Rat-Bite Fever: Updated Recommendations For Culture And Isolation Of Streptobacillus Moniliformis Using An Automated Continuous Blood Culture Instrument In A Clinical Setting

Introduction/Objective

Rat-bite fever and Haverhill fever are difficult to diagnose in a clinical setting due mostly to clinicians and laboratory professionals being unable to culture the causative agent-Streptobacillus moniliformis. SPS in blood culture bottles has historically been implicated as the complicating factor.

Methods

Utilizing the BDFX40 automated continuous blood culture bottle system and novel quantitative PCR data, we present how blood volume is critical in order to consistently detect, isolate and grow the organism in the presence of SPS using modern laboratory instrumentation in a clinical setting.

Results

We demonstrate here that 10ml of blood was determined to provide optimal results for detection and growth of S. moniliformis in 0.05% SPS. For all isolates tested, 100% (n=56) were detected or alerted as positive by the instrument, with the longest time required for detection being 102 hours (n=1) and the fastest time to detection being recorded at 13.4 hours. (n=1) with an average time of 26.5 hours (n=56).

Conclusion

During the course of this study, we determined that blood inoculum volume played a significant role in organism growth and detection. We found that in 100% of the isolates tested (and all the variations of testing within), SPS (up to a concentration of 0.05% w/v) in blood culture media appeared to be counteracted, allowing for the growth detection and culturing of S. moniliformis using an automated continuous blood culture system when 10ml of blood was used as an inoculum. This is the first study to report and suggest that a specific blood volume is critical when utilizing a closed commercial blood culture system to detect S. moniliformis, this research is the largest study of Streptobacillus moniliformis isolates to date.

Haematospirillum jordaniae gen. nov., sp. nov., isolated from human blood samples

A Gram-negative, aerobic, motile, spiral-shaped bacterium, strain H5569(T), was isolated from a human blood sample. Phenotypic and molecular characteristics of the isolate were investigated. Optimal growth was found to occur at 35 °C under aerobic conditions on Heart Infusion Agar supplemented with 5 % rabbit blood. The major fatty acids present in the cells were identified as C16:0, C16:1ω7c and C18:1ω7c. The predominant respiratory quinone was found to be ubiquinone-Q10. The G+C content of genomic DNA for strain H5569(T) was found to be 49.9 %. Based on 16S rRNA gene sequence analysis results, 13 additional isolates were also analysed in this study. Phylogenetic analysis based on 16S rRNA gene sequences revealed that the organism, represented by strain H5569(T), forms a distinct lineage within the family Rhodospirillaceae, closely related to two Novispirillum itersonii subspecies (93.9-94.1 %) and two Caenispirillum sp. (91.2-91.6 %). Based on these results, the isolate H5569(T) is concluded to represent a new genus and species for which the name Haematospirillum jordaniae gen. nov., sp. nov. is proposed. The type strain is H5569(T) (=DSM(T) 28903 = CCUG 66838(T)).

Anaesthesia-Related Haemodynamic Complications in Williams Syndrome Patients: A Review of One Institution's Experience

Williams syndrome is a genetic disorder associated with cardiac pathology, including supravalvular aortic stenosis and coronary artery stenosis. Sudden cardiac death has been reported in the perioperative period and attributed to cardiovascular pathology. In this retrospective audit, case note and anaesthetic records were reviewed for all confirmed Williams syndrome patients who had received an anaesthetic in our institution between July 1974 and November 2009. There were a total of 108 anaesthetics administered in 29 patients. Twelve of the anaesthetics (11.1%) were associated with cardiac complications including cardiac arrest in two cases (1.85%). Of the two cardiac arrests, one patient died within the first 24 hours postanaesthetic and the other patient survived, giving an overall mortality of 0.9% (3.4%). We conclude that Williams syndrome confers a significant anaesthetic risk, which should be recognised and considered by clinicians planning procedures requiring general anaesthesia.

Hyaluronidase for cervical ripening and induction of labour

BACKGROUND

Dilatation and effacement of the cervix are not only a result of uterine contractions, but are also dependent upon ripening processes within the cervix. The cervix is a fibrous organ composed principally of hyaluronic acid, collagen and proteoglycan. Hyaluronic acid increases markedly after the onset of labour. An increase in the level of hyaluronic acid is associated with an increase in tissue water content. Cervical ripening during labour is characterised by changes of the cervix and an increased water content. Cervical injection of hyaluronidase was postulated to increase cervical ripening. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

OBJECTIVES

To determine the effects of hyaluronidase for third trimester cervical ripening or induction of labour in comparison with other methods of induction of labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (January 2006) and bibliographies of relevant papers.

SELECTION CRITERIA

Clinical trials of hyaluronidase for third trimester cervical ripening or labour induction.

DATA COLLECTION AND ANALYSIS

A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. We assessed trial quality. We contacted study authors for additional information. We collected adverse effects information from the trials.

MAIN RESULTS

One trial, with 168 women participating, was included in the review. When compared with placebo for cervical ripening intracervical injections of hyaluronidase resulted in women receiving significantly fewer caesarean sections (18% versus 49%, relative risk (RR) 0.37, 95% confidence interval (CI) 0.22 to 0.61), less need for oxytocin augmentation (10% versus 47%, RR 0.20, 95% CI 0.10 to 0.41), and increased cervical favourability after 24 hours (60% versus 98%, RR 0.62, 95% CI 0.52 to 0.74). No side-effects for mother or baby were reported in this trial.

AUTHORS' CONCLUSIONS

Intracervical injections of hyaluronidase for cervical ripening appear beneficial. However, this is not common practice. In addition it is an invasive procedure that women may find unacceptable in the presence of less invasive methods.

Corticosteroids for cervical ripening and induction of labour

BACKGROUND

The role of corticosteroids in the process of labour is not well understood. Animal studies have shown the importance of cortisol secretion by the fetal adrenal gland in initiating labour in sheep. Infusion of glucocorticosteroids into the fetus has also shown to induce premature labour in sheep. Given these studies it has been postulated that corticosteroids will promote the induction of labour in women. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

OBJECTIVES

To determine the effects of corticosteroids for third trimester cervical ripening or induction of labour in comparison with other methods of cervical priming or induction of labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (December 2005) and bibliographies of relevant papers.

SELECTION CRITERIA

Clinical trials of corticosteroids for third trimester cervical ripening or labour induction.

DATA COLLECTION AND ANALYSIS

A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. We assessed trial quality. We contacted study authors for additional information. We collected adverse effects information from the trials.

