[The so-called "chocolate cyst"--frequently misinterpreted as ovarian endometriosis?]

Limitation of morphological diagnostic and possible misinterpretations are shown in a patient with anamnestic ovarian endometriosis. In cases of "chocolate cysts" it is necessary to differentiate between ovarian endometriosis and functional cysts. Hints for the existence of a functional cyst are an atypical past history or perioperative findings. Biochemical analysis of the cyst fluid may lead to a correct diagnosis.

Partial reconstitution of the respiratory burst oxidase in lymphoblastoid B cell lines lacking p67-phox after transfection with an expression vector containing wild-type and mutant p67 -phox cDNAs: Deletions of the carboxy and amino terminal residues of p67-phox are not required for activity

The respiratory burst oxidase of phagocytes and B lymphocytes in a multicomponent enzyme that catalyzes the reduction of oxygen by NADPH. It is responsible for O-(2) production in response to stimulation with phorbol 12-myristate 13-acetate (PMA). The study of patients with chronic granulomatous disease (CGD), an inherited disorder characterized by deficient of absent respiratory burst activity, has contributed greatly to our understanding of the NADPH-oxidase. The absence of any one of four components results in the clinical expression of CGD: the two membrane-bound components of the cytochrome b-558, gp91-phox and p22-phox, or the cytosolic factors, p47-phox and p67-phox. We used a system to investigate the activity of mutant p67-phox proteins expressed in a reconstitution assay. This system is characterized by the partial reconstitution of O-(2) production in an Epstein-Barr virus (EBV)-transformed lymphoblastoid B cell line from a patient with p67-phox-deficient CGD by transfection with an expression plasmid containing the 67-phox cDNA in the sense orientation. No O-(2) production was detectable in p67-phox-deficient lymphoblastoid B cell lines transfected with an antisense plasmid or in untransfected p67-phox lymphoblastoid cells stimulated by PMA. We tested two mutants, pEBOp67delta1-22 and pEBOp67delta512-526, and found that both recombinant proteins are active in our system. Thus, we conclude that the first 22 amino acid residues and the last 14 amino acid residues are not critical for initiation of O-(2) production

Simplicity-correlated size growth of the nuclear 28S ribosomal RNA D3 expansion segment in the crustacean order Isopoda

The expansion segments within the eukaryote nuclear 23S-like ribosomal RNA molecule are now well characterized in many diverse organisms. A different base compositional bias, a higher propensity for size variability, and an increased evolutionary rate distinguish these regions from the universally conserved "core" regions of the molecule. In addition, some expansion segments of higher eukaryotes exhibit significant sequence simplicity which is hypothesized to occur by slippage-mediated mutational processes. We describe the discovery of extreme size variation of the D3 expansion segment in the crustacean order Isopoda. Among 11 species D3 varies in size from 180 to 518 nucleotides but maintains a homologous secondary structure. The D3 size is significantly positively correlated to relative simplicity factor (RSF), indicating that growth is most likely by insertion of simple sequences. D3 size and RSF correlate approximately with a morphology-based phylogeny, and within oniscideans RSF increases as more recent divergences occur. The D3 of Armadillidium vulgare, with an RSF of 1.87, is the highest value recorded for any known expansion segment. Regions of high sequence simplicity in nuclear ribosomal RNA were previously only known from the higher vertebrate lineage. Here we demonstrate that this phenomenon occurs in a more extreme condition within a monophyletic invertebrate lineage. The extreme size changes identified could indicate that expansion segments are an extraneous element in the functioning ribosome.

[Folate deficiency, cancer and congenital abnormalities. Is there a connection?]

The biochemical role of folate is in the interconversion of one-carbon units in intermediary metabolism; a process in which a methyl group is formed de novo. The methyl group is subsequently transferred to adenosylmethionine, which is an important methyl donor in the methylation of DNA. A negative correlation exists between the intake of folate in pregnancy and the occurrence of neural tube defects and certain malignant brain tumours in children. Numerous clinical studies have pointed to an association between folate status in adults and both the occurrence of cancer and the premalignant changes, cervical dysplasia, bronchial metaplasia, and colorectal adenomas. Folate deficiency may cause chromosomal damage, due to impaired DNA synthesis or repair. Moreover, decreased production of adenosylmethionine may influence the expression of developmental genes and of oncogenes and/or tumour suppressor genes through disturbed methylation of DNA.

