A new therapeutic approach to the fetus with congenital complete heart block: preemptive, targeted therapy with dexamethasone

BACKGROUND

Therapy of established congenital complete heart block in the fetus has resulted in improved survival but persistence of heart block. This exposes the infant to the morbidity of heart block, including the risk of sudden death and pacemaker implantation.

CASE

A 35-year-old gravida 2, para 1, with Sjogren syndrome and a previous pregnancy complicated by congenital complete heart block presented during her second pregnancy. Intensive fetal monitoring with echocardiography was employed. Early evidence of myocardial dysfunction and dysrhythmia was found, dexamethasone therapy was initiated, and the dysfunction and dysrhythmia resolved. The pregnancy went to term without further complication.

CONCLUSION

This represents a new and successful strategy to identify very early signs of myocardial disease in a fetus at high risk of congenital complete heart block, enabling targeted, preemptive therapy.

PSA immunoreactivity in a parotid oncocytoma: a diagnostic pitfall in discriminating primary parotid neoplasms from metastatic prostate cancer

Prostate-specific antigen (PSA) is secreted by both normal and neoplastic acinar cells of the prostate gland, and the immunohistochemical detection of PSA is widely accepted as an excellent method for confirming the prostatic origin of metastatic tumor implants in men with prostate cancer. Less recognized is the observation that certain nonprostatic tissues and their neoplastic counterparts also secrete PSA. As one example, salivary gland ducts and certain salivary gland neoplasms have been reported to be immunoreactive for PSA. Potentially, this nonspecificity could be a diagnostic pitfall when using immunoperoxidase on fine-needle aspiration (FNA) biopsy specimens to differentiate metastatic prostate cancer from primary salivary gland tumors. We report on a case where strong PSA immunoreactivity of a parotid oncocytoma led to its confusion with metastatic prostate cancer.

Irreversible binding of poly(ADP)ribose polymerase cleavage product to DNA ends revealed by atomic force microscopy: possible role in apoptosis

During apoptosis, DNA undergoes fragmentation and caspase-3 cleaves poly(ADP-ribose) polymerase (PARP) into both a 24-kDa fragment containing the DNA binding domain and an 89-kDa fragment containing the catalytic and automodification domains. Atomic force microscopy revealed that recombinant full-length PARP bound to plasmid DNA fragments and linked them into chainlike structures. Automodification of PARP in the presence of NAD+ resulted in its dissociation from the DNA fragments, which, nevertheless, remained physically aligned. A recombinant 28-kDa fragment of PARP containing the DNA binding domain but lacking the automodification domain irreversibly bound to and linked DNA fragments in the absence or presence of NAD+. Identical results were obtained on incubation of internucleosomal DNA fragments from apoptotic cells with the products of cleavage of recombinant PARP by purified caspase-3. The 24-kDa product of PARP cleavage by caspase-3 may contribute to the irreversibility of apoptosis by blocking the access of DNA repair enzymes to DNA strand breaks.

Transposed basilic vein versus polytetrafluorethylene for brachial-axillary arteriovenous fistulas

BACKGROUND

Both transposed basilic vein (BV) and polytetrafluorethylene (PTFE) upper arm arteriovenous fistulas (AVF) are common angioaccess operations. To evaluate the patency and complication rates after AVF, a concurrent series of patients was reviewed.

METHODS

Ninety-eight patients underwent brachial artery to axillary vein AVF: 30 BV and 68 PTFE. The PTFE grafts were performed in the standard fashion, whereas the basilic veins were translocated subcutaneously to the brachial artery.

RESULTS

Risk factors were similar between the two groups. Basilic vein AVF had better patency at 24 months (70% BV versus 46% PTFE, P = 0.023). The dialysis access complications were higher in the BV group (20%) versus PTFE (5%), but the PTFE group had a higher infection rate (10%) than BV (0%).

CONCLUSIONS

The primary and secondary patency rates were superior in the BV AVFs. The BV AVF preserves the venous outflow tract after AVF thrombosis for a future PTFE AVF operation.

Thoracoscopic microsurgical excision of herniated thoracic discs

OBJECT

The authors began using thoracoscopy to treat pathological conditions of the spine in 1992. In this study they delineate their clinical experience in which this procedure was used to resect herniated thoracic discs.

