[Current concepts in maxillo-facial surgery]

The authors make a brief and concise overview of the evolution of maxillofacial surgery over the last decades namely the concepts and methods used. Some case reports are presented which illustrate the application of the current methodology with the purpose of covering various fields of application (traumatologic, othognatic and tumoural). The need for an interdisciplinary assessment of these patients is discussed.

Severe latex allergy after a vaginal examination during labor: a case report

There has been an alarming increase in latex allergy, which can be a potential cause of occupational atopic disease. Physicians should be aware of this entity in high-risk groups and in patients with other allergies. A 32-year-old pregnant woman, with an allergy to orange juice, was first seen with a 39-week pregnancy in the labor room, where she had on two occasions a severe atopic reaction when examined with a latex glove. A latex allergy was suspected, and management with hydrocortisone resulted in remission of symptoms. Two hours later a vaginal delivery was performed with nonlatex, nonvinyl gloves. A week later immunoglobulin E antilatex antibodies determined by radioallergosorbent test were still positive at 585 IU. It is concluded that symptoms of latex allergy may develop in high-risk groups or in those with other known allergies. Because of the increasing frequency of this entity, physicians should take greater care and give more attention to the clinical history, as well as be aware of this possibility in these groups of patients.

Mechanisms underlying degeneration of cryopreserved vascular homografts

OBJECTIVE

To analyze the mechanism(s) underlying homograft degeneration, we designed an experimental model in which the behavior of cryopreserved autografts and homografts, as well as fresh autografts, implanted in the same animal was compared.

METHODS

A cryopreserved homograft was implanted in the aorta of 14 sheep. The excised aortic autologous segment was then subjected to cryopreservation, and 1 to 8 weeks later it was implanted 1 to 2 cm below the cryopreserved homograft. The intermediate segment of the native aorta, the fresh autograft, was dissected at this point. Animals were put to death at different times and the implanted segments were harvested together with a portion of native aorta. Histologic and immunohistochemical analyses, as well as cell viability assessments, were then performed on the explanted segments. Similar studies were also conducted on fragments of cryopreserved autografts and homografts before implantation.

RESULTS

With the exception of a partial loss of the endothelium, cryopreserved specimens retained cell viability and morphologic integrity before implantation. Explanted cryopreserved homografts showed profound changes affecting all strata, as well as a decline in cell viability. Lymphocyte infiltrates were found up to 12 months after implantation. Endothelium was always absent in cryopreserved homografts. However, a reendothelialization of the cryopreserved autografts was observed. After an initial period of neuronal degeneration, reenervation of the cryopreserved autograft segment occurred 6 to 12 months after the operation. Findings regarding the fresh autografts were similar to those of the cryopreserved autografts.

CONCLUSION

Our results suggest that the immunologic reaction rather than the cryopreservation process is responsible for the degenerative process occurring in cryopreserved homografts.

[Severe syndrome of ovarian hyperstimulation. Incidence, value of criteria of risk factors and preventive methods]

Statistical analysis; square Chi test, Pearson, were practiced, from 1994 to 1996. There were 368 hyperstimulated cycles; three SHOS cases without risk factors and 28 cases with risk factors without SHOS. Risk factors presented were: average seric estradiol 6643.59 +/- 2320 pg/ ml; average follicles: 26.6 +/- 6.9; ovules recuperated by aspiration: 19.32 +/- 9.1. There were five groups according to preventive methods: albumin (13 patients, coasting (one patient); albumin-coasting (11 pacientes); albumin-embryo freezing (3 patients); embryo freezing (one patient). None of the patients presented SHOS.

Anatomical and echocardiographic correlates of normal cardiac morphology in the late first trimester fetus

OBJECTIVES

To describe the normal cardiac morphology as seen by transvaginal ultrasound imaging in the first trimester fetus and to compare it with the morphology of the heart as seen by microdissection at the same gestational age.

DESIGN

In 53 mothers undergoing early sonography, the fetal heart was examined and the images recorded. The gestational age range was 5-12 weeks of gestation, which represents 21 to 70 days after conception. Images were analysed frame by frame and compared with the anatomy of embryos and fetuses at the same gestational ages.

RESULTS

After the 9th week of gestation, four cardiac chambers, the aortic origin, and the pulmonary artery could be identified on cross sectional echocardiography in conjunction with colour flow Doppler. At 9 weeks, the apex pointed anteriorly and the right ventricle and pulmonary artery lay to the right of the midline. By the 11th week of gestation, the apex pointed to the left and the pulmonary artery lay to the left of the midline as in the older fetus. Between 9 and 12 weeks' gestation the aorta was larger than the pulmonary artery. These findings were confirmed in the microdissected hearts.

