Towards improved perinatal care--perinatal audit

Perinatal audit is a measure of quality of care given in pregnancy and it gives an idea as to how the resources need to be allocated for better outcome. The perinatal mortality data in the National University Hospital over a 7-year period (1986-1992) were compiled and compared with that of the year 1982. The perinatal mortality rate (PNMR) of 14.6/1000 in 1982 declined to 8.9/1000 for the period 1986 to 1992 and the reduction was noticeable in all ethnic groups, particularly in the Malays. When lethal congenital malformations (LCMs) were excluded, the PNMR decreased to 5.7/1000. Such reduction is due to easy availability and acceptance of antenatal care, improvement in antenatal and intrapartum fetal surveillance and advances in neonatal care. Neonatal audit was extended beyond the first 7 days of birth which showed that the majority (65%) of deaths occurred in the first week and 15% occurred after the first month. The fear that intensive neonatal care serves to postpone death is not entirely substantiated. There was nearly a ten-fold rise in PNMR between the non-low birthweight and low birthweight groups. The important causes of perinatal mortality during the review period were LCMs (35.7%), complications of prematurity (17.9%) and asphyxia (15.3%). No cause was identifiable in 28.5%. Detailed analysis revealed that the standard of care could have been improved in a third of the cases (83/235) which could have led to further reduction of perinatal mortality rate.

Exon organization and sequence of the genes encoding alpha-lactalbumin and beta-lactoglobulin from the tammar wallaby (Macropodidae, Marsupialia)

Clones encompassing the genes encoding alpha-lactalbumin and beta-lactoglobulin were isolated from a tammar wallaby genomic library, the exons localized using end-labeled oligonucleotides and the DNA sequences determined. The tammar beta-lactoglobulin gene has the same 7 exon-6 intron structure as the sheep homologue. Potential binding sites for mammary gland-specific transcription factors were identified, on the basis of similarity to sites in the sheep gene, in the promoter region of the tammar beta-lactoglobulin gene. The tammar gene encoding alpha-lactalbumin appears to contain four introns rather than three as are present in the eutherian homologues, or the evolutionarily related lysozyme gene. The additional intron appears to occur within the 5' noncoding region of the tammar gene.

Interference by nonsteroidal anti-inflammatory drugs in EMIT and TDx assays for drugs of abuse

Fourteen nonsteroidal anti-inflammatory drugs were evaluated for interference in EMIT and TDx assays for drugs of abuse. Only tolmetin demonstrated significant interferences in the EMIT assay. Urine samples that contained high concentrations of tolmetin (1800 mg/L) had characteristic high molar absorptivity at the wavelength used in EMIT assays (340 nm). Consequently, EMIT analysis of samples resulted in instrument error alarms on a Hitachi 704 instrument and depressed milliabsorbance values (delta A) relative to calibrators. Similar results were obtained with urine samples collected from an arthritic patient after the administration of 200 and 400 mg of tolmetin. When tolmetin samples were mixed with drugs of abuse, depressed delta A values were noted in all assays. Samples containing opiates and cannabinoids tested negative, and instrument error alarms were produced with samples that contained amphetamines. A gas chromatographic-mass spectrometric (GC-MS) assay for benzoylecgonine in the presence of tolmetin was successful, and no interferences were noted. Similar interferences by tolmetin were not observed in TDx assays, probably because of the different wavelength (525 nm) used in this assay. However, a potential for false-positive results in the TDx benzodiazepine assay was noted for urine samples containing high concentrations of fenoprofen, flurbiprofen, indomethacin, ketoprofen, and tolmetin. Generally, it was concluded that the presence of tolmetin in urine samples could lead to the production of unacceptable results by the EMIT assay for drugs of abuse. However, TDx and GC-MS assays were useful alternatives for the analysis of urine samples suspected of containing tolmetin.

Growth pattern of the Indian fetus

OBJECTIVES

To determine the pattern of intrauterine growth and the gestation at birth of Indian fetuses.

METHOD

One hundred twenty consecutive women who had reliable menstrual histories, low-risk pregnancies and who were booked for delivery at the Christian Medical College Hospital, Vellore, before 20 weeks' gestation were recruited to the study. Ultrasound fetal biometry was carried out at 4-weekly intervals from 20 weeks and at weekly intervals after 36 weeks until delivery.