METHODS

Fifty-five patients underwent thoracoscopy for the resection of herniated thoracic discs. Thirty-six patients presented with myelopathies and 19 with incapacitating thoracic radicular pain. Forty-three patients underwent a single-level, 11 a two-level, and one a three-level discectomy. The mean operative time for thoracoscopic microdiscectomy was 3 hours and 25 minutes (range 80-542 minutes) and the mean blood loss was 327 ml (range 124-1500 ml). Compared with thoracotomy, which was performed in 18 patients, thoracoscopy was associated with a mean of 1 hour less operative time and less than one-half of the blood loss, duration of chest tube drainage, usage of pain medication, and length of hospitalization. Compared with costotransversectomy, which was performed in 15 patients, thoracoscopy permitted more complete resection of calcified and midline thoracic discs because it provided a direct view of the entire anterior surface of the dura. Thoracotomy was associated with a significantly greater incidence of prolonged, disabling intercostal neuralgia compared with the mild transient episodes of intercostal neuralgia associated with thoracoscopy (50% compared with 16%). Thoracotomy also was associated with a significantly higher incidence of postoperative atelectasis and pulmonary dysfunction than thoracoscopy (33% compared with 7%). Clinical and neurological outcomes were excellent (mean follow-up period 15 months). Among the 36 myelopathic patients, 22 completely recovered neurologically; five improved functionally but had some residual myelopathic symptoms; and nine stabilized. Among the 19 patients with isolated thoracic radiculopathies, 15 recovered completely and four improved moderately; no patient had worsened radicular pain.

CONCLUSIONS

Thoracoscopic microdiscectomy is a reliable surgical technique that can be performed safely with excellent clinical and neurological results.

Australian and South African undergraduates' HIV-related knowledge, attitudes, and behaviors

To understand safe sex behavior in two countries which have been differentially affected by the HIV/AIDS epidemic, the present study compared the AIDS-related knowledge, attitudes, and behaviors of 920 heterosexual undergraduate students in Australia and 228 heterosexual undergraduate students in South Africa. South African students were found to have significantly less knowledge about HIV/AIDS, and significantly less favorable attitudes toward safe sex behavior than their Australian counterparts. They were also more likely to report that they have avoided various groups of people for fear of contracting AIDS. Experience from Australia over the period 1986-1995 suggests that significant improvements in the AIDS-related knowledge, attitudes, and behaviors of South African undergraduates are achievable.

Northern blot identification of mRNA containing sequence for protein allergen, Alt a1, in eight strains of Alternaria alternata

BACKGROUND

Concentrations of Alt a1, a major allergen from Alternaria alternata extracts, exhibit significant batch-to-batch variability. This variability may result from basic strain-related genetic differences or from environmental influences such as growth conditions or extraction methods.

OBJECTIVE

The objective of this work is to determine if strain-to-strain allergen variability in Alternaria alternata, Alt a1 allergen occurs at the nucleic acid level.

METHODS

We compared the content of mRNA for a segment known to contain sequence coding for the reported N-termini of this allergen in eight strains of Alternaria obtained from three individual sources grown under identical conditions. RNA was extracted from rapidly growing mycelia and analyzed by northern blot analysis for the content of a specific segment containing sequence for the Alt a1 allergen. Blots were also analyzed for the content of a specific 5.8S rRNA segment.

RESULTS

The size of the mRNA for this protein was about 700 bases. Sequence for the specific segment was found in all of the eight strains tested. When normalized for extraction variabilities using the content of 5.8S rRNA, the calculated concentrations of Alt a1 mRNA of seven of the eight strains were similar.

CONCLUSIONS

The results of these experiments suggest that this Alt a1 related allergen sequence is found in many strains of Alternaria and that variabilities in allergen protein content noted previously result from posttranslational events.

Assessing outcomes, costs, and benefits of emerging technology for minimally invasive saphenous vein in situ distal arterial bypasses

BACKGROUND

Instrumentation for a minimally invasive angioscopic in situ peripheral arterial bypass (MIAB) with catheter-directed side-branch occlusion has recently been approved for use. Despite the attractiveness of this approach (2 short incisions), benefits such as lower morbidity and shorter hospitalizations remain undocumented. To justify wide acceptance, minimally invasive surgical techniques must match conventional procedures in durability and cost while enhancing patient comfort. Often such comparisons are difficult during the implementation phase of a new procedure.

OBJECTIVE

To compare the outcomes of the MIAB procedures with a concurrent group of patients undergoing conventional in situ bypass procedures.