CONCLUSIONS

The current quality of ultrasound images obtained using transvaginal transducers in the first trimester fetus allows the study of fetal cardiac anatomy. Some of the later developmental changes can be demonstrated. As technology improves further the details of earlier cardiac morphogenesis may also become visible.

Delay in progression of bone metastases in breast cancer patients treated with intravenous pamidronate: results from a multinational randomized controlled trial. The Aredia Multinational Cooperative Group

PURPOSE

Bone metastases are a major cause of morbidity in breast cancer, resulting in complications that include pain, loss of mobility, pathologic fracture, and tumor-induced hypercalcemia (TIH). Inhibition of osteoclast-mediated bone destruction using bisphosphonates represents a promising new management approach.

PATIENTS AND METHODS

Breast cancer patients with bone metastases were randomly allocated to receive chemotherapy alone (152 patients) or chemotherapy plus pamidronate 45 mg in 250 mL of saline as a 1-hour intravenous infusion every 3 weeks (143 patients). Whenever possible, treatment continued until progression of disease (PD) in bone appeared on radiographs or bone scan. Time to PD in bone and pain reduction according to a self-assessment six-point scale were selected as primary end points. PD in bone was verified during extramural review (EMR) of all imaging studies by blinded observers, and these data were used as the main efficacy criterion. Analgesic intake, World Health Organization (WHO) performance status, and complications of bone metastases (radiotherapy, TIH, fractures, orthopedic surgery) were also compared in the two groups.

RESULTS AND CONCLUSION

At EMR, median time to PD in bone was increased by 48% in patients who received pamidronate (249 v 168 days; P = .02, Wilcoxon test). Marked pain relief, defined as a two-point decrease lasting for > or = 6 weeks, was reported by 44% of pamidronate patients and by 30% of controls (P = .025, chi 2 test). The infusions (median, nine per patient; range, 0 to 39) were well tolerated, with no major toxicities reported. Pamidronate by repeated infusion can significantly slow the progression of bone metastases and reduce attendant morbidity.

Autosomal dominant cataracts of the fetus: early detection by transvaginal ultrasound

Cataracts are lens opacities that account for approximately 10% of blindness in children. We report on four consecutive pregnancies in a woman at risk for recurrent autosomal dominant cataracts in which extensive ultrasound studies were helpful in establishing the correct diagnosis. The normal appearance of the fetal lens is that of a ring with a central sonolucency, but in cases of cataracts the lens appears hyperechogenic to various degrees. In the first pregnancy, normal lenses were seen at 15 postmenstrual weeks and, at birth, the baby girl had normal lenses. In the second pregnancy, the male fetus was affected by a left-sided cataract and a right-sided anophthalmia which were diagnosed at 16 postmenstrual weeks. The histological examination of the specimen from the aborted fetus correlated with the sonographic diagnosis. The third pregnancy, also a male fetus, had bilateral cataracts suspected at 14 weeks, but the final diagnosis was made at 19 weeks and confirmed at 21 weeks. The couple opted to terminate the pregnancy and the histology confirmed the presence of congenital cataracts. In the fourth pregnancy, we diagnosed asymmetry of the orbital sizes and bilateral cataracts at 15 weeks. In conclusion, the diagnosis of fetal cataract from the second trimester of pregnancy is possible and imaging of the fetal lenses should be part of the routine anatomical survey. Since the exact onset of fetal cataracts is uncertain at present, in cases at risk, serial sonograms may be indicated.

Serum antibody response to Actinobacillus actinomycetemcomitans in Down's syndrome

Persons with Down's syndrome (DS) are susceptible to severe and precocious periodontal disease. Several organisms have been implicated in the etiology of periodontal disease, including Actinobacillus actinomycetemcomitans (Aa). It is unknown whether circulating antibodies correlate with the severity of periodontal disease in DS. This study determined the circulating antibody titers to Aa in sera of DS and normal patients. Eleven DS patients with periodontal disease (pocket depth > 4 mm), five DS patients with gingivitis (inflammation and pocket depth < or = 3 mm), and 10 non-DS healthy subjects had blood drawn and analyzed for antibody response to Aa. Conventional enzyme-linked immunosorbent assay (ELISA) with goat anti-human IgG was performed for Aa-reactive serum diluted 1:200 to 1:12,800. Geometric mean titer was calculated, and significant differences were noted between the control group and the DS groups (p = 0.05), with the DS periodontal group having the highest response, followed by the DS gingivitis and normal controls, respectively. The DS groups were not significantly different. DS patients may exhibit a higher Aa antibody response, due to the presence of the organism, previous exposure, or in proportion to the extent of their periodontal condition.