RESULTS

Growth patterns of fetal biparietal diameter and femur length were comparable to those reported in Western populations. However there was a lag in growth of abdominal circumference (AC) after 28 weeks in comparison with that reported in Western populations. The median gestation at delivery following spontaneous labor was 39 weeks. No association was observed between rate of growth of AC and gestation at birth.

CONCLUSION

Slowing of growth of the fetal AC after 28 weeks and a shorter length of gestation result in the birth of smaller babies in this ethnic group. The implications of these findings are discussed.

The pruritogenic and inflammatory effects of prostanoids in the conjunctiva

The therapeutic utility of cyclooxygenase (CO) inhibitors, such as ketorolac, in reducing the inflammatory events associated with allergic conjunctivitis is not unexpected since prostanoids (PG) elicit conjunctival redness (PGD2, PGE2, PGF2 alpha), edema (PGD2, TxA2), eosinophil infiltration (PGD2, PGJ2) and mucous cell discharge (PGD2, PGJ2, TxA2). Recently, topically administered ketorolac has also been reported to alleviate the itching associated with allergic conjunctivitis. This was viewed as intriguing since CO inhibitors are not regarded as useful for treating itching dermatoses and PGs do not elicit itching when applied to the skin. In order to investigate the antipruritic activity of ketorolac, we developed a model for reproducibly measuring ocular surface itch responses. The model involves itch-scratch responses to pruritogens applied locally to the ocular surface. Painful and foreign body stimuli do not produce an itch-scratch response. Unlike reported skin studies, PGE2 was a potent itch-producing substances in the conjunctiva. PGD2 was weakly pruritogenic but PGF2 alpha and the TxA2-mimetic U-46619 were inactive. The PG precursor arachidonic acid was also a potent pruritogen and its effects were inhibited by ketorolac pretreatment. Ketorolac also dose-dependently inhibited the itching associated with experimental allergic conjunctivitis. It appears that PGs are potent itch-producing substances in the conjunctiva and the anti-itch efficacy of ketorolac in allergic conjunctivitis appears to involve inhibition of conjunctival PG biosynthesis from arachidonic acid.

Fournier's gangrene: CT findings

Fournier's gangrene is an uncommon gas-forming infection of the scrotum which if not recognized early and treated appropriately may be fatal. In three patients recently seen at our institution, computed tomography (CT) was instrumental in establishing the correct diagnosis and determining the extent of the infectious process prior to surgery. The imaging findings at CT and its differential diagnosis are illustrated. A brief review of the current theories of pathogenesis of this interesting entity is presented.

Molecular cloning of a novel mRNA (neuronatin) that is highly expressed in neonatal mammalian brain

As differential gene expression governs the progression of development into senescence, we attempted to define the genes that are selectively expressed during postnatal brain development. A cDNA fragment selectively expressed in neonatal rat brain was identified by differential display and used to screen a cDNA library prepared from the same mRNA sample. The full length cDNA, neuronatin, was 1195bp long and coded for a novel protein of 81 amino acids. The cDNA detected an mRNA species of similar size that was highly expressed in rat neonatal and human fetal brain. The deduced protein exhibited a hydrophobic N-terminal and hydrophilic C-terminal, suggesting that it is membrane bound and might function in signal transduction. The selective expression of this novel mRNA in late fetal and early postnatal brain development, and loss of expression in adulthood and senescence, suggests that downregulation of neuronatin may be involved in terminal brain differentiation.

The identification of nuclear and mitochondrial genes by sequencing randomly chosen clones from a marsupial mammary gland cDNA library

To increase the number of genes that can be mapped to the genome of the tammar wallaby (Macropus eugenii), we sequenced 100 randomly chosen clones from a mammary gland cDNA library. Provisional identifications were made of seven nuclear genes and one mitochondrial gene encoding two caseins, beta-galactosidase, acetyl-coenzyme A synthetase, lipoprotein lipase, inorganic pyrophosphatase, an ATP-dependent RNA helicase, and cytochrome c oxidase I. Highly conserved genes, such as that encoding acetyl-coenzyme A synthetase, were easily identified even from cross-kingdom matches. Genes which are highly divergent, however, such as those encoding the mature casein peptides, could not be aligned with homologues in the databases. Even in an organ where there is high mRNA species redundancy, the sequence characterization of expressed sequence tags provides a rapid means of gene identification for mapping purposes.