MAIN RESULTS

Only one small trial (66 women) was included. The primary outcome vaginal birth within 24 hours was not reported. No benefit of intramuscular administration of corticosteroids with intravenous oxytocin was found when compared with oxytocin alone. However, given the small size of this trial this result should be interpreted cautiously.

AUTHORS' CONCLUSIONS

The effectiveness of corticosteroids for induction of labour is uncertain. This method of induction of labour is not commonly used and so further research in this area is probably unwarranted.

Breast stimulation for cervical ripening and induction of labour

BACKGROUND

Breast stimulation has been suggested as a means of inducing labour. It is a non-medical intervention allowing women greater control over the induction process. This is one of a series of reviews of methods of cervical ripening and labour induction using a standardised methodology.

OBJECTIVES

To determine the effectiveness of breast stimulation for third trimester cervical ripening or induction of labour in comparison with placebo/no intervention or other methods of induction of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group Trials Register (March 2004) and bibliographies of relevant papers.

SELECTION CRITERIA

Clinical trials of breast stimulation for third trimester cervical ripening or labour induction.

DATA COLLECTION AND ANALYSIS

A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction.

MAIN RESULTS

Six trials (719 women) were included. Analysis of trials comparing breast stimulation with no intervention found a significant reduction in the number of women not in labour at 72 hours (62.7% versus 93.6%, relative risk (RR) 0.67, 95% confidence interval (CI) 0.60 to 0.74). This result was not significant in women with an unfavourable cervix. A major reduction in the rate of postpartum haemorrhage was reported (0.7% versus 6%, RR 0.16, 95% CI 0.03 to 0.87). No significant difference was detected in the caesarean section rate (9% versus 10%, RR 0.90, 95% CI 0.38 to 2.12) or rates of meconium staining. There were no instances of uterine hyperstimulation. Three perinatal deaths were reported (1.8% versus 0%, RR 8.17, 95% CI 0.45 to 147.77). When comparing breast stimulation with oxytocin alone the analysis found no difference in caesarean section rates (28% versus 47%, RR 0.60, 95% CI 0.31 to 1.18). No difference was detected in the number of women not in labour after 72 hours (58.8% versus 25%, RR 2.35, 95% CI 1.00 to 5.54) or rates of meconium staining. There were four perinatal deaths (17.6% versus 5%, RR 3.53, 95% CI 0.40 to 30.88).

AUTHORS' CONCLUSIONS

Breast stimulation appears beneficial in relation to the number of women not in labour after 72 hours, and reduced postpartum haemorrhage rates. Until safety issues have been fully evaluated it should not be used in high-risk women. Further research is required to evaluate its safety, and should seek data on postpartum haemorrhage rates, number of women not in labour at 72 hours and maternal satisfaction.

Arthroscopic treatment of osteochondral lesions of the talus

We reviewed, retrospectively, 65 patients who had undergone arthroscopic treatment for osteochondral lesions of the talus. The 46 men and 19 women with a mean age at operation of 34.25 years, were followed up for a mean of 3.5 years. The medial aspect was affected in 45 patients and the lateral aspect in 20. All the lateral lesions and 35 (75%) of the medial lesions were traumatic in origin. Medial lesions presented later than lateral lesions (3 v 1.5 years) and had a much greater incidence of cystic change (46% v 8%). At follow-up, 34 patients had achieved a good result, and 17 and 14 fair and poor results, respectively. Of the 14 poor results, 13 involved medial lesions. Cystic lesions had a poor outcome in 53% of patients. Excision and curettage led to better results than excision and drilling of the base. Further arthroscopic surgery for patients with a poor result was disappointing. There was no association between outcome and the patient's age.

Vaginal prostaglandin (PGE2 and PGF2a) for induction of labour at term

BACKGROUND

Prostaglandins have been used for induction of labour since the 1960s. Initial work focused on prostaglandin F2a as prostaglandin E2 was considered unsuitable for a number of reasons. With the development of alternative routes of administration, comparisons were made between various formulations of vaginal prostaglandins. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

OBJECTIVES

To determine the effects of vaginal prostaglandins E2 and F2a for third trimester cervical ripening or induction of labour in comparison with placebo/no treatment or other vaginal prostaglandins (except misoprostol).

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register (May 2003) and bibliographies of relevant papers.

SELECTION CRITERIA

Clinical trials comparing vaginal prostaglandins used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods.

DATA COLLECTION AND ANALYSIS

A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction.

MAIN RESULTS

In total, 101 studies were considered: 43 excluded and 57 (10,039 women) included. One study is awaiting assessment. Vaginal prostaglandin E2 compared with placebo or no treatment reduced the likelihood of vaginal delivery not being achieved within 24 hours (18% versus 99%, relative risk (RR) 0.19, 95% confidence interval (CI) 0.14 to 0.25, 2 trials, 384 women), there was no evidence of a difference between caesarean section rates although the risk of uterine hyperstimulation with fetal heart rate changes was increased (4.6% versus 0.51%, RR 4.14, 95% CI 1.93 to 8.90, 13 trials, 1203 women). Comparison of vaginal prostaglandin F2a with placebo showed similar caesarean section rates but the cervical score was more likely to be improved (15% versus 60%, RR 0.25, 95% CI 0.13 to 0.49, 5 trials, 467 women), and the risk of oxytocin augmentation reduced (53.9% versus 89.1%, RR 0.60, 95% CI 0.43 to 0.84, 11 trials, 1265 women) with the use of vaginal PGF2a. There were insufficient data to make meaningful conclusions for the comparison of vaginal PGE2 and PGF2a.PGE2 tablet, gel and pessary appear to be as efficacious as each other. Lower dose regimens, as defined in the review, appear as efficacious as higher dose regimens.

REVIEWER'S CONCLUSIONS

The primary aim of this review was to examine the efficacy of vaginal prostaglandin E2 and F2a. This is reflected by an increase in successful vaginal delivery rates in 24 hours, no increase in operative delivery rates and significant improvements in cervical favourability within 24 to 48 hours. Further research is needed to quantify the cost-analysis of induction of labour with vaginal prostaglandins, with special attention to different methods of administration.

A genetic map in the Mimulus guttatus species complex reveals transmission ratio distortion due to heterospecific interactions

As part of a study of the genetics of floral adaptation and speciation in the Mimulus guttatus species complex, we constructed a genetic linkage map of an interspecific cross between M. guttatus and M. nasutus. We genotyped an F(2) mapping population (N = 526) at 255 AFLP, microsatellite, and gene-based markers and derived a framework map through repeated rounds of ordering and marker elimination. The final framework map consists of 174 marker loci on 14 linkage groups with a total map length of 1780 cM Kosambi. Genome length estimates (2011-2096 cM) indicate that this map provides thorough coverage of the hybrid genome, an important consideration for QTL mapping. Nearly half of the markers in the full data set (49%) and on the framework map (48%) exhibited significant transmission ratio distortion (alpha = 0.05). We localized a minimum of 11 transmission ratio distorting loci (TRDLs) throughout the genome, 9 of which generate an excess of M. guttatus alleles and a deficit of M. nasutus alleles. This pattern indicates that the transmission ratio distortion results from particular interactions between the heterospecific genomes and suggests that substantial genetic divergence has occurred between these Mimulus species. We discuss possible causes of the unequal representation of parental genomes in the F(2) generation.