DESIGN

Retrospective review.

SETTING

University medical center.

PATIENT

The first 20 consecutive MIAB procedures in 19 patients performed between August 1, 1995, and July 31, 1997, were compared with 19 contemporaneous consecutive conventional in situ bypass procedures performed at the same institution.

MAIN OUTCOME MEASURES

Operative time, postoperative length of stay, hospital costs, complications, primary assisted and secondary patency, limb salvage, and survival.

RESULTS

The patient groups were comparable with respect to age, sex, incidence of smoking, coronary artery disease, hypertension, diabetes, renal failure, cerebrovascular disease, indication, and distal anastomosis level. The median operative time was significantly greater for the MIAB group (6.6 hours vs 5.7 hours; P=.009), and intraoperative completion arteriography more frequently showed retained arteriovenous fistulas in the MIAB group (55% vs 21%; P=.05). The median postoperative length of stay and total cost were 6.5 days and $18,000 for the MIAB group and 8 days and $27,800 for the conventional group (P > or = .05). There were no significant differences in major complications (10% in the MIAB group vs 11% in the conventional group), wound complications (10% vs 11%, respectively), primary assisted patency at 1 year (68%+/-11% vs 78%+/-10%, respectively), secondary patency at 1 year (79%+/-10% vs 88%+/-8%, respectively), limb salvage at 1 year (85%+/-10% vs 94%+/-6%, respectively), or patient survival at 1 year (89%+/-8% vs 61%+/-13%, respectively).

CONCLUSION

Patients undergoing the MIAB procedure avoided lengthy vein exposure incisions without sacrificing short-term results. There was a trend toward decreased hospital stay and cost, which may be further realized as the clinical experience broadens. Although longer follow-up and larger cohorts will always be required to define durability, immediate access to outcomes and costs on small numbers of patients facilitates the early assessment of emerging technology.

Iliofemoral venous thrombosis caused by compression of an internal iliac artery aneurysm: a minimally invasive treatment

PURPOSE

To report the success of a minimally invasive treatment for phlegmasia cerulea dolens without gangrene caused by compression from an internal iliac artery aneurysm.

METHODS AND RESULTS

An 81-year-old male with a 1-month history of paralysis owing to a hemorrhagic stroke presented with massive edema and skin mottling of the right lower extremity. Imaging confirmed right iliofemoral deep vein thrombosis caused by compression from a 4-cm internal iliac artery aneurysm. With thrombolysis ruled out, a minimally invasive treatment plan was undertaken, featuring percutaneous coil embolization of the aneurysm and surgical venous thrombectomy with proximal arteriovenous fistula creation and iliac vein stent placement. Failure of the coils to embolize the iliac aneurysm prompted the use of an endovascular graft to exclude the aneurysm. The patient's symptoms subsided, and he has a patent right iliofemoral venous system and internal iliac artery at his latest (16-month) follow-up.

CONCLUSIONS

This case demonstrates that minimally invasive endovascular and open techniques can be combined to achieve an optimum outcome in patients at high risk for standard surgical approaches.

The valvular apparatus in venous insufficiency: a problem of quantity?

Abnormal venous valvular function may produce venous reflux and venous insufficiency. While valvular agenesis is a known, but rare cause of venous insufficiency. While valvular agenesis is a known, but rare cause of venous insufficiency, little work has been done on the relative number of greater saphenous vein (GSV) valves in patients with venous insufficiency. This study investigates whether the GSV in patients with symptomatic venous insufficiency has fewer valves than the GSV of patients without venous insufficiency. The number of GSV valves in patients (n = 51) with symptomatic venous insufficiency undergoing saphenectomy (VI) were compared with the number of GSV valves in patients (n = 26) without venous insufficiency undergoing in situ GSV bypass under angioscopic surveillance who served as a control group. The two groups differed, as expected, in age and sex distribution. The VI group had a mean of 25.7 +/- 11.0 centimeters of GSV between valves, while the control group had 19.0 +/- 9.7 centimeters of GSV between valves (F = 6.99; p = 0.01). The mean number of valves in the saphenous veins of the two groups also differed significantly: VI = 2.3 +/- 0.83 versus control (CTRL) = 4.8 +/- 2.01 (F = 61.86; p < 0.0001). That properly functioning valve leaflets help maintain physiologic antegrade venous flow is indisputable. This study, however, suggests that the relative lack of valves may be related to the development of venous insufficiency. This report documents that patients with symptomatic reflux in the GSV have significantly fewer valves than patients with apparently normal functioning saphenous veins.