The Valby Project. A survey of the hearing in the elderly > or = 80 years of age-provided with hearing aids

This contribution forms part of an epidemiological study of the hearing in the elderly > or = 80 years of age and describes some of the rehabilitative aspects. The sample is defined according to an age > or = 80 years of age, living in the Valby district at the time of data collection (November 1993), and provided with a hearing aid (HA) during this period 1988-1993. All information in this part of the survey is obtained from the records in the Department. The overall prevalence of HA provision was 30% (n = 859/2915) with no differences as a function of gender. The prevalence of HA provision indicated an increase from 20% at the age of 80-84 to 61% at an age of > or = 95 years of age. Among the sample, 42% were first-time applicants, whereas 58% were experienced users. The better and worse ear hearing level, averaged across 0.5-4 kHz, showed significantly poorer hearing in the experienced users compared to the inexperienced users; however, there were no significant differences as a function of 5-year age bands. In the inexperienced users a moderate hearing loss of 43-49 dB was found in the better ear hearing, averaged across 0.5-4 kHz. The average across 4-8 kHz showed significantly poorer hearing in males compared to females, which is compatible with the poorer speech recognition score in background noise (S/N = 10 dB) (SRSN) in males. An immediate benefit of HA provision was found in these elderly subjects, the majority obtained a benefit of 12-32%, measured by SRSN. It is concluded that the prevalence of 30% of HA provision is incompatible with the high prevalence of about 50% of hearing problems, indicated at the defined age, and that additional epidemiological data are needed.

Epidemiology of permanent hearing impairment in children in relation to costs of a hearing health surveillance program

The objective of this investigation was to estimate the prevalence of any permanent hearing impairment (PHI) in the right and or left ear based on children included into a surveillance program in the local pediatric hearing health services (PHHS), and to analyze the costs, generated by the children. The study is a cross-sectional study, which is part of a major prospective study directed towards delineation of all aspects of pediatric audiology. The present sample comprises 228 children, 115 males and 113 females, at a median age of 13 years, range 0-24, and involves all children living in the health district of the City of Copenhagen, who are or have been included in a local surveillance program with one (school children) or two (pre-school children) annual visits for children with PHI > 20 dB HL at any frequency in either the left or the right ear. The prevalence of PHI increases with increasing age, reaching its peak in the age band 10-14 years exhibiting a rate of 5.32 1000 (95% confidence intervals: 4.27 to 6.64 per 1000). The estimated incidence of PHI in a ten year cohort born 1977-1986 is 325 100 000 children born (95% confidence intervals: 277 to 382 per 100 000). The most frequent factor causing PHI is inheritance, showing an increase from 20% in 1977-1981 cohorts, to 37% in 1982-1986 cohorts. The costs involved in the PHHS concerning PHI varies considerably from approximately 345 000 to 990 000 DKr.. depending on the model used for the economical analysis. No data on cost-benefit or cost-effectiveness can be given in this context, and it is concluded that the documented changes in the prevalence and causes of PHI in children emphasize the need for a continuous monitoring and evaluation of the epidemiological figures.

Primary physicians and the elderly hearing-impaired. Actions and attitudes

This study was undertaken in the Valby health district in Copenhagen in order to evaluate the activities and attitudes of GPs concerning hearing problems in their elderly patients. Among 55 GPs offering health services to the 2915 residents > or = 80 years of age in the district, 76% (n = 42) responded to a structured questionnaire or personal interview, evaluating their line of action concerning hearing problems, and their knowledge and attitudes towards hearing aids (HAs). Among the responding GPs, 7% always seek information on the hearing ability of their elderly patients at the defined age, whereas 14% never focus on the hearing; 45% of the GPs always refer to an ENT specialist when hearing problems are present, which causes further delay in the rehabilitation process and increases costs within the primary health care sector. GPs' attitudes to HAs seem to be changing in a positive way, 91% of them revealing a positive attitude to HAs, and 86% indicating that a HA is capable of ameliorating a hearing problem in the elderly. Irrespective of this positive attitude, the knowledge of types of HAs among GPs seems limited. The study cannot support the idea of making HAs prescribable by GPs unless they are first offered intensive courses on audiology.

