Visual disturbances and seizures associated with pregnancy: a diagnostic dilemma and the role of radiological techniques as an aid to diagnosis

We present two cases of visual disturbances associated with tonic-clonic seizures during pregnancy and the associated radiological findings. We review the use of neuroimaging techniques as an aid to diagnosis and their role in elucidating the pathophysiology of cortical blindness.

Delivering a selective neonatal BCG vaccination programme in a multi-ethnic community: an audit of the neonatal BCG immunisation programme in Birmingham and Solihull

Neonatal bacillus Calmette-Guérin (BCG) immunisation is a primary preventive measure against tuberculosis. Local health professionals expressed concern about the variability of knowledge regarding eligible infants and uptake of the vaccine. A questionnaire was sent out to health visitors for use at the routine visit to babies. Details requested included ethnic group and country of origin of the infant, eligibility for BCG vaccination, and vaccination status. BCG vaccination was indicated for 41% of newborns. In total 74% of these eligible infants received the vaccine with a range of 36-83% between the five maternity units. There were inconsistencies within maternity units in identifying high-risk groups by ethnicity and country of origin, resulting in low coverage in certain eligible groups. Confusion exists about which infants are at risk of tuberculosis and should be vaccinated. Current national guidelines are not specific enough for cases of interracial parenting and for the increasingly diverse countries of origin of the population. In the absence of clearer national guidelines there is a need for pragmatic local guidance.

A pilot study of 'fast track' antenatal screening for haemoglobinopathies

The NHS Plan launched in 2000 advocated a linked antenatal and neonatal screening programme for haemoglobinopathies. Currently screening practices vary widely across the UK and patient sampling is generally performed in a hospital setting. The process is flawed and frequently fails to provide accurate and timely information. In this study we demonstrate that organisational changes can improve the efficiency and quality of screening. The primary care screening process described here has increased partner testing rates and allowed early identification of at risk couples.

Paraprosthetic leak unmasked by thrombolysis for thrombosed mitral valve

Prosthetic valve thrombosis (PVT) is classically a cardiothoracic surgical emergency. Case series, however, report thrombolysis as first line management for PVT. A case of mitral PVT treated successfully with thrombolysis is described. Immediately after thrombolysis a trivial paraprosthetic leak noted on pretreatment transoesophageal echocardiography had increased significantly in severity. The paraprosthetic leak subsequently required repeat mitral valve replacement. It is speculated that the thrombolytic treatment interfered with the usual healing process by disrupting the fibrin deposited at the valve ring margin. This suggests that fibrin is important in the formation of the annular seal of the prosthetic valve and that patients receiving thrombolysis should be monitored for this complication.

Definition of Soybean Genomic Regions That Control Seed Phytoestrogen Amounts

Soybean seeds contain large amounts of isoflavones or phytoestrogens such as genistein, daidzein, and glycitein that display biological effects when ingested by humans and animals. In seeds, the total amount, and amount of each type, of isoflavone varies by 5 fold between cultivars and locations. Isoflavone content and quality are one key to the biological effects of soy foods, dietary supplements, and nutraceuticals. Previously we had identified 6 loci (QTL) controlling isoflavone content using 150 DNA markers. This study aimed to identify and delimit loci underlying heritable variation in isoflavone content with additional DNA markers. We used a recombinant inbred line (RIL) population ( $n=100$ ) derived from the cross of “Essex” by “Forrest,” two cultivars that contrast for isoflavone content. Seed isoflavone content of each RIL was determined by HPLC and compared against 240 polymorphic microsatellite markers by one-way analysis of variance. Two QTL that underlie seed isoflavone content were newly discovered. The additional markers confirmed and refined the positions of the six QTL already reported. The first new region anchored by the marker BARC-Satt063 was significantly associated with genistein ( $P=0.009$, $Rcirc;2=29.5\%$ ) and daidzein ( $P=0.007$, $Rcirc;2=17.0\%$ ). The region is located on linkage group B2 and derived the beneficial allele from Essex. The second new region defined by the marker BARC-Satt129 was significantly associated with total glycitein ( $P=0.0005$, $Rcirc;2=32.0\%$ ). The region is located on linkage group D1a+Q and also derived the beneficial allele from Essex. Jointly the eight loci can explain the heritable variation in isoflavone content. The loci may be used to stabilize seed isoflavone content by selection and to isolate the underlying genes.