Carcinoid tumor and the nephrotic syndrome: a novel association between neoplasia and glomerular disease

Various malignancies are associated with the paraneoplastic evolution of the nephrotic syndrome. Renal biopsy in these instances frequently shows membranous glomerulonephritis. We describe a patient who had metastatic bronchial carcinoid tumor with development of microscopic hematuria and subsequent nephrotic syndrome in conjunction with another paraneoplastic process, a malignancy-related neuropathy. A decline in actual glomerular filtration rate led to percutaneous renal biopsy, which revealed fine holes in the glomerular basement membrane and focal capillary corrugation. Electron microscopy showed numerous small subepithelial dense deposits and fusion of foot processes, confirming the diagnosis of stage I membranous nephropathy. We believe this is the first published case of true carcinoid tumor associated with the nephrotic syndrome and a specific paraneoplastic glomerular lesion. Carcinoid tumor should be considered in the spectrum of malignancies associated with paraneoplastic development of the nephrotic syndrome.

Age and the ovarian follicle pool assessed with transvaginal ultrasonography

OBJECTIVE

We tested whether transvaginal ultrasonography could detect the age-related decrease in follicle counts that has been observed in autopsy studies.

STUDY DESIGN

Thirty-one healthy volunteers in three age groups (22 to 25, 30 to 33, and 39 to 42 years) underwent ultrasonography in the follicular and luteal phases of the menstrual cycle. At the conclusion of the study the 124 ovarian scans were randomly ordered and antral follicles > or = 2 mm were counted by an evaluator unaware of age. Ordinary least-squares linear regression was used to estimate the associations of age with the total antral follicle count and with ln (1 + follicle count).

RESULTS

The numbers of antral follicles > or = 2 mm decreased by about 60% between 22 and 42 years. Age-related decreases were similar for both phases of the cycle and held for both smaller (2 to 3.5 mm) and larger (>3.5 mm) follicles.

CONCLUSION

We hypothesize that ultrasonographically derived counts of follicles provide a measure of reproductive age that may help to predict age-related phenomena.

[Hyponatremia as a complication of laparoscopic hysterectomy. Report of a case]

The case of a 42 years old woman, who had laparoscopic hysterectomy and seven hours after presented with a convulsive crisis and later a coma status, secondary to hyponatremia. Hyponatremia causes, are discussed, as well as its relationship with syndrome of inadequate secretion of antidiuretic hormone, diagnosis, management, prognosis factors and risk.

Amantadine stimulates sexual behavior in male rats

The effects of amantadine on sexual behavior, penile erection, and seminal emission of male rats was studied. Amantadine significantly decreased latency of mounts in all doses (1.25 to 50 mg/kg), and decreased the number of mounts and intromission latency at the highest doses used. The lowest dose of amantadine significantly increased ejaculation latency and intromission frequency, while higher doses significantly reduced it, which indicates a biphasic response of the drug. Additionally, seminal emission, erections, and genital grooming were significantly induced by amantadine. Amantadine-induced seminal emissions were impaired by spinal cord transection, which suggests the involvement of supraspinal structures in the drug action. Haloperidol and atropine sulphate significantly reduced seminal emissions and penile erections induced by amantadine. These results demonstrate that amantadine stimulates sexual behavior and genital reflexes in male rats and suggest a facilitatory effect of the drug that probably involves different mechanisms of action.

Histologic and genetic assessment of explanted allograft valves

A possible way of analyzing the immune response triggered by the allograft and the cellular viability is to compare immunocompetent and immunosuppressed patients, such as those having valve replacement and heart transplantation, respectively. These groups differ in immunosuppression therapy, preparation methods, valve hemodynamics. In the present study, we investigated polymerase chain reaction-amplified DNA flanking hypervariable (CA)n regions obtained from valve leaflets taken from patients having valve replacement or heart transplantation and performed a histologic analyses of the cells. In addition, we assessed an autograft valve to compare the hemodynamic effects on the cellular composition of the valve leaflet. We conclude that leaflet cellularity of the heart transplantation and autograft patients is superior to that of the valve replacement patients. These differences were consistent with the occurrence of an immune response in the valve replacement group, which was prevented or abrogated by immunosuppressive therapy administered to the heart transplantation group. However, it cannot be excluded that preparation procedures have a long-term effect on the extracellular matrix, leading to deterioration of cell adhesion and homing conditions.