[Endometriosis--diagnosis and therapy. Results of a current survey of 6,700 gynecologists]

The aim of this study is to obtain an actual survey of diagnostic and therapeutic procedures of endometriosis (EMT) in gynaecological practice in West Germany. A questionnaire was sent to 6,700 gynaecologist; 1,364 responded. Approximately 5% of all the patients in daily practice have symptoms related to EMT. Most of the patients are in their twenties. The common clinical symptoms of EMT are dysmenorrhoea (91.8%), infertility (79.7%), pelvic pain (70.9%), menstrual irregularity (46.3%), dyspareunia (21.8%) and painful defaecation (12.8%). The diagnostic standard is laparoscopy, but there are many doctors diagnosing EMT also by means of gynaecological examination (23.8%) or ultrasound (21.3%) - especially in young patients. Hormones are the first choice of therapy. Progestins and danazol are preferred. GnRH-analogues are only used by a smaller proportion of gynaecologists - particularly in infertile patients. Surgical procedures with or without hormonal suppression are another line of therapy adapted by 70.9% of the gynaecologists, which are often preferred in infertile patients. Psychological problems in EMT are caused by the uncertainties between EMT and infertility and by the difficulties between physiological menstrual discomfort and pain caused by EMT. 68.5% of the gynaecologists suggest that more information beyond diagnosis and therapy should be given to the patients. Promotion of self-supporting groups should be encouraged by the doctors.

Comparative genomic hybridization in clinical cytogenetics

We report the results of applying comparative genomic hybridization (CGH) in a cytogenetic service laboratory for (1) determination of the origin of extra and missing chromosomal material in intricate cases of unbalanced aberrations and (2) detection of common prenatal numerical chromosome aberrations. A total of 11 fetal samples were analyzed. Seven cases of complex unbalanced aberrations that could not be identified reliably by conventional cytogenetics were successfully resolved by CGH analysis. CGH results were validated by using FISH with chromosome-specific probes. Four cases representing common prenatal numerical aberrations (trisomy 21, 18, and 13 and monosomy X) were also successfully diagnosed by CGH. We conclude that CGH is a powerful adjunct to traditional cytogenetic techniques that makes it possible to solve clinical cases of intricate unbalanced aberrations in a single hybridization. CGH may also be a useful adjunct to screen for euchromatic involvement in marker chromosomes. Further technical development may render CGH applicable for routine aberration screening.

Effects of folate deficiency on embryonic development

While there is strong evidence that folate deficiency including the use of anti-folate drugs in early pregnancy is teratogenic and may lead to a range of serious abnormalities of the developing fetus including intrauterine death, the mechanism(s) for these effects have not yet been delineated. In neural tube defects, there is increasing evidence that marginal folate status exacerbates the effect of an underlying genetic defect in the mother, the fetus, or both. An abnormal relationship between the ingestion of folate and the folate levels in red blood cells has been found in women who have given birth to infants with neural tube defects. Periconceptional folate supplementation has been shown to give effective protection against the development of neural tube defects. The mechanism of the prevention is as yet unknown. However, folic acid will not prevent all cases of neural tube defect. Moreover, neither determinations of periconceptional vitamin profiles (Mooij et al, 1993) nor determinations of methylmalonic acid and homocysteine levels will detect all women at risk. Anencephaly and spina bifida can be identified prenatally by detection of excessive levels of alpha-fetoprotein in amniotic fluid and maternal serum and by ultrasonographic scanning (Wilson and Rudd, 1993). Both genetic counselling and prenatal diagnosis should be offered to women who are recognized to be at high risk. Research into the underlying biology of neural tube defects is of major importance. The identification of underlying genetic defects would allow for genetic testing and better counselling of families at risk for the occurrence of a neural tube defect.

Payment and attendance at general practice preventive health examinations

BACKGROUND AND OBJECTIVES

This study's purpose was to determine how conditions of payment influence attendance at preventive health examinations.

