Prevalence and etiology of respiratory distress in infants of diabetic mothers: predictive value of fetal lung maturation tests

The purpose of this study was to investigate the prevalence of respiratory distress syndrome attributable to surfactant deficiency in infants of diabetic mothers tested for fetal lung maturation. Three tests were assessed: (1) lecithin/sphingomyelin ratio, (2) phosphatidylglycerol concentration, and (3) optical density at 650 nm. From January 1987 through June 1989, 526 diabetic gestations were delivered within 5 days of fetal lung maturation testing. Surfactant-deficient respiratory distress syndrome was present in five infants (0.95%); all were less than 34 weeks' gestational age. Other causes of respiratory distress were transient tachypnea of the newborn (n = 5), hypertrophic cardiomyopathy (n = 4), pneumonia (n = 2), polycythemia (n = 1), and meconium aspiration syndrome (n = 1). The use of standard maturity values of lecithin/sphingomyelin ratio greater than or equal to 2.0, phosphatidylglycerol greater than 2% to 5%, and optical density at 650 nm greater than or equal to 0.150 were evaluated. Each test had a 100% sensitivity in identifying surfactant-deficient respiratory distress syndrome and a 100% negative predictive value in identifying the absence of disease. All three tests had a low positive predictive value: 15% for lecithin/sphingomyelin ratio, 9% for phosphatidylglycerol, and 3% for optical density at 650 nm. We concluded that most cases of respiratory distress in the infants of diabetic mothers were unrelated to surfactant deficiency. The standard maturity values used in fetal lung maturation tests were valid in the diabetic gestation. The optical density at 650 nm was useful as a first-line test to predict the absence of surfactant-deficient respiratory distress syndrome.

Normalization of the altered liver function tests after islet transplantation in diabetic rats

The purpose of our study was to determine if streptozotocin induced diabetes (SID) in rats produces alterations in hepatic function, as described in poorly controlled diabetic patients, and if islet transplantation (islet-Tx) would subsequently ameliorate this status. Hepatocellular dysfunction was evaluated by the aspartate aminotransferase (SGOT) and the alanine aminotransferase (SGPT) activities in plasma. For the evaluation of cholestasis the plasma alkaline phosphatase (APase) activity was used. These determinations were performed in normal, SID, SID with Islet-Tx, and SID Wistar rats with sham-Tx. Also, glucose was measured in plasma samples, as well as histological studies of the liver were performed. More than 1,000 isogeneic islets (islet-Tx group) or non viable insular tissue (sham-Tx group) were transplanted via mesenteric ileal vein three weeks after SID. The results showed that SID in rats produces alterations in the hepatic function as well as in the structure of the hepatocytes, and the normalization of carbohydrate metabolism by islet transplantation restores normal hepatic function and morphology.

Metals and the liver in Alzheimer's disease. An investigation of hepatic zinc, copper, cadmium, and metallothionein

Significant alterations of tissue metal levels have been reported in Alzheimer's disease (AD). Because the liver is intimately involved in metabolism and storage of metals, it may provide a useful site for study of these metals in AD. This study compares livers in AD and controls in their concentrations of zinc, copper, cadmium, and metallothionein, a metal-binding protein important in regulation of metal metabolism. Liver tissue was obtained from 17 patients with AD and 17 age- and sex-matched controls within 12 hours of death and stored at -70 degrees C. Neuropathologic confirmation of diagnosis was available in all cases. Liver homogenates (20%) were used for metal analysis by atomic absorption spectroscopy after wet digestion. Cytosolic metallothionein levels were quantitated by the cadmium or silver saturation method. A significant decline in body and liver weight was found in patients with AD, with no significant change in liver protein or DNA concentration. Total hepatic cadmium (P less than .001) and zinc (P less than .030) concentrations were significantly elevated in AD. The Sephadex G75 chromatographic profile was altered in AD with reduction in zinc bound to metallothionein fractions and increased binding to high molecular weight fractions. These data suggest that the metabolism of cadmium and zinc is altered in AD.