The allograft valve in heart transplantation and valve replacement. Genetic assessment of the origin of the cells by means of deoxyribonucleic acid profiles

Assessment of the cellular origin of allograft valves is essential in comprehending their biologic behavior and in improving preparation methods. In this study we retrospectively analyzed 10 allografts obtained from patients who underwent valve replacement or heart transplantation. Histologic evaluation and deoxyribonucleic acid amplification by polymerase chain reaction technology with fluorescence labeled primers was performed on different parts of the valve leaflets. Automated analyses of the obtained amplimers showed in the heart transplantation group the presence of receptor cells interspersed with native donor cells in three cases. Preliminary results for the valve replacement group are inconclusive as yet.

Preparative isolation of the lectin jacalin by anion-exchange high-performance liquid chromatography

The lectin jacalin from Artocarpus integrifolia was purified to homogeneity in a single step by preparative anion-exchange high-performance liquid chromatography (HPLC). Selection of the optimum chromatographic parameters in gradient elution allowed a rapid procedure to be obtained for the qualitative and quantitative isolation of the most important alpha- and alpha'-jacalin components. A recovery of 27-33% was obtained from a total soluble extract using a polyacrylate-DEAE HPLC column. The identities of the two isolated polypeptides were established by N-terminal amino acid sequence analysis and from the IgA1 binding lectin activity.

Amniotic sac, fetal heart area, fetal curvature, and other morphometrics using first trimester vaginal ultrasonography and color Doppler imaging

Ultrasonographic morphometric measurements were obtained with transvaginal ultrasonography from 121 patients with first trimester singleton pregnancies. Amniotic and gestational sac diameters, fetal heart area, and fetal length increased in a linear rate relative to crown-rump length, whereas the amniotic and gestational sac volumes increased at an exponential rate. The yolk sac exhibited a biphasic growth pattern with a peak at a crown-rump length of 3.5 cm. The ratio of crown-rump length to anteroposterior dimension increased over the first trimester, suggesting less curvature in older fetuses. In conclusion, vaginal ultrasonography permits accurate measurement of many new morphometric parameters.

Difficulties in the management of a parathyroid carcinoma - case-report

The case of a parathyroid carcinoma in a 61-year-old woman is described. The patient was referred to our hospital, with the diagnosis of medullary thyroid carcinoma, after a prior thyroidectomy performed at another hospital. On admission, serum calcium was 3.92 mmol/l (n.r. 2.2-2.5), PTH level was 320 ng/l (n.r. 10-65), urinary cAMP was 508.9 mmol/mmol creatinine (n.r. 330- 630) and serum calcitonin was 2.1 ng/l (n.r.<10). The patient was then submitted to a complete neck exploration and multiple nodules were removed. Histopathological diagnosis of parathyroid carcinoma was made by local recurrence and retrospectively upon closer examination of the original specimen. After surgery, normocalcemia was achieved and maintained for about four months. Serum PTH decreased to 28.8 ng/l after surgery but increased quickly to 75.6 ng/l ten days later. Three months later, there was both biochemical and clinical evidence of disease. In the following eight months, calcium levels ranged from 2.99 mmol/l to 4-24 mmol/l and PTH from 135 ng/l to 1431 ng/l. However no distant metastases were found. To Control hypercalcemia, the patient was treated with bisphosphonates but normocalcemia was never achieved. A slight and transient reduction in serum calcium as response to an acute administration of octreotide, made us not to consider this eventual modality of therapy. Sonographically guided percutaneous injection of ethanol was performed but the treatment was not found to be effective. Finally, the use of chemotherapy with 5-fluorouracil, cyclophosphamide and dacarbazine was also unsuccessful. The patient died two years after the initial diagnosis.