METHODS

A multi-practice study of 65 general practitioners (GPs) was conducted in two areas in the county of Aarhus, Denmark. The GPs invited 2,452 men aged 40-49 to a preventive health examination for coronary heart disease (CHD). The examination was free in one area but cost $40 in the other area. A risk profile was estimated, based on a summation of points for risk factors for CHD, including blood pressure, serum cholesterol, smoking behavior, body mass index, and family history of CHD.

RESULTS

Attendance at the examinations was 37% in the required payment area and 66% in the free area. Of the total attenders, 13% had an increased risk of CHD. A slight but significant tendency, a lower risk for developing CHD, existed among attenders who paid for the examination.

CONCLUSION

A requirement for payment for health examination leads to fewer patients obtaining examinations.

Psychological reactions to information about risk of ischaemic heart disease in general practice

OBJECTIVE

To examine the psychological reactions in 40-49 year old men diagnosed as having an increased risk for the development of ischaemic heart disease at a health examination in general practice.

DESIGN

A multipractice study including a questionnaire about the psychological well-being before and 6 months after a health examination aimed at finding an increased risk for ischaemic heart disease.

SETTING

General practice in the county of Aarhus, Denmark. Sixty five general practitioners.

PARTICIPANTS

123 men with and 150 men without an increased risk of ischaemic heart disease.

OUTCOME MEASURES

Psychological well-being was measured by the General Health Questionnaire (12 item version).

RESULTS

No significant change in GHQ-scores after the screening examination.

CONCLUSION

Information about increased risk of IHD in 40-49 year old men at a health examination in general practice did not change the psychological well-being as measured by a General Health Questionnaire 6 months after the examination.

The effect of prosthetic rehabilitation in lower limb amputees

The objectives of this project were to ascertain whether, to date, the views concerning the determination of prosthetic candidacy have been optimal and whether the training methods applied have been effective and have resulted in constant use of the prosthesis after conclusion of the training programme. Secondly it was intended to set up guidelines for future budgeting as well as providing a reference framework for the process of rehabilitation. An inquiry based on questionnaires was the first phase in a quality assurance project carried out among 29 amputees trained in 1990 and 1991. The result of the inquiry was that rehabilitation using PTB prostheses for 19 trans-tibial amputations in 18 cases (one patient was a bilateral trans-tibial amputee) led to constant use of the prosthesis and that advanced age was no hindrance to constant use in this group. For 10 trans-femoral amputees the inquiry revealed that advanced age combined with problems of donning the prosthesis was a hindrance to constant use in two cases. It is concluded that there is a need for testing/developing new types of femoral prostheses. The patients' evaluation of the rehabilitation process and their prostheses stresses the need for communication between the team of professionals and the patients in the decision process concerning the provision of a prosthesis as well as the provision of complete information on the patients' future functional possibilities. Qualitative measurements must include the kind and number of medical complications and the social conditions of the amputee as well as tests of physical and mental resources.

Regional cerebral activation during auditory stimulation in patients with cochlear implants

OBJECTIVE

To evaluate a possible change in the regional cerebral blood flow (rCBF) in the language-related cortical areas of the brain during stimulation of a cochlear implant.

METHODS

The rCBF was measured by single-photon emission tomography and inhalation of Xenon Xe 133, providing information on the regional functional level of the brain. A supplementary single-photon emission tomographic scan was also performed, using technetium Tc 99m hexamethylpropyleneamineoxime as a flow marker. The rCBF was measured during rest (baseline) and during auditory stimulation by presenting white noise and running speech to the ear with the implant.

PATIENTS

Five deaf patients who had undergone intracochlear or extracochlear implantation surgery.

RESULTS

As in subjects with normal hearing, notable activation was not found in the relevant primary auditory cortex on stimulation with white noise. Two of the patients with implants had an increase in the rCBF in the relevant contralateral hemisphere on stimulation with running speech, but in the other three patients, a notable increase was not detected. This lack of increase in the rCBF on speech stimulation was consistent with the lack of speech recognition experienced by the subjects when using the implant. In one subject, the implant had a beneficial effect on speech understanding that was associated with a significant increase in the cerebral blood flow in the Broca's speech area and Wernicke's second speech area.

CONCLUSIONS

Although the results are preliminary, the single-photon emission tomographic technique may be useful when evaluating the function of a cochlear implant. The method may also help select patients and/or ears for cochlear implantation. Four of five patients had functional defects of auditory relevant cortical areas, suggesting that their deafness might be associated with central impairment in addition to their cochlear defects.