Comparison of torsional strengths of bioabsorbable screws for anterior cruciate ligament reconstruction

The goals of this study were to evaluate torsional strength and modes of failure in commercially available bioabsorbable interference screws and to test the effect of screw diameter on torsional strength when screws become jammed during insertion. We tested the Arthrex, BioScrew, Endo-Fix, Phantom, and Sysorb screws, all 20 mm in length. Four major modes of failure were encountered. Analysis of variance revealed that both screw type and diameter had a significant effect on failure torque. The Endo-Fix 7-mm screw had the lowest failure torque (1.07 +/- 0.18 N x m) and the Sysorb 8-mm screw had the highest (5.23 +/- 0.24 N x m). The Sysorb was significantly stronger than all the other screws. The failure torques were within the range that has been reported for manual screw insertion. We concluded that technical factors, which can affect insertion torque, assume particular importance with the use of bioabsorbable interference screws.

Dinoprostone vaginal insert for cervical ripening and labor induction: a meta-analysis

OBJECTIVE

To compare dinoprostone 10 mg controlled-release vaginal insert with other forms of vaginal or cervical prostaglandin for cervical ripening.

DATA SOURCES

Literature search strategy included review of the Cochrane database of randomized trials, on-line searching of MEDLINE, hand searching of bibliographies, and contact with authors of relevant reports.

METHODS OF STUDY SELECTION

Randomized trials were included if they compared a dinoprostone slow-release vaginal insert with an alternative vaginal or cervical prostaglandin for cervical ripening and labor induction in women at term with singleton gestations. Primary end points were delivery by 24 hours postinsertion, uterine hypertonus with fetal heart change, and cesarean delivery rate. Study inclusion, validity assessment, and data extraction were carried out independently by two reviewers, and cross-checked for consistency. Data were combined when appropriate, using the Mantel-Haenszel fixed-effects method. Statistical heterogeneity was assessed using chi-square statistics.

TABULATION, INTEGRATION, AND RESULTS

Nine relevant trials were identified, seven comparing the dinoprostone 10 mg vaginal insert with dinoprostone gel and two with misoprostol. Five trials reported adequate methods for randomization concealment. None were double blind. The likelihood of delivery by 24 hours was similar with the vaginal insert and alternatives: common odds ratio (OR) 0.80 (95% confidence interval [CI] 0.56, 1.15). Uterine hypertonus with change in fetal heart and cesarean delivery rate were also similar: common OR 1.19 (95% CI 0.56, 2.54) and 0.78 (95% CI 0.56, 1.08), respectively. The secondary end points of mean time to delivery and delivery by 12 hours appeared to favor misoprostol-dinoprostone gel. However, data for these end points were heterogeneous and their combination is therefore of limited value and potentially misleading.

CONCLUSION

No clinically significant differences were identified between the vaginal insert and alternatives used for cervical ripening at term.

Castor oil, bath and/or enema for cervical priming and induction of labour

BACKGROUND

Castor oil, a potent cathartic, is derived from the bean of the castor plant. Anecdotal reports, which date back to ancient Egypt have suggested the use of castor oil to stimulate labour. Castor oil has been widely used as a traditional method of initiating labour in midwifery practice. Its role in the initiation of labour is poorly understood and data examining its efficacy within a clinical trial are limited. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

OBJECTIVES

To determine the effects of castor oil or enemas for third trimester cervical ripening or induction of labour in comparison with other methods of cervical ripening or induction of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Last searched: November 2000.

SELECTION CRITERIA

(1) clinical trials comparing castor oil, bath or enemas used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions.

DATA COLLECTION AND ANALYSIS

A strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involves a two-stage method of data extraction.

MAIN RESULTS

In the one included study of 100 women, which compared a single dose of castor oil versus no treatment, no difference was found between caesarean section rates (relative risk (RR) 2.31, 95% CI 0.77, 6.87). No data were presented on neonatal or maternal mortality or morbidity. There was no difference between either the rate of meconium stained liquor (RR 0.77, 95% CI 0.25,2.36) or Apgar score < 7 at 5 minutes (RR 0.92, 95% CI 0.02,45.71) between the two groups. The number of participants was small hence only large differences in outcomes could have been detected. All women who ingested castor oil felt nauseous.

REVIEWER'S CONCLUSIONS

The only trial included in this review attempts to address the role of castor oil as an induction agent. The trial was small and of poor methodological quality. Further research is needed to attempt to quantify the efficacy of castor oil as an induction agent.

Oestrogens alone or with amniotomy for cervical ripening or induction of labour

BACKGROUND

Studies in sheep showed that there is a pre-labour rise in oestrogen and a decrease in progesterone, both of these changes stimulate prostaglandin production and may help initiate labour. Though oestrogen has been suggested as an effective cervical ripening or induction agent, research in humans have failed to demonstrate a similar physiological mechanism. The use of oestrogen as an induction agent is not currently common practice, as such this systematic review should be regarded as an historical review. This is one of a series of reviews of methods of cervical ripening and labour induction using a standardised methodology.

OBJECTIVES

To determine, from the best available evidence, the effectiveness and safety of oestrogens alone or with amniotomy for third trimester cervical ripening and induction of labour in comparison with other methods of induction of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Last searched: April 2001.

SELECTION CRITERIA

(1) randomised controlled trials comparing oestrogens alone used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions.

DATA COLLECTION AND ANALYSIS

A generic strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally.

MAIN RESULTS

When comparing oestrogen with placebo there was no difference between the rate of caesarean section (7.1% versus 10.3%, relative risk (RR) 0.70, 95% confidence interval (CI) 0.30,1.62). There were no differences between rates of uterine hyperstimulation with or without fetal heart rate changes or instrumental vaginal delivery. None of the studies reported the rates of either vaginal delivery not achieved in 24 hours, or cervix unfavourable/unchanged after 12-24 hours. There were insufficient data to make any meaningful conclusions when comparing oestrogen with vaginal PGE2, intracervical PGE2, oxytocin alone or extra amniotic PGF2a, as to whether oestrogen is effective in inducing labour.

