Detection of fetal fibronectin as a predictor of preterm delivery in high risk asymptomatic pregnancies

OBJECTIVE

The study was designed to determine whether fetal fibronectin would predict delivery before 37 weeks in women at high risk of preterm delivery.

STUDY METHODS

Forty-three women considered at risk of preterm delivery were recruited antenatally into a blind longitudinal study. Quantitative assays of fetal fibronectin were obtained from sequential high vaginal swabs taken fortnightly from 24 to 34 weeks of gestation. Fibronectin concentrations of 0.05 microgram/ml or more were considered as positive.

RESULTS

Results were calculated by swab and by subject. The sensitivity of an individual fibronectin swab in predicting preterm delivery within 14 days of testing was 71% and the specificity was 93%. The overall positive predictive value was 31% and the negative predictive value was 99%. The sensitivity of the fibronectin swab in predicting delivery before 37 weeks was 17% and the specificity was 93%. The positive predictive value was 50% and the negative predictive value was 73%. For a woman who has had a positive swab the sensitivity in predicting preterm delivery within 14 days of testing was 80% and the specificity was 83%; a woman was counted as positive only if the final swab was positive and preceded delivery by not more than 14 days. The positive predictive value was 36% and the negative predictive value was 97%. For a woman who has had a positive swab the sensitivity in predicting delivery before 37 weeks was 54%. The specificity, the positive predictive value and the negative predictive value were 85%, 64% and 79%, respectively. Women were counted as positive if any swab in the sampling sequence was positive. Fibronectin swabbing when calculated by patient did predict preterm delivery within 14 days of testing (P=0.01) and before 37 weeks (P=0.01). Analysis of the accuracy of predicting delivery from 7 to 28 days after sampling revealed that the best prediction for delivery was within the following 14 days.

CONCLUSION

Serial fetal fibronectin assessment from 24 to 34 weeks of gestation anticipated preterm delivery within 14 days of testing and before 37 weeks for high risk asymptomatic women. Such testing should be performed every two weeks.

Urticaria

Urticaria (hives) is a common disorder that affects 15 to 20 percent of the population at some time. Lesions are clinically characterized by a transient, pruritic, patchy eruption that consists of lightly erythematous papules or wheals. When attacks are protracted, urticaria is an annoying condition for the patient and a challenge for the physician. Foods, drugs and many other agents may cause urticaria by inducing mediator release from mast cells in the skin. Identification of the precipitating agent is crucial for effective treatment of urticaria. Newer antihistamines that are nonsedating offer promise for control of symptoms without the problem of frequent side effects.

Physical urticarias

Chronic urticaria can be produced by a number of stimuli that cause mast cell mediator release. Patients with urticaria caused by physical agents account for roughly one-fifth of all cases of chronic urticaria. There are about 20 different types of physical urticaria. Two forms, dermographism and cholinergic urticaria, are quite common and represent more than two-thirds of all cases of physically caused urticaria. More than one agent may precipitate urticaria in a given individual. Urticarial response can be easily reproduced in the sensitive patient and, generally, lasts less than one hour. Systemic features such as flushing, dizziness, headaches, and even hypotension, may occur during severe episodes. Identification of the causative physical agent is necessary for effective therapy.

Management of prelabour rupture of the membranes in term primigravidae: report of a randomized prospective trial

OBJECTIVE

To compare a conservative and an active policy (immediate oxytocin infusion) of management of prelabour rupture of the membranes in term primigravidae.

DESIGN

Randomized trial involving 444 women.

SETTING

District maternity hospital.

MAIN OUTCOME MEASURES

Caesarean section rate in each group; also the rate of forceps deliveries, spontaneous deliveries, length of labour, number of vaginal examinations, type of analgesia, pyrexia in labour or the puerperium and antibiotic use in the mother and the infant in each group. The caesarean section rate for the whole trial where the latent period was greater than 12 h was compared to that where the latent period was less than or equal to 12 h.