Characteristics of attenders and non-attenders at health examinations for ischaemic heart disease in general practice

OBJECTIVE

To clarify the importance of health beliefs and some socio-demographic data for accepting an invitation to take part in a health examination by comparing attenders and non-attenders with respect to health beliefs and social status.

DESIGN

Multipractice study including questionnaires for men.

SETTINGS

65 GPs in two areas in the county of Aarhus, Denmark, invited 2452 40-49 year old men to a health examination for ischaemic heart disease. The examination was free in one area, whereas there was a fee in the other. All 1272 attenders and 423/1180 non-attenders completed the questionnaire.

RESULTS

The attendance rate was 66% in the area with free examination and 37% in the fee-paying area. The attendance was significantly higher for cohabitants than for single men in both areas. There was a slightly higher attendance of men with an occupational training in both areas, but the difference was not significant. In general, all agreed that IHD is a serious disease, and that it can be prevented by a personal effort. There were only minor differences in the attenders' and non-attenders' health beliefs.

CONCLUSION

The main conclusion is that 40-49 year old men are in general concerned about IHD. Whether they want to have a health examination for IHD depends mainly on its availability (exemplified here as fee versus free), since the differences were small with respect to health beliefs between attenders and non-attenders.

Image analysis in comparative genomic hybridization

Comparative genomic hybridization (CGH) is a new technique by which genomic imbalances can be detected by combining in situ suppression hybridization of whole genomic DNA and image analysis. We have developed software for rapid, quantitative CGH image analysis by a modification and extension of the standard software used for routine karyotyping of G-banded metaphase spreads in the Magiscan chromosome analysis system. The DAPI-counterstained metaphase spread is karyotyped interactively. Corrections for image shifts between the DAPI, FITC, and TRITC images are done manually by moving the three images relative to each other. The fluorescence background is subtracted. A mean filter is applied to smooth the FITC and TRITC images before the fluorescence ratio between the individual FITC- and TRITC-stained chromosomes is computed pixel by pixel inside the area of the chromosomes determined by the DAPI boundaries. Fluorescence intensity ratio profiles are generated, and peaks and valleys indicating possible gains and losses of test DNA are marked if they exceed ratios below 0.75 and above 1.25. By combining the analysis of several metaphase spreads, consistent findings of gains and losses in all or almost all spreads indicate chromosomal imbalance. Chromosomal imbalances are detected either by visual inspection of fluorescence ratio (FR) profiles or by a statistical approach that compares FR measurements of the individual case with measurements of normal chromosomes. The complete analysis of one metaphase can be carried out in approximately 10 minutes.

Prenatal aneuploidy detection in interphase cells by fluorescence in situ hybridization (FISH)

FISH is a quick, inexpensive, accurate, sensitive and relatively specific method for aneuploidy detection in samples of uncultured chorionic villus cells and amniotic fluid cells. FISH allows detection of the autosomal trisomies 13, 18 and 21 and X and Y abnormalities and any other chromosome abnormality for which a specific probe is available. The detection rate of these abnormalities is high in informative samples which have a concordance of > 99.5% with cytogenetic results. A relatively high number of abnormal cases are found in uninformative samples. However, such samples should be regarded as samples to be investigated further. Clinical experience with the use of FISH for prenatal diagnosis is now beyond 10,000 cases; a number of clinical protocols and smaller trials have also been carried out, resulting in 90% of attempted analyses giving informative results with a high detection rate and extraordinarily low false-positive and false-negative rates. Unsolved problems remain, such as occasional technical failures, admixtures of maternal blood and up to 20% uninformative scoring results, especially for abnormal specimens. FISH is at present used as an adjunct to classical cytogenetic analysis. However, this should not be interpreted as meaning that FISH could not be used as a methodology in its own right. If FISH were to be considered a diagnostic test then this might be the case, due to the risk of false-negative and false-positive results and the fact that FISH does not allow a diagnosis of certain structural abnormalities. If, on the other hand, FISH is considered a screening test, which means that in all abnormal (or indeterminate) cases, classical cytogenetic analysis would follow the abnormal screening test, the accuracy which is potentially higher than for other screening methods, for example in cases of trisomy 21, justifies FISH as a prenatal screening test in its own right.