PCR and the notification of meningococcal disease

The polymerase chain reaction (PCR) can be used to investigate suspected meningococcal infection, with rapid results. We became aware that Birmingham Health Authority was not being informed about certain patients on whom meningococcal PCR had been performed. To establish whether notification was overlooked in some patients with suspected meningococcal disease, or whether PCR was performed on patients in whom it was thought meningococcal disease was unlikely, we compared numbers of patients notified to us over six months who had PCR with numbers of patients not notified who had PCR. Between 1st August 1999 and 31st January 2000, 54 PCR requests were made on seventy-seven notified patients; 51 PCR requests were made on non-notified patients and none were positive. Median age and length of stay were shorter in the non-notified patients. We conclude: (i) PCR may be being used inappropriately on younger patients who have shorter admissions and are unlikely to have meningococcal disease; (ii) in a number of patients initially admitted and notified with meningococcal disease the diagnosis is subsequently reconsidered. A 'denotification' procedure for such patients could make information on meningococcal disease more reliable.

Optic fibre bundle contact imaging probe employing a laser scanning confocal microscope

A small diameter (600 micro m) fused optic fibre imaging bundle was used as a probe to compare fluorescent specimens by direct contact imaging using both a conventional fluorescence microscope and a laser scanning confocal microscope (LSCM) system. Green fluorescent polyester fibres placed on a green fluorescent cardboard background were used to model biological tissue. Axial displacement curves support the hypothesis that pinhole size in the LSCM system reduces the contribution of non-focal plane light. Qualitative comparison showed that the LSCM system produced superior image quality and contrast over the conventional system. The results indicate that the new LSCM-probe combination is an improvement over conventional fluorescence-probe systems. This study shows the feasibility of employing such a small diameter probe in the investigation of biological function in difficult to access areas.

Randomized trial of group therapy for repeated deliberate self-harm in adolescents

OBJECTIVE

To compare group therapy with routine care in adolescents who had deliberately harmed themselves on at least two occasions within a year.

METHOD

Single-blind pilot study with two randomized parallel groups that took place in Manchester, England. Sixty-three adolescents aged 12 through 16 years were randomly assigned to group therapy and routine care or routine care alone. Outcome data on suicide attempts were obtained without knowledge of treatment allocation on all randomized cases (62/63 by direct interview) on average 29 weeks later. The primary outcomes were depression and suicidal behavior.

RESULTS

In intention-to-treat analyses, adolescents who had group therapy were less likely to be "repeaters" at the end of the study (i.e., to have repeated deliberate self-harm on two or more further occasions) than adolescents who had routine care (2/32 versus 10/31; odds ratio 6.3), but the confidence intervals for this ratio were wide (95% confidence interval 1.4 to 28.7). They were also less likely to use routine care, had better school attendance, and had a lower rate of behavioral disorder than adolescents given routine care alone. The interventions did not differ, however, in their effects on depression or global outcome.

CONCLUSIONS

Group therapy shows promise as a treatment for adolescents who repeatedly harm themselves, but larger studies are required to assess more accurately the efficacy of this intervention.

Hypothetical ratings of coronary angiography appropriateness: are they associated with actual angiographic findings, mortality, and revascularisation rate? The ACRE study

OBJECTIVE

To determine whether ratings of coronary angiography appropriateness derived by an expert panel on hypothetical patients are associated with actual angiographic findings, mortality, and subsequent revascularisation in the ACRE (appropriateness of coronary revascularisation) study.

DESIGN

Population based, prospective study. The ACRE expert panel rated hypothetical clinical indications as inappropriate, uncertain, or appropriate before recruitment of a cohort of real patients.

SETTING

Royal Hospitals Trust, London, UK.

PARTICIPANTS

3631 consecutive patients undergoing coronary angiography (no exclusion criteria).