[Laparoscopic hysterectomy. Initial experience]

The results of the first twelve cases of Laparoscopic Assisted Vaginal Hysterectomy, are presented. The indications for hysterectomy were myomatosis, suspicion of adenomyosis and endometriosis. The surgical technique is described in detail in which a combination of bipolar Kleppinger forceps and reusable scissors were employed. There were two intraoperative accidents. One subcutaneous emphysema of the left half of the abdominal wall, thorax, neck, face and upper limb. The second case was a damage to a branch of the left epigastric artery. The average time was 4 hours 31 minutes which includes 9 patients to which another surgical procedure was practiced. There was no significant bleeding in any of the patients. The postoperative complications were 1 hyponatremia that needed the use of an Intensive Care Unit and the other was periumbilical hematoma of 3 cm. of diameter. The patient was discharged on the one to three postoperative day with an average of two days. The average hospital fee was 35% higher than an abdominal hysterectomy. All the surgery were videotaped and later viewed by the patients. It was concluded that the laparoscopic assistance that is offered to the vaginal hysterectomy is particularly advantageous for hysterectomy especially in the cases where absence of genital prolapse, when uni or bilateral Adnexectomy is required, previous past history of abdomino-pelvic surgery, endometriosis and adhesions. This procedure should be included in the armamentarium of the Gynecological Surgeons but only after and appropriate training.

Triiodothyronine (T3) modifies cholinergic-induced hypothermia and tremor in rats

Hypothermia and tremor responses of oxotremorine and eserine were studied in rats after several T3 treatment regimens. The T3 antagonized oxotremorine-induced hypothermia and failed to antagonize eserine hypothermic effect, but potentiated oxotremorine- and eserine-induced tremors. Acetylcholinesterase activity was not altered in T3 rats. The hypothetical mechanisms to explain changes of central cholinergic responses caused by T3 are discussed.

Immunoscintigraphy with 99mTc-labelled anti-CEA monoclonal antibody in colorectal carcinoma

With the introduction of immunoscintigraphy (IS) with 99mTc-labelled anti-CEA monoclonal antibodies (MoAb), a clinical relevant method in nuclear medicine can be expected in the diagnosis and follow up of colorectal cancers. We performed IS (whole body, planar and SPECT) with a 99mTc-labelled intact anti-CEA MoAb (BW 431/26) in 18 patients with primary colorectal carcinoma, metastases or suspicious recurrences from colorectal carcinoma. The results of anti-CEA IS, serum CEA and Ca 19-9 levels were evaluated. Immunoscintigraphy yielded an overall sensitivity of 70.0%, 37.5% for primary tumors, 75.0% for recurrences and 100% for distant metastases. Serum CEA levels were elevated in 10 out of 18 patients (sensitivity 55.5%) and Ca 19-9 were elevated in eight out of 18 patients (sensitivity 44.4%). In the group of patients with metastases, CEA had a sensitivity of 100% and Ca 19-9, of 83.3%. From this prospective study, we can conclude that IS with 99mTC-BW 431/26 is a reliable tool in the post-operative follow-up study of patients with colorectal carcinoma, namely in the detection of distant metastases.

Transvaginal ultrasonographic characterization of ovarian masses by means of color flow-directed Doppler measurements and a morphologic scoring system

OBJECTIVE

The aim of the study was to test the hypothesis that a combination of a previously devised morphologic scoring system and color flow-directed Doppler measurements would afford better discrimination between benign and malignant ovarian masses.

STUDY DESIGN

The scoring system and color flow-directed Doppler measurements for 115 masses were prospectively analyzed and correlated with histopathologic surgical findings.

RESULTS

In 21 masses (18 patients) no flow was obtained. Seventy-eight masses in 70 patients were benign, and 16 masses in 12 patients were malignant. The mean total score for the benign masses was 6.7 and for the malignant masses 11.7. The resistance index was 0.64 for the benign lesions and 0.39 for the malignant masses (range 0.2 to 0.98). The mean pulsatility index of the benign masses was 1.17 and 0.52 for the malignancies (range 0.2 to 2.6). There were no malignancies in the group with no flow obtained. The sensitivity and specificity of score alone was 94% and 87%, respectively, with a 60% positive predictive value. By means of resistance index or pulsatility index the sensitivity was 94%, the specificity 99%, and the positive predictive value 94%.

CONCLUSION

These results suggest that Doppler flow measurements alone and in conjunction with a scoring system help differentiate benign from malignant masses.