Islet transplantation restores normal serum amylase levels in diabetic rats

Diabetes is associated with a diminution in exocrine pancreatic function. The goal of our study was to investigate whether the altered exocrine pancreatic function of streptozotocin-induced diabetic rats could be ameliorated by islet transplantation. Diabetic rats received either more than 1,000 syngeneic islets intraportally (islet transplantation group) or pancreatic, nonviable insular tissue (sham transplantation group). Plasma amylase and insulin levels in diabetic rats were significantly lower than in normal rats. The exocrine pancreas of streptozotocin-induced diabetic rats showed alterations (decrease of zymogen granules, diminution of endoplasmic reticulum, clusters of ribosomes without organization) in the structure of acinar cells at the electron microscopic level. After islet transplantation, plasma glucose levels were restored to normal values, and those of amylase and insulin gradually increased to normal values. A positive correlation between plasma levels of amylase and insulin was found. Three months after islet transplantation, the islet-transplanted rats did not show morphologic alterations of the acinar cells which were still found in the sham-transplanted rats. It is concluded that alterations of exocrine pancreas in streptozotocin-induced diabetic rats are ameliorated by islet transplantation.

MRI and diabetic foot infections

The role of magnetic resonance imaging and plain radiographs in evaluating osteomyelitis in the diabetic foot was studied. Fifty patients were prospectively examined by magnetic resonance imaging and plain radiographs to determine the extent of infection. Thirty-seven patients had positive MRI for osteomyelitis and 19 were positive with conventional radiography. Thirteen patients had negative MRI healed with short course of antibiotics. Five patients with positive MRI received four weeks' course of intravenous antibiotics with two still having persistent infection in the six weeks follow-up. Thirty-two patients underwent surgery with favorable results. Sixty-two bone specimens were obtained for histologic evaluation of osteomyelitis. In cases with histologic proof of diagnosis, magnetic resonance sensitivity was 99%, specificity was 81%, and accuracy was 94%. Thus magnetic resonance imaging was shown to have a high sensitivity, specificity, and accuracy in detecting osteomyelitis.

Changes in triticale chromosome heterochromatin visualized by C-banding

The distribution and characterization of heterochromatin in a series of cultivars, parents, new amphiploids and progeny of hexaploid triticale were comparatively studied using C-banding and morphometric analysis. A high level of intervarietal polymorphism was detected for the banding pattern. The chromosome pairs 4A and 1R presented the most constant pattern of heterochromatin distribution among 31 triticale lines studied. A total of 126 bands have been catalogued, from which 28, 59, and 39 belong, respectively, to the A, B and R genomes. The ratio of polymorphic bands per genome was 23/28, 36/59, and 30/39. The chromosomes displayed heterochromatin modifications consistent in both presence–absence and relative length of their content per genome, when passed from the parents to the amphiploids. Variations in the heterochromatin were also observed among sister plants coming from crosses between wheat and triticale. The heterochromatin content showed gradual tendencies either to increase or decrease in each genome during successive self-cross generations after that cross. The existence of a systematic process of variation of heterochromatin content in triticale is assumed, and the nature of this phenomenon is discussed.Key words: triticale, tetraploid wheat, rye, C-banding, heterochromatin.

[Surgical treatment of chronic pulmonary embolism using thromboembolectomy under extracorporeal circulation and deep hypothermia--a new approach route. 3 cases]

The authors, who have successfully performed thrombectomy of the pulmonary artery under extracorporeal circulation and deep hypothermia in three patients, wish to draw attention to the principal factors of success. The decision to operate, as accepted by most surgeons, rests on the patient's functional status (stage III or IV) and on the presence of a systolic pulmonary arterial pressure exceeding 50 mmHg. Deep hypothermia combined with circulatory arrest seems to be the best method, as it improves visual control, thereby avoiding damage to the endothelium or fracture of the distal thrombi during thrombectomy. Finally, a new approach route (severing of the superior pulmonary vein, opening of the pulmonary artery and use of Volmar-Sisteron strippers) makes it possible to remove the entire thrombus, thus obtaining an almost normal pressure in the pulmonary artery. In all three patients, the complications that are mostly due to intrabronchial haemorrhage by disruption of the endothelium, fracture of the distal thrombus or pulmonary artery contusion were avoided.

Effects of inhibitors of the renin-angiotensin system on water intake after insulin administration

Male wistar rats drank in a dose-related manner, in response to 1 to 40 U/kg of i.p. insulin. Maximum intakes took place during the first 30 min after i.p. insulin administration, coinciding with the period of maximal drop of blood glucose. Plasma renin activity (PRA) in rats treated with i.p. insulin was higher than in basal conditions or after saline injection. Nephrectomy and adrenalectomy did not abolish insulin-induced drinking. A low dose of captopril (0.1 mg/kg s.c.) did not modify insulin-induced drinking, but a higher dose (10 mg/kg s.c.), or enalapril (0.5 mg/microgram s.c.), significantly increased insulin-induced drinking. Enhancement of insulin-induced drinking by s.c. captopril was not secondary to an increased diuresis. Captopril (50 micrograms i.c.v.) significantly reduced the cumulative water intake after i.p. insulin (20 U/kg i.p.) plus s.c. captopril (10 mg/kg). The blockade of central receptors for angiotensin II with sarile-AII (5 micrograms) significantly diminished insulin-induced drinking. It appears that the peripheral renin angiotensin system is not necessary for insulin-induced drinking but central angiotensin II plays an important role.