Autoradiographic thyroid evaluation in short-term experimental diabetes mellitus

Previous studies have shown that in vitro thyroid peroxidase (TPO) iodide oxidation activity is decreased and thyroid T4-5'-deiodinase activity is increased 15 days after induction of experimental diabetes mellitus (DM). In the present study we used thyroid histoautoradiography, an indirect assay of in vivo TPO activity, to determine the possible parallelism between the in vitro and in vivo changes induced by experimental DM. DM was induced in male Wistar rats (about 250 g body weight) by a single i.p. streptozotocin injection (45 mg/kg), while control (C) animals received a single injection of the vehicle. Seven and 30 days after diabetes induction, each diabetic and control animal was given i.p. a tracer dose of 125I (2 microCi), 2.5 h before thyroid excision. The glands were counted, weighted, fixed in Bouin's solution, embedded in paraffin and cut. The sections were stained with HE and exposed to NTB-2 emulsion (Kodak). The autohistograms were developed and the quantitative distribution of silver grains was evaluated with a computerized image analyzer system. Thyroid radioiodine uptake was significantly decreased only after 30 days of DM (C: 0.38 +/- 0.05 vs DM: 0.20 +/- 0.04%/mg thyroid, P < 0.05) while in vivo TPO activity was significantly decreased 7 and 30 days after DM induction (C: 5.3 and 4.5 grains/100 micron 2 vs DM: 2.9 and 1.6 grains/100 micron 2, respectively, P < 0.05). These data suggest that insulin deficiency first reduces in vivo TPO activity during short-term experimental diabetes mellitus.

Safe sex or safe love: competing discourses?

The way in which sex may be constructed as safe through its relationship with 'love' is the concern of this study. Interviews with 112 heterosexual women and men from discos and bars in Melbourne, Australia, catering to single adults revealed the pervasive construction of sex within the discourses of 'love' and 'romance'. The relationship of these discourses to unsafe practices is discussed and the article presents an analysis of the normative function of the sex-as-love/sex-as-desire opposition in terms of safe sex and HIV/AIDS prevention. We conclude that health messages which emphasize that 'sex is unsafe' may be counterproductive. We illustrate how women and some men construct casual sex as a strategy for obtaining the possibility of 'love'. For these women and men, 'safe sex' as 'unprotected sex' is viewed as a strategy for maximizing the possibility that the casual encounter will result in a longer term relationship. On the other hand, 'unsafe sex' as 'unprotected sex' is viewed as a strategy that is more likely to interrupt the construction of romance in the causal encounter thus risking the possibility of love as the desired outcome.

Popliteal artery aneurysm treated with a minimally invasive endovascular approach: an initial report

PURPOSE

To report a minimally invasive approach to popliteal artery aneurysm (PAA) treatment.

METHODS AND RESULTS

A 48-year-old male with a 3-cm PAA was treated electively with an endovascular in situ saphenous vein bypass and transluminal antegrade coil embolization of the PAA prior to completion of the proximal anastomosis. Two short incisions at the anastomosis sites resulted in no wound complications, and the patient was discharged after 2 days. After 14 months of follow-up, the patient is asymptomatic with continued patency of the in situ bypass and occlusion of the PAA.

CONCLUSIONS

This endovascular approach for minimally invasive femoropopliteal in situ saphenous vein bypass grafting appears feasible for treatment of PAAs. This method may reduce the rate of wound complications attending classic open in situ bypass grafts.

Diagnosis of aortocaval fistula by computed tomography

A case of an aortocaval fistula documented by contrast-enhancement computed tomography is reported. In the presence of a large abdominal aortic aneurysm, the computed tomography (CT) triad findings of: (1) vena caval effacement, (2) loss of the fat plane between the aorta and vena cava, and (3) rapid flow of contrast from the aorta into a dilated inferior vena cava is characteristic of an aortocaval fistula.

Traumatic carotid artery dissection and pseudoaneurysm treated with endovascular coils and stent

PURPOSE

To report a case of post-traumatic internal carotid artery dissection and pseudoaneurysm formation at the C-1 level successfully treated by a percutaneous endovascular technique.