Type 1 Gaucher disease: molecular, biochemical, and clinical characterization of patients from northern Portugal

We report the study of 16 catholic type 1 Gaucher disease patients originating from a well-defined region in the north of Portugal where a relatively high incidence is observed. The patients were screened for mutations: 3060G-->A, 5841A-->G, 5976C-->G, and 6433T-->C, which enabled the identification of 27 of the 32 mutated alleles. Four different genotypes were identified, namely 5841G/6433C (n = 6), 5841G/5841G (n = 5), 5841G/? (n = 4), and 6433C/? (n = 1). All but one of the patients carried at least one 5841G mutated allele, making its frequency 62.5%, which is similar to that described for Ashkenazi Jewish patients. The 5841G homozygotes presented an overall milder clinical profile, whereas no clear genotype/phenotype correlation could be established for heterozygous patients. On the basis of residual glucocerebrosidase activity, no distinction could be made between 5841G homozygotes and 5841G/6433C compound heterozygotes. Patients that had at least one 5841G allele (encoding the Ser 370 mutated enzyme) all presented a cell-type-specific residual glucocerebrosidase activity as well as an increased molecular activity when measured in the presence of the physiological activators.

[Inadequate demand in a pediatric hospital emergency department: factors involved]

BACKGROUND

The massification of pediatric hospital emergency departments (PED) is due to bad use of the same by a large number of users. The causes related with this inadequate use have not been properly evaluated.

METHODS

A sample representative of the population demanding medical care in a PED of a regional hospital was studied with the motives and sociodemographic and cultural factors presumably related with this inadequate demand being analyzed.

RESULTS

52% of the cases had had no previous contact with the primary level of health care and 79% had gone to the PED on their own initiative. With regard to consultations, 65.0 +/- 4.8% were catalogued as inadequate and a statistical relation was found with the age of the patient (less than one year), place of residence (urban) and the arrival by initiative of the patients themselves.

CONCLUSIONS

Pediatric hospital emergency departments receive a high number of inadequate consultations at the second level of health care. The importance of the age of the patient, accessibility of pediatric hospital emergency departments and who takes the initiative to come must be emphasized as predictive variables of the bad use of these pediatric departments.

Reliability of the measurement of postprandial thermogenesis in men of three levels of body fatness

To determine the reliability of the measurement of postprandial thermogenesis by indirect calorimetry and to clarify further the relationship of obesity to thermogenesis in men, the thermic effect of a 720-kcal, mixed liquid meal was compared in 13 lean men (mean +/- SEM, 11.2% +/- 1.4% body fat), 10 average men (22.4% +/- 1.6% body fat), and 12 obese men (33.4% +/- 1.6% body fat) on two occasions. Resting metabolic rate (RMR) was measured for 3 hours: (1) in the fasted state, and (2) after a 720-kcal mixed liquid meal, on two occasions. The thermic effect of the meal, calculated as the postprandial energy expenditure minus the fasting RMR (kcal/3h), was greater for the lean and average men than for the obese men during both trials (P less than .001), but was only marginally different between the lean and average groups (P = .16). The mean values for the two trials were similar and the measurement of thermogenesis was highly reproducible with a reliability coefficient of r = .932 (P less than .001). Across all groups, thermogenesis correlated strongly with percent body fat (r = -.64, P less than .01), but within the average men, thermogenesis was uncorrelated with percent body fat (r = .09) but highly correlated with the glucose response to the meal (r = -.75, P less than .05). Thus, factors other than body fatness, such as insulin sensitivity, may determine thermogenesis within this heterogeneous middle group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Multidisciplinary experience in the approach to the hypertensive patient]

PURPOSE

To evaluate the impact of the educational activities on the approach of patients with hypertension, with an interdisciplinary team.

METHODS

Fifty patients divided into two groups: A) with 25 patients who participated in educational activities in the Hypertension League (HL) and B) who were also registered and did not take part in the activities. They were studied regarding blood pressure (BP), weight control, smoking habits, alcoholic beverage consumption, physical activities and frequency of medical care.

RESULTS

There was a drop in BP of 84% of the patients in group A and 88% in group B, a drop in weight in 60% of group A and 44% of group B. We registered the presence of 4% of smokers in group A and 16% in group B. Physical activities were regular in 56% of group A and 36% in group B. Absenteeism to meetings was slightly higher among group B (44%) when compared with group A (30%).

CONCLUSION

In spite of not having observed any significant differences between both approaches, regarding to strict BP control, we were able to observe a noticeable advantage in favor of the educational approach to the group, with participation of interdisciplinary team.

Indirect sonographic guidance for epidural anesthesia in obese pregnant patients

BACKGROUND AND OBJECTIVES

Obesity and edema frequently obscure anatomic landmarks and result in technical difficulties during epidural anesthesia administration. However, the method of indirect sonographic guidance permits identification of the midline by sagittal scan of the laminae of lumbar vertebrae 2, 3, and 4.