Acquired epileptic aphasia (the Landau-Kleffner syndrome) due to neurocysticercosis

A healthy 7-year-old boy developed a language disorder associated with clinical seizures and a paroxysmal EEG. Computed tomography and magnetic resonance imaging revealed a small cysticercus deep in the left Sylvian fissure. We postulate a cause and effect relationship between the parasitic cyst and the clinical manifestations supported by the strategic location of the cyst and the critical age at which this lesion developed. This case provides evidence that the syndrome of acquired epileptic aphasia may be explained in terms of an unilateral structural brain lesion.

Twice a cesarean, always a cesarean?

The cesarean delivery rate has quadrupled during the past two decades, resulting in considerable attention focused on alternatives to cesarean birth. One option, vaginal birth after one previous cesarean, has come to be recognized as an acceptable alternative to routine elective repeat cesarean delivery. The purpose of this report was to evaluate whether women with two previous cesareans can safely undergo a trial of labor. Between July 1, 1982 and June 30, 1986, data were collected prospectively on all women with previous cesareans. Those with a known classical incision or a medical or obstetric contraindication to a trial of labor were excluded from an attempted vaginal delivery. During this period, 67,784 patients were delivered, of whom 6250 (9.2%) had had a previous cesarean. Of the 6250 previous-cesarean patients, 1088 (17.4%) had had two previous cesareans; of these, 501 (46%) underwent a trial of labor and 346 (69%) delivered vaginally. Whereas the overall rate of uterine dehiscence was 3%, the rate in those women who attempted a vaginal delivery was 1.8%, versus 4.6% in those who did not. Overall, oxytocin was used in 284 (57%) and was associated with a dehiscence rate of 2.1%, versus 1.4% in the no-oxytocin group. Successful vaginal delivery was related significantly to the use of oxytocin and to a previous vaginal delivery. Trial of labor in patients with two previous cesareans appears to be a reasonable consideration.

Replacement of the transverse aortic arch during emergency operations for type A acute aortic dissection. Report of 26 cases

In type A aortic dissection, the intimal disruption is located on or extends to the transverse arch in about 20% of patients. Replacement of the arch may then be necessary to avoid leaving an unresected, acutely dissected aorta and to prevent bleeding, progression of aneurysm, rupture, and ultimately reoperation or death. From 1970 to September 1987, 119 patients were operated on for type A acute dissection. Starting in January 1977, gelatin-resorcin-formaldehyde biologic glue was used in 91 patients to reinforce the dissected tissues at the suture sites. Among these 119 patients, 26 (ages 32 to 76 years) underwent replacement of the transverse aortic arch in addition to replacement of the ascending aorta. In 20 patients cerebral protection was achieved by profound hypothermia (16 degrees to 20 degrees C) associated with circulatory arrest (15 to 40 minutes, mean 27 minutes) during the distal anastomosis. In six patients the carotid arteries were selectively perfused with cold blood (6 degrees C) during moderate core hypothermia (28 degrees C) while cardiopulmonary bypass was discontinued (19 to 34 minutes, mean 25 minutes) to allow the prosthesis to be sutured without the distal aorta being cross-clamped. Moderate hypothermia avoided the long rewarming time necessitated by profound hypothermia. The hospital mortality rate was 34% (9/26). Two of the 20 patients subjected to profound hypothermia and circulatory arrest died during the operation and seven patients died of postoperative complications. No deaths or major complication were observed in the other six patients. Follow-up of the 17 survivors ranges from 3 to 90 months (mean 39). One patient died 6 months after the operation of cerebral hemorrhage. One patient is disabled by neurologic sequelae. Fifteen patients are in good clinical condition (New York Heart Association class I or II). Postoperative aortograms in 12 patients, and computed tomographic scans in all, have shown a stable repair of the transverse arch in all survivors but a persisting dissection of the descending aorta in 11 (70%). Growing experience and improving results in emergency operations for type A aortic dissection have led us to extend the replacement of the aorta to the transverse arch whenever necessary. The gelatin-resorcin-formaldehyde glue has proved to be an efficient adjunct. The best cerebral protection was obtained in our experience by carotid perfusion with cold blood during circulatory arrest at moderate core hypothermia.

