewer than 22), medium (22-42) or high (more than 42). Regression models were used to measure volume-outcome relations.

RESULTS

The likelihood of postoperative death was higher in low-volume and medium-volume centres than in high-volume centres (odds ratio 5.1 and 4.5 respectively; p < 0.01 for both). Mean length of stay was greater in low- and medium-volume centres than in high-volume centres (by 7.7 and 9.2 days respectively, p < 0.01 for both).

INTERPRETATION

This study adds to growing evidence that, for pancreatic resection for neoplasm, patients may have better outcomes if they are treated in high-volume hospitals rather than low-volume hospitals.

[Clinical importance of fetal pulse oximetry. I. Methodological evaluation. Multicenter study. French Study Group on Oximetry of Fetal Pulse]

OBJECTIVE

To evaluate the feasibility of intrapartum fetal pulse oximetry, the distribution of fetal oxygen saturation values, and the relation with the neonatal outcome in a population with an abnormal fetal heart rate (FHR).

STUDY DESIGN

A prospective multicenter observational study, from June 1994 to November 1995. Fetal oxygen saturation was continuously recorded using a Nellcor N-400 fetal pulse oximeter in case of abnormal FHR during labor. Simultaneous readings of fetal oxygen saturation and of fetal blood analysis (FBA) were obtained at inclusion and before birth. Feasibility, adverse effects, distribution of fetal oxygen saturation values and relation with neonatal outcome were assessed.

RESULTS

74 patients were included. From 172 attempted sensor placements, the procedure was impossible in three cases and fetal oxygen saturation values were obtained in 164 cases (95.3%). Physicians considered sensor placement an easier task than FBA attempt (easy in 87.5% vs 78.9% for FBA, p = 0.03). The mean reliable signal time (+/- SD) was 64.7 +/- 32% during the first stage. There were no serious adverse effects in the study population. The mean fetal oxygen saturation during the first stage of labor was 42.2 +/- 8.0% (10th-90th centile range: 30-53%). Fetal oxygen saturation was significantly correlated with scalp pH (r = 0.29; p = 0.01) but not with neonatal umbilical artery pH or gas values. There was a significant association between a low fetal oxygen saturation (< 30%) and a poor neonatal condition.

CONCLUSION

The feasibility of fetal pulse oximetry is satisfactory in clinical practice. It is easy to use and provides a fair rate of recorded values, even in a population with suspicion of fetal distress. A low fetal oxygen saturation is significantly associated with an abnormal neonatal outcome.