METHODS

Thirty-six obese women scheduled for elective repeat cesarean delivery were prospectively studied. Use of a 5-MHz transducer positioned with the transducer center site over the second or third interspace allowed measurement of skin-to-lamina distance by the electronic calipers of a Toshiba SAL-32B or RT 3000 GE machine, prediction of needle depth for epidural puncture (EP), and skin marking of the site. After the transducer was removed, a 9.5- or 11.4-cm Tuohy needle was percutaneously advanced perpendicularly from the site until EP was achieved.

RESULTS

Needle depth was measured by marker and measure, and epidural anesthesia was successfully administered to all patients. Simple linear regression analysis was performed with strong positive results. Indirect and continuous sonographic guidance studies designed to determine whether sonography reduces complications are planned.

Modified enucleation via lateral orbitotomy for choroidal melanoma with orbital extension: a report of two cases

We report two cases of choroidal melanoma with massive orbital extension that were managed by modified enucleation by way of a lateral orbitotomy. In both cases, the orbital component of the tumor was removed intact along with the globe. This approach allows placement of an orbital implant and avoids the long healing process associated with orbital exenteration.

Linkage disequilibrium between phenylketonuria and RFLP haplotype 1 at the phenylalanine hydroxylase locus in Portugal

RFLPs of 36 normal and 41 mutant alleles at the phenylalanine hydroxylase locus were determined in 31 Portuguese kindreds. A total of 14 haplotypes including 10 normal and 7 mutant alleles were observed. Almost 75% of all mutant alleles were confined within only two haplotypes, namely haplotype 9 (17.1%) and haplotype 1 (56.1%). This frequency of mutant haplotype 1 in Portugal is, to our knowledge, the highest for this mutant haplotype in all studies reported to date. Other mutant haplotypes were either rare (haplotype 2, 9.7%) or totally absent (haplotype 3, 0%). Only 24.5% of all mutant alleles were found to consistently carry identified mutations, particularly R261Q (9.8%), R252W (3.3%), R408W (1.6%) and delta I94 (3.3%). A new mutation, L249F, located in the seventh exon of the gene, accounted for 6.5% of all mutant alleles in our series. Interestingly, this mutant genotype was consistently associated with mutant haplotype 1 (P less than 0.01), as also observed for the R261Q mutation. It appears, therefore, that mutant haplotype 1 is genotypically heterogeneous in Portugal and that more than two mutations account for its prevalence in this country.

Birthweight, early passive respiratory system mechanics, and ventilator requirements as predictors of outcome in premature infants with respiratory failure

Early respiratory mechanics have been reported to predict outcome in newborns with respiratory failure. However, it remains unknown whether measurements of pulmonary function add significantly to the predictive value of more readily available variables The present study was designed to answer this question. Passive respiratory system mechanics were measured by an airway occlusion technique in 104 ventilator-dependent premature infants between 6 and 48 hours of life and corrected for infant size. A ventilation index [FiO2 x mean airway pressure (MAP)] was calculated at the time of pulmonary function testing. Poor outcome was defined as death from respiratory failure or need for supplemental oxygen at 28 days. Stepwise logistic function regression examined whether ventilation index and respiratory mechanics added predictive power over and above birthweight. Five infants died, and 45 patients required supplemental oxygen at 28 days. Birthweight was a strong predictor and would have entered the logistic model first in any case. Ventilation index added significantly to the predictive model (P = 0.038). Respiratory system conductance (P = 0.15) and compliance (P = 0.93) entered on the third and last step, respectively. We conclude that in premature infants with respiratory failure, birthweight is a strong predictor of outcome. Early ventilator requirements but not respiratory system mechanics, add significantly to this predictive model.

Respiratory response and pharmacokinetics of intravenous salbutamol in infants with bronchopulmonary dysplasia

The effects of iv salbutamol on respiratory mechanics were studied in six infants with bronchopulmonary dysplasia. Salbutamol was infused at a dose of 30 micrograms/kg over 30 min in five infants; a sixth infant received 66.7 micrograms/kg over 4 min. Salbutamol caused improvement in total respiratory system compliance and in airflow resistance. There was no correlation between salbutamol serum concentration and pulmonary function. Elimination half-time appears to be dictated in these infants more by the distribution volume (Vd) than by clearance (Cl). The area under concentration-time curve of salbutamol correlated inversely to the change in heart rate (HR). There was a significant positive correlation between Vd and percent HR change. These data provide evidence that preterm infants have measurable activity of bronchiolar beta 2 receptor responsive to salbutamol.