RESULTS

There were fewer caesarean sections in the conservative group (odds ratio (OR) 0.60, 95% confidence interval (CI) 0.35 to 1.02; P = 0.06). There was a similar number of forceps deliveries (OR 0.79; 95% CI 0.52 to 1.19; P = 0.26) but more spontaneous deliveries (OR 1.57; 95% CI 1.08 to 2.29; P = 0.02) in the conservative group. More women managed conservatively required inhalational analgesia only for pain relief in labour (OR 2.88; 95% CI 1.46 to 5.68; P = 0.003), a similar number required pethidine (OR 1.29; 95% CI 0.85 to 1.94; P = 0.23), and fewer required epidural analgesia (OR 0.57; 95% CI 0.39 to 0.84; P = 0.005). The number of vaginal examinations was less in the conservative group (difference between mean 0.53; 95% CI 0.25 to 0.80; P less than 0.001). Fewer women managed conservatively experienced four or more vaginal examinations in labour (OR 0.58; 95% CI 0.39 to 0.86; P = 0.007). There were no differences in the lengths of labour, the proportions of women who developed pyrexia in labour or the puerperium or who required antibiotics or in the proportions of infants who required antibiotics.

CONCLUSIONS

These results argue in favour of a conservative policy in managing primigravidae at term with prelabour rupture of the membranes.

Home-based intravenous therapy for oncology patients

It is desirable to keep cancer patients at home whenever possible to maximize their physical comfort and mental well-being. However, physicians should be aware of all the serious limitations in terms of patient selection and avoidance of the abuses of overutilization of the system.

Detection of anti-basement membrane zone antibodies in bullous systemic lupus erythematosus

We describe a 42-year-old black woman with long-standing systemic lupus erythematosus in whom vesiculobullous lesions developed. Routine histologic and immunologic studies fulfilled the criteria for the diagnosis of bullous systemic lupus erythematosus. Indirect immunofluorescence showed antinuclear antibodies without basement membrane zone fluorescence. We destroyed the nuclear antigens of the indirect immunofluorescence substrate with 2 mol/L sodium chloride, which unmasked basement membrane zone linear IgG staining. We also confirmed anti-basement membrane zone antibodies by employing a new technique of direct immunofluorescence on sodium chloride-split skin. Our finding prove that a thorough search for anti-basement membrane zone antibodies can be revealing. Our results support the idea that a subset of bullous systemic lupus erythematosus has the staining characteristics of epidermolysis acquisita, with the dermal side of the split skin showing linear immunoglobulin deposition.

Non-terpenoidal constituents from Azadirachta indica

Studies on the acidic fraction of the fresh, uncrushed twigs of AZADIRACHTA INDICA JUSS (Meliaceae) (Neem) have resulted in the isolation and structure elucidation of one new and three unreported isocoumarins along with two unreported coumarins. The petroleum ether extract of the fresh leaves yielded a hydrocarbon fraction, the GC-MS of which led to the identification of eight saturated hydrocarbons. Fatty acid compositions of leaves, twigs, and fruits of neem have also been determined.

Prevention of duodenal ulcer formation in the rat by dietary vitamin A supplementation

We have shown previously that supplemental vitamin A (Vit. A) increases the early inflammatory response to wounding and enhances the collagen content of the intestine of normal and injured rats. We now report the effect of dietary supplementation with Vit. A on the prevention of duodenal ulcer (DU) in rats caused by intragastric administration of cysteamine-HCl. A major way cysteamine-HCl induces DU formation is by enhancing gastric acid secretion. Adult male rats were divided into two groups: (1) rats fed a standard rat Chow (Purina) (15 IU Vit. A/g diet) containing two to three times the National Research Council recommended daily allowance for Vit. A for normal rats; (2) rats fed the same supplemented with 150 IU of Vit. A palmitate per/g Chow. One week later, all rats were given 1 ml of cysteamine-HCl (135 mg) intragastrically. The rats were maintained on their respective diets. Two days later, all rats were killed with ether, the stomach and duodenum excised, and examined for the presence of ulcers. No gastric ulcers were found in either group. There was a statistically significant decrease in the incidence of DUs in the Vit. A-supplemented group when compared to the control group (p less than 0.01) 48 hr following cysteamine-HCl administration; 32% of the Vit. A-supplemented rats developed a DU whereas 74% of rats fed standard Chow had DUs. Most rats had a single DU in the first part of the duodenum, occasionally a second ulcer was noted in the same area. Dietary supplementation with Vit. A had no effect on gastric acid production. In conclusion, our data show that Vit. A dietary supplementation is effective in preventing formation of DUs caused by cysteamine-HCl administration to rats. This effect does not appear to be due to reduction of gastric acid output.