Double staining in situ study of mRNAs encoding milk proteins in the mammary gland of the tammar wallaby (Macropus eugenii)

Oligonucleotides, differentially tagged with fluorochromes, were used to determine whether the distribution of mRNAs encoding the major milk proteins is heterogeneous within the mammary gland of the tammar wallaby (Macropus eugenii). This method also allowed direct visualization of two species of mRNA within the same cell. Sections of early and late lactating glands of tammar wallabies were hybridized with oligonucleotides labelled with fluorescein isothiocyanate or rhodamine isothiocyanate either alone or in combination. The results support the hypothesis that milk secretion is an all-or-none process with all epithelial cells in a given alveolus producing the same suite of milk proteins. In tammar wallabies, a gene encoding a protein specific to the latter phase of lactation appears to be expressed in those cells already secreting the other major milk proteins.

Alteration of semen characteristics and regulatory factors in human semen with bacterial infection

Semen samples (n = 40) obtained from males attending an infertility clinic were subjected to bacteriological culture and categorized as bacteriologically negative (group I) and bacteriologically positive (group II) depending on the culture positivity. Semen samples from both groups were simultaneously analyzed for routine parameters such as volume, count, motility, viability, morphology, pH, and hypoosmotic swelling. Seminal plasma was assayed for levels of prolactin (PRL), prolactin-suppressing factor (PSF), prostatic inhibin peptide (PIP) and zinc (Zn). Patients in group II (n = 25) showed statistically significant alteration (p < .01) in semen parameters such as motility, percent normal morphological forms, and percent normal HOS test as compared to group I (n = 15). There was a negligible change in the sperm concentration between the two groups. The semen volume, viability, and pH did not show any variation. Among the regulatory factors assayed, there was a significant change in the Zn, PSF (p < .05), and PIP (p = .01), while no such alterations were seen for PRL. The results suggest that bacterial infection affects fertility either by affecting the seminal characteristics directly or by acting on the regulatory systems.

Occurrence and de novo biosynthesis of follicle stimulating hormone (FSH) in benign and malignant conditions of human breast

We report the occurrence as well as biosynthesis of a pituitary hormone, follicle stimulating hormone (FSH) in human breast. Using immunoperoxidase localization technique, both FSH and beta-FSH were localized in cytoplasm of epithelial cells but not in stromal cells. Immunostaining was more intense in benign and malignant specimens as compared to normal. In vitro radiolabelled precursor experiments with breast tissue explants indicate de novo synthesis of FSH. Human milk had higher concentrations of FSH as compared to serum. In gonads, FSH is involved in the cellular growth, differentiation and function. The presence of higher levels of FSH in benign mammary tumors and breast cancer when compared to normal breast supports the suggestion that FSH might have a role in the process of breast malignant transformation.

Neuronal beta-amyloid precursor protein gene expression: regulation by aurintricarboxylic acid

beta-Amyloid precursor protein (beta-APP) and its derivative, amyloid beta-protein (beta-A4), may cause death of differentiated neurons and aurintricarboxylic acid (ATA), a metabolic inhibitor, improves neuronal survival. Therefore, we studied the effect of ATA on neuronal beta-APP gene expression. ATA decreased beta-APP mRNA levels by increasing its degradation, without changing the rate of transcription. ATA decreased both steady state and interleukin-1 (IL1)-induced increase in beta-APP mRNA levels. These effects of ATA were associated with rounding of cells suggestive of decreased cell adhesion or neurite retraction that was completely reversible when ATA was removed. However, beta-APP mRNA levels continued to remain suppressed in neurons that were actively regrowing neurites following discontinuation of ATA. In studies carried out upto 24 h, ATA did not damage cells as determined by Trypan blue exclusion, lactate dehydrogenase (LDH)-release and transmission electron microscopy. The findings suggest that constitutive or steady state levels of beta-APP mRNA may not be essential for the survival and growth of neurons and that ATA suppresses beta-APP expression without causing cell damage. These observations may be a basis for studying whether ATA or a related compound could beneficially regulate beta-APP levels in vivo.

Gonadal function in prepubertal boys following treatment for Hodgkin's disease

PURPOSE

Gonadal functions were evaluated in 26 male patients with Hodgkin's disease (HD), who were in continuous unmaintained remission following combination chemotherapy consisting of COPP/MOPP.