REVIEWER'S CONCLUSIONS

There were insufficient data to draw any conclusions regarding the efficacy of oestrogen as an induction agent.

Intravenous oxytocin alone for cervical ripening and induction of labour

BACKGROUND

Oxytocin is the commonest induction agent used worldwide. It has been used alone, in combination with amniotomy or following cervical ripening with other pharmacological or non-pharmacological methods. Prior to the introduction of prostaglandin agents oxytocin was used as a cervical ripening agent as well. In developed countries oxytocin alone is more commonly used in the presence of ruptured membranes whether spontaneous or artificial. In developing countries where the incidence of HIV is high, delaying amniotomy in labour reduces vertical transmission rates and hence the use of oxytocin with intact membranes warrants further investigation. This review will address the use of oxytocin alone for induction of labour. Amniotomy alone or oxytocin with amniotomy for induction of labour has been reviewed elsewhere in the Cochrane Library. Trials which consider concomitant administration of oxytocin and amniotomy will not be considered. This is one of a series of reviews of methods of cervical ripening and labour induction using a standardised methodology.

OBJECTIVES

To determine the effects of oxytocin alone for third trimester cervical ripening or induction of labour in comparison with other methods of induction of labour or placebo/no treatment.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group Trials Register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Last searched: May 2001.

SELECTION CRITERIA

The criteria for inclusion included the following: (1) clinical trials comparing vaginal prostaglandins used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions.

DATA COLLECTION AND ANALYSIS

A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally, and incorporated into a series of primary reviews arranged by methods of induction of labour, following a standardised methodology. The data is to be extracted from the primary reviews into a series of secondary reviews, arranged by category of woman.

MAIN RESULTS

In total, 110 trials were considered; 52 have been excluded and 58 included examining a total of 11,129 women. Comparing oxytocin alone with expectant management: Oxytocin alone reduced the rate of unsuccessful vaginal delivery within 24 hours when compared with expectant management (8.3% versus 54%, relative risk (RR) 0.16, 95% confidence interval (CI) 0.10,0.25) but the caesarean section rate was increased (10.4% versus 8.9%, RR 1.17, 95% CI 1.01,1.36). This increase in caesarean section rate was not apparent in the subgroup analyses. Women were less likely to be unsatisfied with induction rather than expectant management, in the one trial reporting this outcome (5.5% versus 13.7%, RR 0.43, 95% CI 0.33, 0.56). Comparing oxytocin alone with vaginal prostaglandins: Oxytocin alone was associated with an increase in unsuccessful vaginal delivery within 24 hours (52% versus 28%, RR 1.85, 95% CI 1.41, 2.43), irrespective of membrane status, but there was no difference in caesarean section rates (11.4% versus 10%, RR 1.12, 95% CI 0.95, 1.33). Comparing oxytocin alone with intracervical prostaglandins: Oxytocin alone was associated with an increase in unsuccessful vaginal delivery within 24 hours when compared with intracervical PGE2 (51% versus 35%, RR 1.49, 95% CI 1.12,1.99). For all women with an unfavourable cervix regardless of membrane status, the caesarean section rates were increased (19.0% versus 13.1%, RR 1.42, 95% CI 1.11, 1.82).

REVIEWER'S CONCLUSIONS

Overall, comparison of oxytocin alone with either intravaginal or intracervical PGE2 reveals that the prostaglandin agents probably overall have more benefits than oxytocin alone. The amount of information relating to specific clinical subgroups is limited, especially with respect to women with intact membranes. Comparison of oxytocin alone to vaginal PGE2 in women with ruptured membranes reveals that both interventions are probably equally efficacious with each having some advantages and disadvantages over the others. With respect to current practice in women with ruptured membranes induction can be recommended by either method and in women with intact membranes there is insufficient information to make firm recommendations.

Breast stimulation for cervical ripening and induction of labour

BACKGROUND

Breast stimulation has been suggested as an effective means of inducing labour. It is both an inexpensive and non-medical intervention which allows women greater control over the induction process. It is not clear how breast stimulation increases uterine contractions, however it has been shown to be effective for contraction stress tests and for the augmentation of labour. This is one of a series of reviews of methods of cervical ripening and labour induction using a standardised methodology.

OBJECTIVES

To determine the effectiveness of breast stimulation for third trimester cervical ripening or induction of labour in comparison with placebo/no intervention or other methods of induction of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Last searched: April 2001.

SELECTION CRITERIA

(1) randomised controlled trials comparing breast stimulation used for third trimester cervical ripening or labour induction with no intervention or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or the control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaning outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions.

DATA COLLECTION AND ANALYSIS

A generic strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction. The initial data extraction was done centrally.

MAIN RESULTS

Six randomised controlled trials were included in the analysis involving 719 women. When trials comparing breast stimulation with no intervention were analysed there was a significant reduction in the number of women not in labour at 72 hours (62.7% versus 93.6%, relative risk (RR) 0.67, 95% confidence interval (CI) 0.60 - 0.74). However, this result did not remain significant in women with an unfavourable cervix. There were no instances of uterine hyperstimulation. A reduction in the rate of postpartum haemorrhage was reported (0.7% versus 6%, RR 0.16, 95% CI 0.03 - 0.87). No significant difference was detected in the caesarean section rate (9% versus 10%, relative risk RR 0.90, 95% CI 0.38 - 2.12) or rates of meconium staining. Three perinatal deaths were reported (1.8% versus 0%, RR 8.17, 95% CI 0.45 - 147.77). This finding should be interpreted with caution. The three deaths occurred in the breast stimulation arm of a three-armed trial (breast stimulation versus no intervention versus oxytocin) of questionable quality. The study was very small (n = 57), involved only high risk women, and the method of randomisation was not reported. When comparing breast stimulation with oxytocin alone the analysis found no difference in caesarean section rates (28% versus 47%, RR 0.60, 95% CI 0.31 - 1.18). No difference was detected in the number of women not in labour after 72 hours (58.8% versus 25%, RR 2.35, 95% CI 1.00 - 5.54). There was no significant difference in the rates of meconium staining. There were four perinatal deaths. Three in the breast stimulation arm, and one in the oxytocin arm of the three-armed trial noted above (17.6% versus 5%, RR 3.53, 95% CI 0.40-30.88).

REVIEWER'S CONCLUSIONS

Breast stimulation cannot be fully evaluated on efficacy and safety grounds from the included studies. Whilst it would appear beneficial in terms of a reduction in the number of women not in labour after 72 hours, and a reduction in postpartum haemorrhage, until safety issues have been fully evaluated it should not be considered for use in a high risk population.