Elevated sacroiliac joint uptake ratios in systemic lupus erythematosus

Sacroiliac joint radiographs and radionuclide sacroiliac joint uptake ratios were obtained on 14 patients with active systemic lupus erythematosus. Elevated joint ratios were found unilaterally in two patients and bilaterally in seven patients when their lupus was active. In patients whose disease became quiescent, the uptake ratios returned to normal. Two patients had persistently elevated ratios with continued clinical and laboratory evidence of active lupus. Mild sacroiliac joint sclerosis and erosions were detected on pelvic radiographs in these same two patients. There was no association between low back pain or HLA-B27 positivity and the radiographic or scintigraphic abnormalities. Elevated quantitative sacroiliac joint uptake ratios may occur as a manifestation of active systemic lupus erythematosus.

Modulation of venom-induced leukocyte histamine release by mononuclear cells: effect of venom immunotherapy

Leukocyte histamine release and blood mononuclear cell proliferative responses to venoms were evaluated in nine patients with sting anaphylaxis. The effect of venom-activated mononuclear cells on the autologous mononuclear cell proliferative response and venom-induced leukocyte histamine release was also studied before and on maintenance immunotherapy. The mononuclear cell proliferative response was low (specific incorporations less than 2.0) and antigen nonspecific both before and during maintenance immunotherapy. Venom-induced in vitro leukocyte histamine release did not change significantly with immunotherapy. However, when patients were on maintenance immunotherapy, venom-activated mononuclear cells cocultured with autologous leukocytes significantly (p less than 0.05) suppressed venom-induced histamine release. The suppressive effect of mononuclear cells was antigen specific and enhanced by in vitro mononuclear cell activation. Suppression of leukocyte histamine release by mononuclear cells extends the regulatory potential of these cells and may identify an additional mechanism by which immunotherapy protects Hymenoptera-sensitive individuals against systemic anaphylaxis.

Extension of myeloid tissue into the lower extremities in polycythemia

Biopsies of the posterior iliac crest, greater trochanter, and proximal tibia were done for 27 polycythemic patients before myelosuppressive therapy was begun. Five had relative polycythemia, thirteen had secondary polycythemia, and nine had polycythemia vera. None of five biopsy specimens of the greater trochanter in cases of relative polycythemia contained myeloid tissue (erythroblasts, granulocytic precursors, and megakaryocytes). Four of six biopsy specimens of the greater trochanter and one of eight of the tibia in cases of secondary polycythemia contained myeloid tissue. All seven biopsy specimens of the greater trochanter and two of five biopsy specimens of the proximal tibia in cases of polycythemia vera contained myeloid tissue. A trochanter biopsy specimen devoid of myeloid tissue probably eliminates the diagnosis of polycythemia vera. Myeloid tissue extends from the axial skeleton to the greater trochanter, therafter to the tibia. Extension of myeloid tissue does not imply that marrow failure is imminent in polycythemia vera.

Pseudothrombocytopenia associated with vasculitis

A patient with pseudothrombocytopenia due to the anticoagulant EDTA is described. The thrombocytopenia was secondary to platelet agglutination and required the presence of EDTA in a critical concentration and the patient's plasma. Both homologous and autologous platelets were affected by this plasma factor in the presence of EDTA. The platelet agglutination was temperature independent and could be prevented by divalent cations. The agglutination phenomenon was irreversible. The platelet count in oxalate, not heparin, and citrate anticoagulated blood was normal. The patient's clinical course was benign and no hemorrhagic complications occurred. We believe this is the first reported case of pseudothrombocytopenia associated with a vasculitis. The diagnosis of this disorder, its implications and the pertinent literature is discussed.

Macrocytic anemia, thrombocytosis and nonlobulated megakaryocytes: the 5q-syndrome, a distinct entity

The clinical, hematologic and histologic characteristics of six patients with refractory anemia with deletion of the long arm of chromosome No. 5 are described. These patients had a distinct hematologic picture with macrocytic anemia of mild to moderate severity, normal to low leukocyte count and increased platelet count. The long arm of chromosome No. 5 was deleted in the majority of bone marrow metaphases. The main cause of anemia was underproduction with decreased erythroid precursors in the bone marrow and no increase in peripheral blood reticulocytes. Two of five patients responded transiently to the administration of androgens. In vitro evaluation of the bone marrow growth pattern in semisolid agar culture system was performed in three patients and was found to be normal and distinct from that in patients with preleukemia. In a follow up of up to five years, no patient had changed hematologically and in none had leukemia developed. The 5q-syndrome is a distinct hematologic entity and probably more common than hitherto realized. This diagnosis may have therapeutic and prognostic implications.