MATERIALS AND METHODS

These patients had received chemotherapy during the prepubertal phase. The median duration after termination of chemotherapy was 72 months.

RESULTS

Semen analysis of 18 patients showed azoospermia. Hormonal analysis showed elevated mean levels follicle-stimulating hormone (FSH) and inhibin as compared to age-matched controls, whereas luteinizing hormone levels were only marginally elevated.

CONCLUSIONS

These results suggest that COPP/MOPP causes severe damage to germinal epithelium even when given during prepubertal age. Sertoli cells, which are responsible for secretion of inhibin, are resistant to these cytotoxic agents. Our data emphasize the lack of gross dysfunction of Leydig cells. It is possible that an alternative chemotherapy protocol (ABVD) may be used in young patients to minimize the gonadal damage.

Free thyroxine as a supplement to thyrotropin in cord screening for hypothyroidism

The low specificity of cord serum T4 levels for detecting hypothyroidism, the need to reduce recall rates and the availability of a reliable and quick assay system led to this study designed to determine the advantages of using cord serum free thyroxine levels over total thyroxine levels as a supplement to cord thyroid stimulating hormone (TSH) determination. Sixty-eight out of 75 newborns with a cord TSH > 23 mU/l had both free thyroxine (fT4) and T4 levels measured in the cord serum. All were recalled within the first month of life for reevaluation of their thyroid status. In the majority of cases (46), the fT4 and T4 values corresponded. Hypothyroidism was diagnosed in eight cases; both fT4 and T4 were below the mean in five cases and above the mean in one case; only T4 was below the mean in one and in the remaining one, only fT4 was below the mean. Recall rates were 0.9% with TSH alone and 0.7% when either a fT4 or T4 level that was less than 1 sd above the mean was used as a supplement to TSH. In this cohort, using the fT4 levels instead of the T4 levels brought no change to the specificity or the sensitivity of the screening. The diagnostic sensitivity would have dropped from 100% to 75% if either T4 or fT4 values below the mean were used as a cut-off point for recall.

A novel member of the lipocalin superfamily: tammar wallaby late-lactation protein

The finding that tammar wallaby late-lactation protein is linked to beta-lactoglobulin prompted a search of current GenPeptide and NBRF-PIR protein databases for sequence similarities to late-lactation protein. Similarities were found to von Ebner's gland protein and other members of the lipocalin superfamily of proteins. A conservative replacement of Trp with Tyr suggests that late-lactation protein may represent an unusual member of this protein superfamily.

Neuronal death, cytoplasmic calcium and internucleosomal DNA fragmentation: evidence for DNA fragments being released from cells

Neuronal death, secondary to endogenous agents such as glutamate, may involve changes in cytoplasmic calcium. Besides its well recognized role as a second messenger mediating cellular response, calcium is necessary for the activation of endonuclease(s), resulting in DNA fragmentation and cell death. Therefore, we investigated the relationship between changes in cytoplasmic calcium, DNA fragmentation and neuronal death, using PC12 and NCB-20 cell lines. The calcium ionophore, A23187, caused a dose-dependent increase in cytoplasmic calcium, loss of cell viability, increased lactate dehydrogenase (LDH)-release, and DNA fragmentation. DNA fragments, typical of internucleosomal digestion of genomic DNA, characteristic of endonuclease(s) activation, were consistently detected in the incubating medium. Release of DNA fragments into the medium was seen with A23187 in concentrations as low as 10 nM, and within an hour of treatment. Furthermore, calcium added to preparations of PC12 nuclei also produced DNA fragmentation, although, less pronounced than when intact cells were treated with A23187. The findings indicate that A23187-induced neuronal death involves the activation of endonuclease(s). The role of cytoplasmic calcium in this process is supported by evidence that A23187 selectively mobilizes cytoplasmic calcium, and that calcium can directly activate endonuclease(s) in nuclear preparations.