Sexual intercourse for cervical ripening and induction of labour

BACKGROUND

The role of prostaglandins for cervical ripening and induction of labour has been examined extensively. Human semen is the biological source that is presumed to contain the highest prostaglandin concentration. The role of sexual intercourse in the initiation of labour is uncertain. The action of sexual intercourse in stimulating labour is unclear, it may in part be due to the physical stimulation of the lower uterine segment, or endogenous release of oxytocin as a result of orgasm or from the direct action of prostaglandins in semen. Furthermore nipple stimulation may be part of the process of initiation. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

OBJECTIVES

To determine the effects of sexual intercourse for third trimester cervical ripening or induction of labour in comparison with other methods of induction.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Last searched: November 2000.

SELECTION CRITERIA

(1) clinical trials comparing sexual intercourse for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusion.

DATA COLLECTION AND ANALYSIS

A strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involves a two-stage method of data extraction.

MAIN RESULTS

There was one included study of 28 women which reported very limited data, from which no meaningful conclusions can be drawn.

REVIEWER'S CONCLUSIONS

The role of sexual intercourse as a method of induction of labour is uncertain. Any future trials investigating sexual intercourse as a method of induction need to be of sufficient power to detect clinically relevant differences in standard outcomes. However, it may prove difficult to standardise sexual intercourse as an intervention to allow meaningful comparisons with other methods of induction of labour.

Hyaluronidase for cervical priming and induction of labour

BACKGROUND

Dilatation and effacement of the cervix are not only a result of uterine contractions, but are also dependent upon ripening processes within the cervix. The cervix is a fibrous organ composed principally of hyaluronic acid, collagen and proteoglycan. Hyaluronic acid increases as pregnancy progresses, increases markedly after the onset of labour and decreases rapidly after birth of the infant. An increase in the level of hyaluronic acid is associated with an increase in tissue water content. Cervical ripening during labour is characterised by changes of the cervix with softening of the tissue and an increased water content. Cervical injection of hyaluronidase was postulated to increase cervical ripening. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

OBJECTIVES

To determine the effects of hyaluronidase for third trimester cervical ripening or induction of labour in comparison with other methods of induction of labour

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group Trials Register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Last searched: November 2000.

SELECTION CRITERIA

(1) clinical trials comparing hyaluronidase used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions.

DATA COLLECTION AND ANALYSIS

A strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involves a two-stage method of data extraction.

MAIN RESULTS

There were no included trials.

REVIEWER'S CONCLUSIONS

The role of hyaluronidase as a method of cervical priming or induction of labour is uncertain.

Relaxin for cervical ripening and induction of labour

BACKGROUND

Relaxin is a protein hormone composed of two amino acid chains. The role played by relaxin in human pregnancy and parturition is unclear. Its use and involvement as a cervical ripening agent has been debated since the 1950s. Because the main source of human relaxin is the corpus luteum of pregnancy much of the early work on induction of labour has focused on porcine or bovine preparations. With the advent of DNA recombinant technology human relaxin has become available for evaluation. Relaxin is thought to have a promoting effect on cervical ripening. Due to a possible inhibitory effect on human myometrial activity, relaxin may not be associated with the concomitant increase in the rate of uterine hyperstimulation seen with other induction agents. This is one of a series of reviews of methods of cervical ripening and labour induction using a standardised methodology.

OBJECTIVES

To determine the effects of relaxin (both purified porcine and recombinant human) for third trimester cervical ripening or induction of labour in comparison with other methods of induction.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled trials register and bibliographies of relevant papers. Last searched: November 2000.

SELECTION CRITERIA

(1) clinical trials comparing relaxin used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusion.

DATA COLLECTION AND ANALYSIS

A strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involves a two-stage method of data extraction.

MAIN RESULTS

In total, nine studies were considered; five have been excluded and four included examining a total of 267 women. There were no reported cases of uterine hyperstimulation with fetal heart rate changes in any of the studies. The rate of caesarean section was not different in those women given relaxin compared with placebo (15.3% versus 14.2%; relative risk (RR) 0.79, 95% confidence interval (CI) 0.42,1.50). There was a reduction in the risk of the cervix remaining unfavourable or unchanged with induction with relaxin (21.9% versus 49.3%; RR 0.45, 95% CI 0.28,0.72). There were no reported cases of uterine hyperstimulation without FHR changes.

REVIEWER'S CONCLUSIONS

The place of relaxin, either purified porcine or recombinant human, as an induction or cervical priming agent is unclear. Further trials are needed to estimate the true effect of relaxin within current clinical practice.

Corticosteroids for induction of labour

BACKGROUND

The role of corticosteroids in the process of labour is not well understood. Animal studies have shown the importance of cortisol secretion by the fetal adrenal gland in initiating labour in sheep. Infusion of glucocorticosteroids into the fetus has also shown to induce premature labour in sheep. Some assumptions have been proposed regarding the mode of action of corticosteroids, including both a paracrine and autocrine action, following the identification of glucocorticoid receptors on human amnion. Given these studies it has been postulated that corticosteroids given intraamniotically will promote the induction of labour. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.

OBJECTIVES

To determine the effects of corticosteroids for third trimester cervical ripening or induction of labour in comparison with other methods of cervical priming or induction of labour.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register and bibliographies of relevant papers. Last searched: November 2000.

SELECTION CRITERIA

(1) clinical trials comparing corticosteroids used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods; (2) random allocation to the treatment or control group; (3) adequate allocation concealment; (4) violations of allocated management not sufficient to materially affect conclusions; (5) clinically meaningful outcome measures reported; (6) data available for analysis according to the random allocation; (7) missing data insufficient to materially affect the conclusions.

DATA COLLECTION AND ANALYSIS

A strategy has been developed to deal with the large volume and complexity of trial data relating to labour induction. This involves a two-stage method of data extraction.

MAIN RESULTS

There are no included trials, hence no results are presented.

REVIEWER'S CONCLUSIONS

The effectiveness of corticosteroids for induction of labour is uncertain. Use of this method of induction of labour is not commonly used and further research in this area is probably unwarranted.

A secreted Salmonella protein induces a proinflammatory response in epithelial cells, which promotes neutrophil migration

In response to Salmonella typhimurium, the intestinal epithelium generates an intense inflammatory response consisting largely of polymorphonuclear leukocytes (neutrophils, PMN) migrating toward and ultimately across the epithelial monolayer into the intestinal lumen. It has been shown that bacterial-epithelial cell interactions elicit the production of inflammatory regulators that promote transepithelial PMN migration. Although S. typhimurium can enter intestinal epithelial cells, bacterial internalization is not required for the signaling mechanisms that induce PMN movement. Here, we sought to determine which S. typhimurium factors and intestinal epithelial signaling pathways elicit the production of PMN chemoattractants by enterocytes. Our results suggest that S. typhimurium activates a protein kinase C-dependent signal transduction pathway that orchestrates transepithelial PMN movement. We show that the type III effector protein, SipA, is not only necessary but is sufficient to induce this proinflammatory response in epithelial cells. Our results force us to reconsider the long-held view that Salmonella effector proteins must be directly delivered into host cells from bacterial cells.