Central responses to cholinergic drugs of REM sleep deprived rats

The present work studied the effects of REM sleep deprivation on the responses to cholinomimetic drugs in rats. Cataleptic behavior induced by pilocarpine, oxotremorine and eserine was not modified by previous REM sleep deprivation. On the other hand, the intensity of oxotremorine- and eserine-induced tremors, but not that of pilocarpine, was clearly augmented in the REMd rats and latency to the first tremor was shorter. REM sleep deprivation also potentiated the convulsions induced by nicotine. Two hypothetical mechanisms through which REM sleep deprivation could lead to the described hyperresponsiveness to cholinomimetic drugs are discussed.

Red lacrimal secretion (chromodacryorrhea) induced by cholinergic drugs in rats subjected to the watertank technique

Red tears (chromodacryorrhea) in rats are due to porphyrin pigments secreted by Harder's glands and are believed to involve muscarinic mechanisms. Chromodacryorrhea was observed in rats treated with pilocarpine, oxotremorine and neostigmine and this response was blocked by anticholinergic drugs. However, in rats deprived of rapid eye movement (REM) sleep (REMd) for 3 days, through the watertank technique, chromodacryorrhea did not develop even when cholinergic agonists were given in doses severalfold higher than those active in non-REMd animals. Decrease of chromodacryorrhea also was obtained in rats previously treated with neostigmine; conversely, previous treatment with atropine induced an increased chromodacryorrhea when the rats were further challenged with pilocarpine and oxotremorine. It is proposed that the absence of red tears in REMd rats might be due to a down regulation of peripheral cholinergic receptors.

Gamete intrafallopian transfer (GIFT): use of minilaparotomy and an individualized regimen of induction of follicular development

The performance of the gamete intrafallopian transfer (GIFT) technique, utilizing an individualized regimen of follicular induction and minilaparotomy in 45 patients with infertility of varying etiologies is reported. The induction regimen consisted of the administration of clomiphene citrate, 100 mg, from day 3 to day 7, and 150 IU FSH/LH (human menopausal gonadotropin [hMG]) from day 6 on. Human chorionic gonadotropin (hCG; 10,000 IU) was administered when at least two follicles measured 16 mm or more in diameter and when serum estradiol (E2) measurement revealed levels of 350 pg/ml per each main follicle. Up to two oocytes and 100,000 motile sperm were transferred to the fallopian tubes via the fimbria, using a catheter. Of the 45 cases, 13 became pregnant by clinical criteria (29 per cent). Of these 13 pregnancies, nine continued to term (69 per cent), three miscarried spontaneously (12 per cent) and one was an ectopic (7 per cent). Of the nine pregnancies that continued to term, five (55 per cent) were twins. Details of the GIFT procedure as well the preliminary non-human primate research studies that led to the development of the GIFT technique are discussed. It is concluded that GIFT is an excellent alternative to in vitro fertilization and embryo transfer (IVF; ET) in all cases of infertility that failed to conceive using conventional forms of therapy and in which the female partner presents at least one normal fallopian tube.

Serotonin receptor activation in rats previously deprived of REM sleep

The effects of serotonin precursors (L-5-hydroxytryptophan and L-tryptophan, with or without MAO inhibitors) and of agonists (quipazine and 5-methoxy-N,N-dimethyltryptamine-MeO-DMT) were studied in 3 day REM-deprived or control rats, by recording the presence of the serotonin syndrome and the number of head shakes. The REM sleep-deprived rats showed a larger incidence of the serotonin syndrome and a greater number of head shakes in comparison to the control animals, when challenged with the serotonin precursors. Conversely, REM sleep deprivation did not modify the responsiveness of rats to 0.75-6.0 mg/kg of MeO-DMT and to 2.4-6.0 mg/kg of quipazine. However, REM-deprived rats reacted less than controls to 0.3-1.25 mg/kg of quipazine. Increased turnover due to REM sleep deprivation could explain the augmented responsiveness of the rats to the serotonin precursors. Conversely, the decreased responsiveness to quipazine could result from receptor hyposensitivity due to intense receptor activation, caused by the increased turnover, during the 3 day period of REM sleep deprivation.

Photoacoustic effect in solids: influence of heat loss

The effects of taking into account the heat loss on the production of the photoacoustic signal are presented. A comparison with the previous results is also made.