[Replacement of the ascending aorta with reimplantation of coronary vessels. Apropos of 81 cases]

Between 1973 and 1985, 81 patients underwent Bentall's operation. 90 p. 100 of the patients had cystic medionecrosis, but only 24 showed signs of Marfan's syndrome. It must be noted that 12 patients were reoperation cases, 18 were operated upon in an emergency for tamponade (stage V) on acute dissection, and 7 had lesions that involved the aortic arch. The operative procedure was that described by Bentall; Cabrol's modification was used in only 26 patients. The most recent improvements concerned myocardial and (in case of aortic involvement) cerebral protection with an autonomous perfusion of blood at very low temperature. Mortality was low in patients with annulo-aortic ectasia (1 death in 53 cases; 1.8 p. 100) and rose to 34.5 p. 100 (33.3 p. 100 in reoperation cases) in patients with chronic dissection. Evaluation of mortality by stage showed virtually no risk in stages I and II, whereas 4 of the 9 stage IV patients died within the first post-operative month. Late mortality with a mean follow-up of 4 years was 14.2 p. 100; 2 of the 10 deaths were accidental, and 4 of the remaining 8 deaths were due to the anticoagulant therapy (death was precipitated in 2 cases by the presence of a cerebral aneurysm). No case of systemic embolism was observed, and the authors raise the question of whether long-term anticoagulant therapy should be abandoned. None of the patients who underwent Bentall's operation were reoperated upon, whereas 7 out of the 23 patients who had had supracoronary aortic replacement before 1976 had been reoperated upon within a few years.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgery of aortic stenosis and lesions of the ascending aorta

Between 1978 and 1986, 442 aortic valvular replacements were performed for chronic calcified aortic stenosis. In 11 patients (2.5%, seven men and four women) replacement of the ascending aorta was associated with the valvular replacement, because of: seven supra-coronary aneurysms, two aneurysms involving the Valsalva sinuses, and two acute dissections of the ascending aorta. The repair of the ascending aorta consisted in inserting: one patch on one Valsalva sinus, seven supra coronary Dacron prostheses, three valved conduits (according to the Bentall technique). One patient died postoperatively (9%).

Vaginal birth after cesarean

Allowing a woman with a previous cesarean birth a trial of labor rather than performing an elective repeat cesarean section continues to be a controversial area in obstetrics today. In an effort to evaluate the risks associated with a trial of labor, a prospective investigation was undertaken from July 1, 1982, through June 30, 1984. During the first year of the study, patients with a known vertical scar or more than one prior cesarean birth were excluded from an attempted trial of labor. Beginning July 1, 1983, patients with two prior cesarean births were no longer excluded and were studied prospectively. During this 2-year period, 32,854 patients were delivered of their infants at the Los Angeles County/University of Southern California Medical Center. Of these patients, 2708 (8.2%) had undergone a prior cesarean birth, and 1796 women (66%) underwent a trial of labor. A total of 1465 (81%) of them achieved a vaginal delivery. Successful vaginal delivery by the number of prior cesarean sections was as follows: one, 82%; two, 72%; three, 90%. When contrasted with the group without a trial of labor, the group with a trial of labor had significantly less maternal morbidity. In a comparison of the groups with and without a trial of labor, the incidence of uterine dehiscence (1.9% versus 1.9%) and rupture (0.3% versus 0.5%) was similar. With the application of attempted vaginal delivery in our patients with a previous cesarean birth, we were able to reduce our cesarean delivery rate for this population alone by 54%. In summary, the benefits associated with a trial of labor in the patient with a prior cesarean birth far outweigh the risks. The policy of "once a cesarean section, always a cesarean section" should be abandoned.

[Clinical experience with the Saint Jude prosthesis. Results over a period of 7 years]