METHODS AND RESULTS

A 20-year-old female presented 72 hours after a motor vehicle accident with incomplete occulosympathetic paresis (Horner's syndrome), carotidynia, and leftsided 1.5-cm x 2.5-cm pseudoaneurysm at the C-1 level. Neuroradiologists embolized the pseudoaneurysm with Guglielmi detachable coils and controlled the dissection with placement of a Wallstent.

CONCLUSIONS

This report illustrates successful percutaneous endovascular treatment of a carotid dissection and pseudoaneurysm near the base of the skull.

Topical undecylenic acid for herpes simplex labialis: a multicenter, placebo-controlled trial

A multicenter, patient-initiated, double-blind, placebo-controlled trial of 15% undecylenic acid cream was conducted with 573 patients with recurrent herpes labialis. Treatment was applied 5 or 6 times daily until crusting and then thrice daily until healing. Patients were assessed daily until 48 h after crusting and then every other day until healing. Undecylenic acid significantly reduced the incidence and duration of viral shedding and the duration and severity of itching but did not increase abortive episodes or reduce times to healing, crusting, or progression of lesion size. When treatment was initiated during the prodrome, the time to crusting was reduced (P = .02) and the area under the symptom-time curve for pain and tenderness was reduced, approaching statistical significance (P = .06). Active treatment was well tolerated but caused dysgeusia and local irritation. Undecylenic acid 15% cream reduces viral shedding in recurrent herpes labialis, but clinical benefits are minimal and largely restricted to patients initiating therapy during the prodrome.

Thyroid hormone induces protein secretion and morphological changes in astroglial cells with an increase in expression of glial fibrillary acidic protein

Thyroid hormone (T3) induces in vitro differentiation of astrocytes from the developing rat brain. T3 treatment induced the appearance of long processes in cultured cerebral hemisphere and mesencephalon astrocytes from embryonic and newborn rats. T3 treatment also produced a change in the morphology of cultured cerebellar astrocytes from 10-day-old rats, but not in cerebellar astrocytes from newborn rats. An increased expression of glial fibrillary acidic protein (GFAP) was also seen in the T3-treated newborn cerebral hemisphere and mesencephalic astrocytes. The morphological changes were induced earlier when the astrocytes were treated with conditioned medium (CM) obtained from cultures previously exposed to T3. Our results show that astrocytes from the developing rat brain are not homogeneous in their responsiveness to T3. Furthermore, the fact that CM produces a response similar to that obtained with T3 treatment but in less time, suggests that T3 might induce the secretion of factors by cultured astrocytes. These factors might, by an autocrine/paracrine effect, induce the expression of GFAP and differentiation in developing brain astrocytes.

Angioscopy in vascular surgery

The role of intraoperative angioscopy continues to evolve. To better define the role of angioscopy in vascular surgery, a review of the recent literature was performed. The most well-established indication for angioscopy is preparation of the saphenous vein for in situ bypass; however, angioscopy has also been demonstrated to be useful in the assessment of carotid endarterectomy, femoral vein valve repair, thromboembolectomy, and may be beneficial during endovascular stent grafting. Angioscopy is now a valuable adjunct in the management of the patient with peripheral vascular disease.

Sex, alcohol and drugs? Young people's experience of Schoolies Week

The 'Schoolies Week' phenomenon attracts more than 10,000 school leavers to Surfers Paradise in November and December each year. In a survey of these young people (N = 1796), from Queensland, New South Wales (NSW), and Victoria, about two-thirds of the young men and one-third of the young women expected to have sexual intercourse while in Surfers Paradise. Of these, about 80 per cent expected to use condoms. Most expected to be drunk most nights or every night of their holidays and 27 per cent of young men and 17 per cent of young women expected to be 'stoned' most nights or every night. Most young men and a significant proportion of young women achieved these expectations, with respondents from NSW and Victoria being more likely to do so than Queensland residents. Over one-third of the sample had engaged in sexual intercourse prior to interview, and of these, two-thirds of young men and over half the young women always used condoms with casual partners. The rates for sexual intercourse with regular partners were slightly lower. Those who were inconsistent condom users on holiday were likely to have a history of inconsistent condom use and to have multiple casual partners and/or regular partners in addition to casual partners. It is recommended that the NSW and Victorian governments accept some responsibility for the behaviour of young people attending Schoolies Week. A coordinated intervention strategy is required because there are significant prior indicators of young people's risk practices in Surfers Paradise during Schoolies Week.