Endogenous and exogenous factors contributing to the surface expression of HLA B27 on mutant APC

We have examined the expression of HLA B*2705 in the mutant cell line 721.220, which lacks endogenous HLA A and B alleles and expresses a defective tapasin molecule. Several peptide sensitive mAbs distinguish between HLA B*2705 expressed on the surface of 721.220 cells (B27.220) and 721.220 cells co-transfected with human tapasin (B27.220.hTsn). This differential staining defines subtle differences in the conformation of HLA B27, which most likely reflect changes in the repertoire of antigenic peptides bound to B27 in the presence and absence of wild type tapasin. HLA B27 molecules expressed on the surface of 721.220 display increased levels of "free" B27 heavy chain (HC-10 staining), an epitope that is dependent on TAP-translocated peptides. The conformation and stability of B27 molecules was examined by investigating the integrity of mAb epitopes and the half-lives of these complexes on cells cultured with and without serum. The decay of surface B27 epitopes occurred more rapidly in B27.220 and this effect was exaggerated in serum free media. Importantly, the decay of surface B27 molecules in B27.220.hTsn cells was characterized by an early increase in HC-10 staining when the cells were grown in serum free media. This decay of B27 molecules via HC-10 reactive intermediates was not observed in B27.220 cells, implying molecules on these cells may already have passed through this stage prior to surface expression. Taken together these observations indicate that tapasin has a significant contribution to the composition and stability of the B27-bound peptide repertoire.

Ordered expression of ftsQA and ftsZ during the Caulobacter crescentus cell cycle

The mechanisms by which bacterial cell division and DNA replication are co-ordinated are still unknown. We have used the easily synchronizable bacterium Caulobacter crescentus to determine when the cell division genes ftsQ and ftsA are transcribed during the DNA replication cycle and to compare their transcription with that of ftsZ. Unlike the situation in Escherichia coli, transcription of ftsQ and ftsA does not extend into ftsZ in Caulobacter. ftsQ and ftsA are co-transcribed by a strong promoter, P(QA), present within the end of the ddl gene upstream of ftsQ. Transcription of P(QA) is turned on at the end of the DNA replication period, coincident with the end of the ftsZ transcription period. ftsA is also transcribed by another promoter, P(A), present between ftsQ and ftsA. P(A) transcription is approximately 10 times weaker than P(QA) and occurs during the DNA replication period. Transcription of ftsA by P(A) is sufficient for cell viability, but is not sufficient for normal cell division. When the transcription of ftsA is increased constitutively, cell division is inhibited and stalks are synthesized at aberrant positions. Thus, transcription of ftsA and ftsZ mimics their order of action in Caulobacter and proper transcription of ftsA has to be maintained for normal cell division and differentiation.

Septic sacroiliitis: an unusual causative organism in a rare condition

Streptococcus pneumoniae is a relatively uncommon cause of septic arthritis, and Infection of the sacroiliac joint by this organism has been rarely described. We present such a case.

Cell cycle-dependent transcriptional and proteolytic regulation of FtsZ in Caulobacter

In the differentiating bacterium Caulobacter crescentus, the cell division initiation protein FtsZ is present in only one of the two cell types. Stalked cells initiate a new round of DNA replication immediately after cell division and contain FtsZ, whereas the progeny swarmer cells are unable to initiate DNA replication and do not contain FtsZ. We show that FtsZ expression is controlled by cell cycle-dependent transcription and proteolysis. Transcription of ftsZ is repressed in swarmer cells and is activated concurrently with the initiation of DNA replication. At the end of the DNA replication period, transcription of ftsZ decreases substantially. We show that the global cell cycle regulator CtrA is involved in the cell cycle control of ftsZ transcription. CtrA binds to a site that overlaps the ftsZ transcription start site. Removal of the CtrA-binding site results in transcription of the ftsZ promoter in swarmer cells. Decreasing the cellular concentration of CtrA increases ftsZ transcription and conversely, increasing the concentration of CtrA decreases ftsZ transcription. Because CtrA is present in swarmer cells, is degraded at the same time as ftsZ transcription begins, and reappears when ftsZ transcription decreases at the end of the cell cycle, we propose that CtrA is a repressor of ftsZ transcription. We show that proteolysis is an important determinant of cell type-specific distribution and cell cycle variation of FtsZ. FtsZ is stable when it is synthesized and assembles into the cytokinetic ring at the beginning of the cell cycle. After the initiation of cell division, the rate of FtsZ degradation increases as both the constriction site and the FtsZ ring decrease in diameter. When ftsZ is expressed constitutively from inducible promoters, the abundance of FtsZ still varies during the cell cycle. The coupling of transcription and proteolysis to cell division ensures that FtsZ is inherited only by the progeny cell that will begin DNA replication immediately after cell division.

Does early wound infection after elective orthopaedic surgery lead on to chronic sepsis?

Infection is an uncommon, but occasionally devastating, complication of orthopaedic surgery. The definition of post-operative infection remains problematic. A high rate of early post-operative sepsis has previously been reported using a clinical definition of wound infection as recommended by the Surgical Infection Study Group. The purposes of this study is to determine the rate of ongoing wound problems and deep sepsis 1 year after these early wound infections. Of 1131 consecutive orthopaedic procedures, there were 70 wound infections occurring within 30 days of surgery. Adequate follow-up data were obtained in 67 (97%) of the 69 patients alive at 1 year. Of these 67, three had definite evidence and two possible evidence of ongoing wound problems and/or deep sepsis. It is concluded that early post-operative wound infection as defined by the Surgical Infection Study Group is a poor predictor (4-10%) of ongoing wound problems and deep sepsis at 1 year. All of the confirmed cases of late sepsis were found to be associated with revision arthroplasty and/or pin tract sepsis.

An anatomical study of a new portal for ankle arthroscopy

We describe a medial midline portal between the tendons of extensor hallucis longus and tibialis anterior for arthroscopy of the ankle. We dissected 20 cadaver specimens to compare the risk of neurovascular injury using this approach with that of using standard arthroscopic portals. Compared with the anterocentral portal, the medial midline was a mean of 11.2 mm further from the nearest branch of the superficial peroneal nerve and 10.3 mm further from the dorsalis pedis artery. This portal allows good access to the joint surface and intra-articular structures and has a lower risk of injury to the dorsalis pedis artery, deep peroneal nerve or the medial branch of the superficial peroneal nerve.