On the significance of different aequorin loading techniques on intracellular aequorin discharge, baseline calcium, platelet aggregation and aequorin-indicated Ca(2+)-transients

The study compares the decay of intracellular luminescence activity (Lmax), the levels of basal [Ca2+]i in resting platelets, and agonist-induced peak [Ca2+]i-signals in platelets loaded with aequorin using the EGTA-, DMSO- and hypoosmotic shock treatment (HOST)-techniques. The highest load of intracellular aequorin with almost unchanged luminescence activity during 4 h was achieved with HOST. Lmax decreased linearly in EGTA- and HOST-platelets, but the decay rate and the levels of basal [Ca2+]i were significantly lower in HOST-platelets. Platelet aggregation and aequorin-indicated [Ca2+]i-rise induced by thrombin and collagen were similar in EGTA- and HOST-platelets. In HOST-platelets, ADP-induced platelet aggregation was always accompanied by aequorin-signals, while at a similar time point, aequorin-signals were absent in 3 of 5 cases in EGTA-platelets. The initial aequorin loading was highest in DMSO-platelets, but Lmax described an exponential decay, which was most pronounced when DMSO-platelets were maintained in Ca(2+)-free buffer (R2 = 0.86). Agonist-induced platelet aggregation was significantly reduced in DMSO-platelets: thrombin-stimulation was accompanied by a significantly lower and delayed [Ca2+]i-rise and no aequorin-signal was obtained in response to ADP in 3 of 5 cases. The study shows that in addition of being a rapid loading-technique, the criteria of high intracellular aequorin load with low luminescence consumption, low basal [Ca2+]i and completely preserved platelet functions are most convincingly met by the HOST-method.

Diagnosis of acute diffuse pulmonary infiltrates in immunosuppressed patients by open biopsy of the lung

Herein is a review of the results of open biopsies of the lung performed upon immunosuppressed patients between the years 1982 and 1988. The goal was to assess the safety and value of the procedure on a group of patients who are many times in extremis because of multiorgan failure. Obtaining the correct diagnosis and establishing treatment poses a challenge. The study includes 74 patients. Fifty-four had malignant tumors; 20 had various diseases associated with immunosuppression. The biopsy was obtained from the left side in 65 instances. An adequate thoracotomy was done to permit exploration of the thoracic cavity and obtain a representative sample of tissue. The mortality rate related to the operation was 1.4 percent and the complication rate was 11.0 percent. Forty-six percent of the infiltrates were the result of infection. In 42 percent, a change in treatment was made. Thirty-two percent survived and were discharged from the hospital. Patients with adverse drug reaction, with nonspecific pneumonitis and with bacterial infection had a favorable prognosis and benefited most from open biopsy of the lung.

Septic arthritis following arthroscopy: clinical syndromes and analysis of risk factors

During a 4-year study of 4,256 knee arthroscopies, eighteen patients became infected (infection rate 0.42%). Occurrence of infection was strongly associated with use of long-acting intraarticular intraoperative corticosteroids. Infection was more common among patients with longer surgery operating times, increased numbers of procedures during surgery, prior procedures, and performance of chondroplasty or soft tissue debridement. Subsequent to the study, the infection rate fell to 0.1%. Twenty-four infections were studied (our eighteen plus six other concurrent community cases); twelve were due to Staphylococcus aureus, eleven to coagulase-negative staphylococci, and one to Enterobacter cloacae. Seventy percent of the patients had onset of symptoms within 3 days of surgery. Most patients with coagulase-negative staphylococcal infections had fevers less than 38.3 degrees C (101 degrees F), negative Gram stains on synovial fluid, normal peripheral leukocyte counts, and somewhat indolent, mild clinical syndromes, while most patients with S. aureus infections had higher fevers, positive synovial Gram stains, peripheral leukocytosis, and more acute and severe clinical syndromes. Knee pain, swelling, and warmth always occurred, but erythema was noted in only 30% of patients. Treatment with 2 weeks of intravenous antibiotics was successful in all but one patient. Long-term results were excellent in sixteen of twenty-two patients.

Amyloid beta-protein fragment 25-35 causes activation of cytoplasmic calcium in neurons

The cellular mechanism by which beta-amyloid has its effect on neurons is unknown. Based on observations that endogenous neurotoxins, such as glutamate and platelet activating factor (PAF), cause activation of cytoplasmic calcium, we tested if this was true with beta-amyloid. Using nerve growth factor-treated PC12 cells, we noted that the active beta-amyloid fragment, containing residues 25 to 35, caused a specific and dose-dependent increase in intracellular calcium due to an influx of extracellular calcium.