MAIN OUTCOME MEASURES

Angiographic findings, mortality (n = 226 deaths), and revascularisation (n = 1556 procedures) over 2.5 years of follow up.

RESULTS

The indications for coronary angiography were rated appropriate in 2253 (62%) patients. 166 (5%) coronary angiograms were performed for indications rated inappropriate, largely for asymptomatic or atypical chest pain presentations. The remaining 1212 (33%) angiograms were rated uncertain, of which 47% were in patients with mild angina and no exercise ECG or in patients with unstable angina controlled by inpatient management. Three vessel disease was more likely among appropriate cases and normal coronaries were more likely among inappropriate cases (p < 0.001). Mortality and revascularisation rates were highest among patients with an appropriate indication, intermediate in those with an uncertain indication, and lowest in the inappropriate group (log rank p = 0.018 and p < 0.0001, respectively).

CONCLUSION

The ACRE ratings of appropriateness for angiography predicted angiographic findings, mortality, and revascularisation rates. These findings support the clinical usefulness of expert panel methods in defining criteria for performing coronary angiography.

Neuropsychological sequelae of 50 Hz magnetic fields

PURPOSE

The effects of occupational levels of 50 Hz magnetic fields on cognitive function were studied on 30 human volunteers.

MATERIALS AND METHODS

The exposure system consisted of Merrit-type modified Helmholtz coils forming a 2 m cube, employing two orthogonal sets of coils producing a 28 microT (resultant) circularly polarized 50 Hz magnetic field. Subjects sat at a desk within the coils where they undertook a series of verbal and written tests of cognitive function. After these tests were concluded (approximately 30 min) subjects were either exposed or sham-exposed to fields (double-blinded) for 50 min. A second set of tests (employing alternate versions) was administered 20 min from the start of this period. Each subject returned after 7 days to repeat the sequence, but with the opposite field/sham status.

RESULTS AND CONCLUSIONS

The majority of the results indicated no significant effect of exposure on cognition. However, verbal recall of a list of 15 words after an interference (the different list) was significantly impaired in the 'field on' condition. This is indicative of a reduction in short-term memory of words. The mean baseline score was somewhat higher in the 'field on' condition. However, this difference is within the parameters of normal variation. The other significant result occurred during performance of a trail-making task (alternating 1-A-2-B-3-C, etc.), with a decrease in performance as a result of exposure to the 50 Hz field. This task requires executive functioning with a working memory load, involving parietal spatial processing coordinated by prefrontal executive processing. In summary, the data are suggestive of detrimental effects on cognitive processes, particularly short-term learning and executive functioning. However, larger sample sizes are required to demonstrate statistically a more specific pattern of cognitive effects.

beta -Amyloid peptide-induced apoptosis regulated by a novel protein containing a g protein activation module

Degeneration of neurons in Alzheimer's disease is mediated by beta-amyloid peptide by diverse mechanisms, which include a putative apoptotic component stimulated by unidentified signaling events. This report describes a novel beta-amyloid peptide-binding protein (denoted BBP) containing a G protein-coupling module. BBP is one member of a family of three proteins containing this conserved structure. The BBP subtype bound human beta-amyloid peptide in vitro with high affinity and specificity. Expression of BBP in cell culture induced caspase-dependent vulnerability to beta-amyloid peptide toxicity. Expression of a signaling-deficient dominant negative BBP mutant suppressed sensitivity of human Ntera-2 neurons to beta-amyloid peptide mediated toxicity. These findings suggest that BBP is a target of neurotoxic beta-amyloid peptide and provide new insight into the molecular pathophysiology of Alzheimer's disease.