A novel high-dose chemotherapy protocol with autologous hematopoietic rescue in patients with metastatic breast cancer or recurrent non-Hodgkin's lymphoma

In this phase II trial, we used a double dose-intensive chemotherapy and stem cell rescue protocol to treat breast cancer (BCA) patients or non-Hodgkin's lymphoma patients (NHL). The first cycle consisted of high-dose melphalan followed by ABMT. The second cycle used a novel chemotherapy combination; thiotepa, etoposide, carboplatin and cyclophosphamide (TECC) followed by ABMT. We treated 12 patients in total, nine with BCA, three with NHL. All nine BCA patients were treated with the two cycle protocol. The three NHL patients were treated with the second cycle only. Bone marrow (BM, 1 patient), peripheral blood stem cells (PBSC, 10 patients) or both (1 patient) were reinfused 60-72 h after completion of each cycle of chemotherapy. Recovery was rapid; the ANC rose to greater than 500/microl on day +11 (+8 to + 20) and the platelet count to greater than 20000/microl on day +12 (+6 to +20). The toxicities included the expected neutropenic fevers, severe mucositis, diarrhea, and a low incidence of mild renal insufficiency. No patients developed veno-occlusive disease, hemorrhagic cystitis or overt bleeding. With a mean follow-up of 37 months, 83.3% of the patients are alive. Six patients are in complete remission; one patient with BCA relapsed and expired; one patient with NHL is in CR now over 18 months after relapse and subsequent treatment with interferon; one patient is too early to evaluate. Progression-free survival overall is 75%, which is at least equivalent to many other recent studies using similar regimens. In addition, we have also found that delayed addition of G-CSF during the mobilization of PBSC was feasible and resulted in excellent CD34+ cell counts and engraftments, and reduced treatment costs. These results indicate that this chemotherapy is effective with good remission rates and high progression-free survival rates. It is also well tolerated with acceptable toxicities that are manageable. Long-term follow-up of a larger cohort of patients will be needed to ascertain the overall efficacy of this type of therapy.

Is manipulation of moderately displaced Colles' fracture worthwhile? A prospective randomized trial

Thirty elderly patients with moderately displaced Colles' fractures were randomly assigned to manipulation under Bier's block or plaster immobilization alone. Moderately displaced was defined as 10 degrees to 30 degrees of dorsal angulation and less than 5 mm of radial shortening compared with the uninjured side. The groups were well matched for age, sex, fracture type and displacement; immobilization time and rehabilitation were standardized. The outcome measures were: radiological position at union, the functional score of Gartland and Werley, grip strength, cosmesis and algodystrophy assessment. There was no detectable difference between the groups in any of the outcome measures. Two-thirds of the correction of dorsal angulation achieved by manipulation was lost by 5 weeks. We conclude that up to 30 degrees of dorsal angulation and 5 mm of radial shortening may be accepted in selected elderly patients.

Absence of innervation of the uteroplacental arteries in normal and abnormal human pregnancies

The spiral arteries of the human uterus are considerably remodeled structurally during pregnancy to facilitate an increase in blood flow. An immunohistochemical study was undertaken to determine whether the spiral arteries were innervated and, if so, whether they were denervated in the process of the physiologic vascular changes of normal pregnancy or, conversely, remained innervated in the absence of physiologic changes in abnormal pregnancy. Uterine tissues from nonpregnant nulliparous women, from normal early pregnancy, from normal late pregnancy, from abnormal early pregnancy (i.e. spontaneous abortions), and from abnormal late pregnancy (i.e. preeclampsia and intrauterine growth retardation) were subjected to immunohistochemistry using a panel of neuron-associated antibodies (neurofilament, neuron-specific enolase, S100 protein, protein gene product 9.5). All sections of the nonpregnant uterus showed an abundance of nerves deep in the myometrium, some of which were associated with radial and arcuate arteries. Very few nerves were demonstrated at the endomyometrial junction and no nerves were seen accompanying the intramyometrial spiral arteries. In both normal and abnormal pregnancy, nerves were not detected in the decidua or accompanying intradecidual spiral arteries, whether they were physiologically altered or not. Nerves were seen in the myometrium in 7 of 10 normal and in 1 of the 8 third-trimester abnormal placental beds, but none were seen accompanying intramyometrial spiral arteries, whether showing physiological changes or not. The lack of innervation of the spiral arteries in the nonpregnant state as well as in normal and abnormal pregnancy suggests that nonneurogenic mechanisms control blood flow at the spiral-arterial level.

Poor reproducibility in radiographic grading of femoral cementing technique in total hip arthroplasty

The first study of the reproducibility of a widely accepted grading system for femoral cementation in total hip arthroplasty is reported. Sixty postoperative radiographs were graded on two occasions at least 2 weeks apart by two experienced observers. The test-retest reproducibility rate was 60% for observer 1 and 70% for observer 2. The interobserver reproducibility varied between 60 and 63% for the different assessments. Between 5 and 6% of cases differed by more than one grade between tests. Kappa statistical analysis confirmed that reproducibility was poor in all cases. This cement grading system, even in the hands of experienced observers, has too high a rate of intraobserver and interobserver error to recommend its use.

An audit of early wound infection after elective orthopaedic surgery

The incidence of early post-operative wound infection was studied prospectively in 1053 patients undergoing elective orthopaedic procedures over a 3-month period. The study was repeated in 1131 patients a year later, 6 months after the hospital had moved to new premises. A clinical definition of wound infection identified disturbingly high sepsis rates. A total of 44% of all infections occurred after discharge from hospital. Despite the large sample, there was no significant difference in the rate of early wound infection between the two periods (7.85 and 6.82%). There was no significant difference in infection rates between theatres with and without laminar air flow. In the majority (35 out of 53) of minor infections, bacteriological confirmation was not available because no microbiological specimens were received. Conversely, there were five negative swabs out of 16 wounds defined clinically as major infections. We conclude that, where the rate of bacteriological confirmation of wound infection is low, the use of a clinical definition gives higher audited sepsis rates. Large audit samples are required to demonstrate differences as a result of a changed practice.