Between January, 1979 and December, 1985, 193 Saint Jude medical valves (SJM) were implanted in 165 patients (74 male, 91 female) aged from 14 to 78 years (mean age: 49 years). 101 patients underwent aortic valve replacement, 36 had mitral valve replacement and 21 had multiple valve replacement. Fitting with an SJM prosthesis was a primary emergency operation for 15 patients (9%) and a reoperation for 49 patients (31%). A concomitant surgical procedure was carried out in 39 patients (24%). The overall peri-operative mortality rate was 9% (15 patients), this figure falling to 5% (6/112 patients) when emergency surgery and reoperations are excluded. No patient was lost sight of. Mean follow-up was 37 +/- 3 months (range: 4 to 84 months), for a total duration of 413 years/patient. Five patients died of heart disease during the follow-up period, representing a mortality rate of 1.2% per year/patient. The actual survival rate was calculated as 90% at 1 year and 83% at 7 years. During that period 7 thromboembolic accidents occurred among 5 patients (actual rate: 1.7 accident per 100 years/patient). Two mechanical valve desinsertions requiring reoperation were recorded. Altogether, the actuarial rate of patients without any post-operative complication was 88% at 1 year and 65% at 7 years. Functional improvement was dramatic since 94% of survivors are now in class I or II, whilst 67% of patients were in class III or IV prior to surgery. It may be concluded that the mid-term

Vascular risk factors and leuko-araiosis

Leuko-araiosis was found in 49 of 140 demented patients compared with 12 out of 110 control subjects. Thirty-one of 95 patients with dementia of the Alzheimer's type had leuko-araiosis. A history of stroke was four times more frequent in patients with leuko-araiosis than in those without leuko-araiosis (17.4% and 4.4%, respectively). It occurred in 25% of controls with leuko-araiosis compared with only 2% of those without leuko-araiosis. Mean systolic blood pressure was associated with leuko-araiosis. No association was found for diastolic blood pressure, myocardial infarction, angina, diabetes, or carotid bruits. On logistic regression analysis, the strong association between dementia and leuko-araiosis was mainly explained by a history of stroke. There are common factors in leuko-araiosis and stroke, but stroke alone does not account for leuko-araiosis.

Cognitive and neurologic findings in subjects with diffuse white matter lucencies on computed tomographic scan (leuko-araiosis)

As part of a prospective clinicopathologic study, a cohort of 105 "normal" elderly volunteers was investigated with computed tomographic scans, psychometric testing (Extended Scale for Dementia [ESD]) and neurologic examination. Computed tomographic scans were evaluated for the presence or absence of white matter lucencies, termed leuko-araiosis. These are defined as patchy or diffuse areas of decreased attenuation involving only white matter and with no change in adjacent ventricles or sulci. The nine controls with leuko-araiosis had lower scores on the ESD than the 96 controls without leuko-araiosis (mean ESD with leuko-araiosis, 227.1 +/- 14; without leuko-araiosis, 237.1 +/- 8), and the difference remains significant even after adjusting for the possible confounding effects of age, sex, education, and infarct detected on computed tomography. Significant differences were also found comparing subjects with leuko-araiosis and those without in respect to abnormal gait, limb power, plantar response, and the rooting and palmomental reflexes. Leuko-araiosis may represent a marker for early dementia. The pathophysiology of this finding remains uncertain. Our results suggest that white matter abnormalities play a role in the development of intellectual impairment in the elderly.

[Aneurysm of the aortic arch. Surgical therapy. 60 cases]

Sixty patients with aortic arch aneurysm have been operated upon at the Foch Medico-Surgical Centre between 1964 and 1984. This period can be subdivided into: January, 1964 to December, 1975 (24 cases) and January, 1976 to April, 1984 (36 cases). The technique used (closure by patch or segmental replacement prosthesis) depended on the type of lesion encountered. In most cases, the cardiopulmonary bypass was between the femoral artery and the right atrium. After experimenting with different methods, we now protect the brain by selective cold blood carotid perfusion, using independent circuit and heat-exchanger. Operative mortality was 12% in series I (1964-1975) and 0% in series II (1975-1984) patients. Hospital mortality was 25% in series I and 13% in series II patients. The improvements obtained during the last few years, using cold blood carotid perfusion and circulatory arrest in the lower half of the body, have made it possible to perform open distal anastomoses. This method ensures excellent brain protection and short cardiopulmonary bypass period.

The significance of white matter lucencies on CT scan in relation to cognitive impairment

As part of a prospective clinicopathological study a cohort of "normal" elderly volunteers (n = 110) has been investigated with CT scans, psychometric testing (Extended Scale for Dementia) and neurological examination. CT scans were evaluated by a neuroradiologist for the presence or absence of white matter lucencies (WML). WML were defined as patchy or diffuse areas of decreased attenuation involving only white matter and with no change in adjacent ventricles or sulci. The 12 subjects with WML had lower scores on the ESD than the 98 subjects without WML (mean ESD with WML 229.5 +/- 14; without WML 236.7 +/- 8.6, t-test p less than .01) and the difference remains significant even after adjusting for the possible confounding effects of age (ANCOVA, P less than .043).