Effects of bupropion SR on anterior paralimbic function during waking and REM sleep in depression: preliminary findings using

This study sought to clarify the effects of bupropion SR on anterior paralimbic function in depressed patients by studying changes in the activation of these structures from waking to REM sleep both before and after treatment. Twelve depressed patients underwent concurrent EEG sleep studies and [18F]fluoro-2-deoxy-D-glucose ([18F]-FDG) positron emission tomography (PET) scans during waking and during their second REM period of sleep before and after treatment with bupropion SR. Nine subjects completed pre- and post-treatment waking PET studies. Five subjects completed pre- and post-treatment waking and REM sleep PET studies. Bupropion SR treatment did not suppress electrophysiologic measures of REM sleep, nor did it alter an indirect measure of global metabolism during either waking or REM sleep. Bupropion SR treatment reversed the previously observed deficit in anterior cingulate, medial prefrontal cortex and right anterior insula activation from waking to REM sleep. In secondary analyses, this effect was related to a reduction in waking relative metabolism in these structures following treatment in the absence of a significant effect on REM sleep relative metabolism. The implications of these findings for the relative importance of anterior paralimbic function in REM sleep in depression and for the differential effects of anti-depressant treatment on brain function during waking vs. REM sleep are discussed.

Acute erythremic myelosis (true erythroleukaemia): a variant of AML FAB-M6

AIMS

Classic erythroleukaemia (acute myeloid leukaemia M6, or M6 AML) is defined as an excess of myeloblasts in an erythroid predominant background. Leukaemia variants in which the primitive blast cells are demonstrably erythroid are extremely rare and poorly characterised. Variably referred to as "true erythroleukaemia" or "acute erythremic myelosis", they are often included within the M6 AML category even though they do not meet strict criteria for this type of AML.

METHODS

Two cases of acute erythroid neoplasia are presented with clinical, morphological, immunophenotypic, and cytogenetic analysis.

RESULTS

Both patients presented with profound anaemia, one in a setting of long standing myelodysplasia. Bone marrow examination revealed a predominant population of highly dysplastic erythroid cells in both cases. In one case, the liver was infiltrated by neoplastic erythroid cells. Both patients died within four months of diagnosis.

CONCLUSIONS

This report illustrates that cases of acute leukaemia occur in which the dominant neoplastic cell is a primitive erythroid cell without an accompanying increase in myeloblasts. This does not preclude the neoplastic clone originating in a multipotent haemopoietic stem cell, as suggested by cases arising in patients with myelodysplasia. Acute erythremic myelosis should be recognised as a distinct variant of M6 AML.

Underuse of coronary revascularization procedures in patients considered appropriate candidates for revascularization

BACKGROUND

Ratings by an expert panel of the appropriateness of treatments may offer better guidance for clinical practice than the variable decisions of individual clinicians, yet there have been no prospective studies of clinical outcomes. We compared the clinical outcomes of patients treated medically after angiography with those of patients who underwent revascularization, within groups defined by ratings of the degree of appropriateness of revascularization in varying clinical circumstances.

METHODS

This was a prospective study of consecutive patients undergoing coronary angiography at three London hospitals. Before patients were recruited, a nine-member expert panel rated the appropriateness of percutaneous transluminal coronary angioplasty (PTCA) and coronary-artery bypass grafting (CABG) on a nine-point scale (with 1 denoting highly inappropriate and 9 denoting highly appropriate) for specific clinical indications. These ratings were then applied to a population of patients with coronary artery disease. However, the patients were treated without regard to the ratings. A total of 2552 patients were followed for a median of 30 months after angiography.

RESULTS

Of 908 patients with indications for which PTCA was rated appropriate (score, 7 to 9), 34 percent were treated medically; these patients were more likely to have angina at follow-up than those who underwent PTCA (odds ratio, 1.97; 95 percent confidence interval, 1.29 to 3.00). Of 1353 patients with indications for which CABG was considered appropriate, 26 percent were treated medically; they were more likely than those who underwent CABG to die or have a nonfatal myocardial infarction--the composite primary outcome (hazard ratio, 4.08; 95 percent confidence interval, 2.82 to 5.93)--and to have angina (odds ratio, 3.03; 95 percent confidence interval, 2.08 to 4.42). Furthermore, there was a graded relation between rating and outcome over the entire scale of appropriateness (P for linear trend=0.002).

CONCLUSIONS

On the basis of the ratings of the expert panel, we identified substantial underuse of coronary revascularization among patients who were considered appropriate candidates for these procedures. Underuse was associated with adverse clinical outcomes.