Characterization of a gene transcribed in the L2 and L3 layers of the tobacco shoot apical meristem

Recent genetic and molecular studies have been initiated to uncover the fundamental cellular processes unique to the shoot apical meristem. Our previous work resulted in the isolation of a cDNA clone derived from tobacco apex RNA, A3, that appeared to be transcriptionally restricted to the shoot apex regardless of developmental stage. Here the DNA sequence and in situ RNA analysis of A3 is presented. The A3 gene potentially encodes a small hydrophilic polypeptide, the sequence of which is unique to current data bases. It has been found that transcripts of the A3 gene are confined to the subepidermal and internal cell layers of the tobacco shoot apical meristem throughout development, become localized to undifferentiated floral organ primordia, and diminish as the developmental potential of the meristematic tissue becomes restricted.

NFL, the tobacco homolog of FLORICAULA and LEAFY, is transcriptionally expressed in both vegetative and floral meristems

The homologous genes FLORICAULA (FLO) of Antirrhinum and LEAFY (LFY) of Arabidopsis regulate the formation of determinate floral meristems. Transcripts of these single-copy genes are confined to floral meristems and some floral organs as well as to the leaflike bracts that subtend Antirrhinum flowers. Based on these observations, we hypothesized that the transcription of genes homologous to FLO and LFY in tobacco, a determinate plant in which the primary shoot apex is consumed in the production of a terminal flower, would serve as a molecular marker for floral commitment. Surprisingly, transcripts of the tobacco homologs NFL1 and NFL2 (Nicotiana FLO/LFY) were found not only in floral meristems, but also in indeterminate vegetative meristems. This implies that the transcriptional expression of the FLO/LFY homologous genes in the apical meristem is not sufficient for the initiation of floral meristem development. In addition, the transcript patterns of the NFL genes identified a previously undescribed subset of cells within the shoot apical meristem that may indicate unique functional compartmentalization. This suggests that, unlike FLO and LFY, which specify determinacy only during floral development, the NFL genes act to specify determinacy in the progenitor cells for both flowers and leaves.

Cloning and expression of a novel human brain inward rectifier potassium channel

A complementary DNA encoding an inward rectifier K+ channel (HRK1) was isolated from human hippocampus using a 392-base pair cDNA (HHCMD37) as a probe. HRK1 shows sequence similarity to three recently cloned inwardly rectifying potassium channels (IRK1, GIRK1, and ROMK1, 60, 42, and 37%, respectively) and has a similar proposed topology of two membrane spanning domains that correspond to the inner core structure of voltage gated K+ channels. When HRK1 was expressed in Xenopus oocytes, large inward K+ currents were observed below the K+ reversal potential but very little outward K+ current was observed. In on-cell membrane patches, single channel conductance (g) was estimated to be 10 picosiemens by both direct measurement and noise analysis, in 102 mM external [K+]. HRK1 currents were blocked by external Ba2+ and Cs+ (K(0) = 183 microM, and K(-130) = 30 microM, respectively), and internal tetraethylammonium ion (K(0) = 62 microM), but were insensitive to external tetraethylammonium ion. The functional properties of HRK1 are very similar to those of glial cell inward rectifier K+ channels and HRK1 may represent a glial cell inward rectifier.

Low levels of amniotic fluid pregnancy specific beta-1-glycoprotein in Down's syndrome

Amniotic fluid levels of beta-1-glycoprotein (SP1) were measured in 46 cases of Down's syndrome and compared with levels in 106 pregnancies of normal karyotype from 10 to 23 weeks of gestation. In normal pregnancies, levels rose from 87.5 iu/l at 10 weeks to a peak of 610.0 iu/l at 19 weeks of gestation. In cases of Down's syndrome, levels were reduced prior to 19 weeks of gestation (median multiple of the median, MoM = 0.75, P = 0.02). This effect was most marked prior to 16 weeks of gestation when the median multiple of the median (MoM) was 0.51 (P = 0.006). These data demonstrate that amniotic fluid levels of SP1 are low in Down's syndrome before 19 weeks of gestation.

Structure and organization of hip, an operon that affects lethality due to inhibition of peptidoglycan or DNA synthesis

High-frequency persistence to the lethal effects of inhibition of either DNA or peptidoglycan synthesis, the Hip phenotype, results from mutations at the hip locus of Escherichia coli K-12. The nucleotide sequence of DNA fragments which complement these mutations revealed an operon consisting of a possible regulatory region, including sequences with modest homology to an E. coli promoter, and two open reading frames which are translated both in vitro and in vivo. The stop codon of a 264-bp open reading frame, hipB, and the start codon of a 1,320-bp open reading frame, hipA, share an adenine residue. Assays of promoter strength, the location of the probable promoter with respect to the start of transcription, and codon usage all indicate that hipB and hipA are weakly expressed genes. The activity of the promoter is impaired by an adjacent downstream sequence which includes the coding region of hipB. The impairment is partially relieved by insertion of a premature translation termination signal within the coding region of hipB, suggesting involvement of the HipB protein in the regulation of this promoter. The arrangement of hipB and hipA within the operon and the toxicity of hipA for strains defective in or lacking hipB suggest an important interaction between the products of these genes.

The circadian rhythm of intact parathyroid hormone-(1-84): temporal correlation with prolactin secretion in normal men

Serum PTH-(1-84), PRL, and adjusted calcium concentrations were determined at 30-min intervals for a 24-h period in six normal adult men. PTH-(1-84) and PRL both exhibited two peaks of increased secretion [1600-1900 and 0200-0600 h for PTH-(1-84); 2000-2200 and 0400-0800 h for PRL]. For each subject there was a striking similarity in the magnitude of secretion of the two hormones and a consistent temporal relationship. Thus, the maximum correlation coefficients of 0.62-0.83 were obtained for the six subjects when the PRL surge lagged that of PTH-(1-84) by 0.5-3.5 h. In contrast, the correlation between PTH-(1-84) and adjusted calcium was weaker (r = -0.36 to -0.66) and showed no consistent temporal relationship (0.0-10.5 h). These data support the concept of higher center control of PTH-(1-84) secretion with the possible involvement of factors common to the control of PRL secretion.

Identification of genes expressed in the tobacco shoot apex during the floral transition

The shoot apex of higher plants contains undifferentiated meristematic cells that serve as the origin of post-embryonic organs. The transition from vegetative to reproductive growth results in the commitment of the apical meristem to floral organ formation. To identify the molecular signals that initiate floral development, we have pursued the isolation of genes that are transcriptionally active in the shoot apex of tobacco during the transition from vegetative to floral growth. The small size of the apex led us to utilize polymerase chain reaction shoot apices. This approach enabled the isolation of the apex-specific and floral apex-specific cDNA clones described in this paper. One clone, A3, detected an equivalent level of transcript in the shoot apex during all developmental stages observed. The second clone, FA2, detected a unique transcript that increased in abundance in the shoot apex during the transition to flowering and showed high levels of expression in developing petals, stamens, and pistils.