Development and reversion of methionine dependence in a human glioma cell line: relation to homocysteine remethylation and cobalamin status

We investigated the biochemical changes which accompanied the development and reversion of methionine dependence in a human glioma cell line GaMg. This cell line attained a higher proliferation rate and more malignant morphology with increasing passages in vitro. Early passages (P10, P25, and P45) were able to grow in a methionine-deficient medium supplemented with homocysteine (Met-Hcy+), while a later passage (P60) had lost this ability, i.e., it had become methionine-dependent. From P60 cells, a methionine-independent revertant (P60R) was established by exposing the cells to 5-aza-2-deoxycytidine, followed by culture in a Met-Hcy+ medium. In these genetically related cell lines, we investigated homocysteine remethylation and the functional state of cobalamin-dependent methionine synthase, the enzyme responsible for remethylation of homocysteine to methionine. The methionine synthase activity in cell extracts was similar in all cell sublines. Intact cell methionine biosynthesis and nitrous oxide-dependent homocysteine export reflect homocysteine remethylation in cells cultured in a Met-Hcy+ and methionine-containing (Met+Hcy-) medium, respectively. Both of these parameters, as well as the cellular content of the substrate 5-methyltetrahydrofolate, and the cofactor methylcobalamin, in addition to adenosylcobalamin, were high in P10, declined progressively in P45 and P60, and were restored in P60R. P25 cells had some unique features among the methionine-independent phenotypes because both homocysteine remethylation and the level of 5-methyltetrahydrofolate were low in Met+Hcy- medium. The maximal homocysteine export rate in the presence of nitrous oxide, which reflects the overall transmethylation rate, was high in P60 and even higher in P60R compared to the lower passages. The basis for development of methionine dependence during culture of this glioma cell line seems related to the combined effects of reduced methionine biosynthesis and an increased overall transmethylation rate. The single parameter which most closely correlated to the ability to use homocysteine for growth was methylcobalamin. These data support a model for methionine dependence, which implies impaired provision of cobalamin to methionine synthase.

Preoperative methionine loading enhances restoration of the cobalamin-dependent enzyme methionine synthase after nitrous oxide anesthesia

BACKGROUND

Prolonged exposure to nitrous oxide causes adverse effects mimicking those of cobalamin deficiency. This is explained by irreversible oxidation of cobalamin bound to the enzyme methionine synthase. The inactivation of methionine synthase by nitrous oxide in cultured human fibroblasts is decreased at high concentrations of methionine in culture medium.

METHODS

We investigated the possible protection against cobalamin inactivation by preoperative methionine loading in patients undergoing nitrous oxide anesthesia. Fourteen patients receiving anesthesia for 75-230 min were included. Half of these patients received a peroral methionine loading dose 2 h before anesthesia.

RESULTS

After nitrous oxide exposure, a considerable inactivation of methionine synthase in mononuclear white blood cells was seen in all patients, reaching a nadir after 5-48 h. In the patients not subjected to a methionine load, recovery of enzyme activity was not complete within 7 days. In the patients receiving a methionine load, the kinetics of inactivation of methionine synthase were similar, but the rate and extent of enzyme recovery was higher than in patients not receiving methionine, and in four patients, the enzyme activity even exceeded the preoperative level. The inactivation of methionine synthase was associated with a transient increase in plasma homocysteine, and the homocysteine concentration was still increased (mean 28.7%) 7 days after anesthesia in the patients not receiving methionine. A marked peak in homocysteine concentration was observed immediately after anesthesia in the methionine-loaded patients, but the homocysteine level was still increased (mean of 30.5%) after 7 days. The activity of the other cobalamin-dependent enzyme, methylmalonyl coenzyme A mutase, in the mononuclear white blood cells, and the serum concentration of the cobalamin marker methylmalonic acid, were not altered after nitrous oxide anesthesia or methionine loading or both.

CONCLUSIONS

Our data suggest that short time exposure to nitrous oxide selectively impairs the function of the cobalamin-dependent methionine synthase. Furthermore, preoperative administration of methionine should be considered as a means to counteract adverse effects of nitrous oxide.