Two new species of dactylogyrids (Monogenea: Dactylogyridae) infecting the gill filaments of fishes in the southern Peruvian Amazon

Two new dactylogyrid species were found infecting the gill filaments of two freshwater fishes collected in the Amazon River basin around Madre de Dios, Peru, namely, Demidospermus wilveri n. sp. from Loricaria sp. (Siluriformes: Loricariidae), and Notozothecium agusti n. sp. from Brycon amazonicus (Spix & Agassiz) (Characiformes: Bryconidae). Demidospermus wilveri n. sp. is characterized by having the following combination of characteristics: (1) a male copulatory organ (MCO) with 1½ rings and a spoon-shaped distal end, (2) an accessory piece with expanded distal end, (3) dorsal and ventral bars with broadly V-shaped and expanded ends, and (4) hooks similar in size. Notozothecium agusti n. sp. differs from its ten congeners by the following combination of characteristics: (1) a coiled MCO with 1½ rings and a sinuous accessory piece with kidney-shaped distal end, (2) an rod-shaped and straight dorsal bar, (3) and anchors with robust superficial roots. Demidospermus wilveri n. sp. represents the thirty-second species in the genus, the eighth from Peru and the fifth parasitising a loricariid catfish from the Peruvian Amazon. Notozothecium agusti n. sp. is the second species of the genus described in Peru and the first species infecting a bryconid host.

A redescription of Hedruris moniezi Ibáñez & Córdova, 1976 (Nematoda: Hedruridae), an endoparasite of the Titicaca water frog Telmatobius culeus (Garman, 1876) (Anura: Telmatobiidae), with comments on all other known Hedruris species in Peru

Hedruris moniezi Ibáñez & Córdova, 1976 (Nematoda: Hedruridae) was described using light and scanning electron microscopy (SEM) based on specimens collected from the stomach of Telmatobius culeus (Anura: Telmatobiidae) in Peru. We observed some characteristics not reported previously, including sessile and pedunculated papillae and amphid on the pseudolabia, bifid deirids, morphology of the retractable chitinous hook, morphology and arrangement of the plates on ventral surface of the posterior end of the males, and arrangement of caudal papillae. Telmatobius culeus represents a new host of H. moniezi. In addition, H. basilichtensis Mateo, 1971 is considered to be a junior synonym of H. oriestae Moniez, 1889. A key to valid species of Hedruris in Peru is provided.

Four new species of Anenterotrema Stunkard, 1938 (Digenea: Dicrocoellidae) infecting phyllostomid bats in the Peruvian Amazon

During a research of digeneans (Platyhelminthes: Trematoda) infecting leaf-nosed bats (Chiroptera: Phyllostomidae) from the Kawsay Biological Station in Madre de Dios, southeastern Peru, four new species were described based on light and scanning electron microscopy (SEM): Anenterotrema paramegacetabulum n. sp. from the seba's short-tailed bat Carollia perspicillata Linnaeus, A. hastati n. sp., A. kawsayense n. sp., and A. peruense n. sp. from the greater spear-nosed bat Phyllostomus hastatus (Pallas). Anenterotrema paramegacetabulum n. sp. differs from all congeners by having a terminal oral sucker, a transversely elongated ventral sucker without clamp-shaped, and by having the testes located immediately posterior to ventral sucker. Anenterotrema hastati n. sp. is easily differentiated from the other congeneric species by having an almost clamp-shaped oral sucker, well-developed cirrus sac, a bilobulated seminal receptacle, and a group of well-developed unicellular glands located anterolateral to cirrus sac. Anenterotrema kawsayense n. sp. is characterized by possessing protuberances on the anterior margin of the oral sucker. Anenterotrema peruense n. sp. is mainly characterized by having the testes located principally anterior to ventral sucker and the cirrus sac located perpendicular to midline of the body. The present finding brings to 12, the number of known species of Anenterotrema. A key to the species of Anenterotrema Stunkard, 1938 is provided.

First records of marine microturbellarians (Platyhelminthes: Rhabdocoela, Fecampiida and Prolecithophora) from Peru, with the description of a new species

The marine microturbellarian diversity is scarcely known from the Pacific coastline of South America. The coastal margin of Peru is highly influenced by cold-water currents (Humboldt Current System). These cold-water currents play important roles in shaping the marine species diversity in this area. However, there are no previous records of marine microturbellarians for Peru. Here, we describe a new species of Rhabdocoela and report on five other species of marine microturbellarians for this country. Carcharodorhynchus giaae n. sp. (Kalyptorhynchia, Schizorhynchidae), can be identified based on the configuration of the proboscis lips and the male and female genital systems. The male copulatory organ lacks a cirrus, but has a funnel-like, curved stylet with three pairs of spines along it, which distinguishes this species from its congeners. The female system has a vagina with a sclerotized, heavily coiled structure - a feature not mentioned in any known species of the same genus. In addition, we describe noteworthy features for another rhabdocoel, Trigonostomum galapagoense (Dalytyphloplanida, Trigonostomidae). Finally, we provide new records for three rhabdocoel species (Alcha evelinae, Itaipusa divae, Utelga heinckei), one species of Fecampiida (Urastoma cyprinae), and an unidentified species of Prolecithophora.

Life cycle inference and phylogeny of Ortholinea labracis n. sp. (Myxosporea: Ortholineidae), a parasite of the European seabass Dicentrarchus labrax (Teleostei: Moronidae), in a Portuguese fish farm

Ortholinea labracis n. sp. is described and its life cycle is inferred from a Southern Portuguese fish farm, with basis on microscopic and molecular procedures. This myxosporean parasite infects the urinary bladder of the European seabass Dicentrarchus labrax and the intestinal epithelium of a marine oligochaete of the genus Tectidrilus. Myxospores subspherical in valvular view and ellipsoidal in sutural view measuring 7.6 ± 0.3 (6.8-8.7) μm in length, 7.2 ± 0.2 (6.7-7.7) μm in width and 6.5 ± 0.4 (5.8-7.7) μm in thickness. Two polar capsules, 3.0 ± 0.2 (2.6-3.4) μm long and 2.4 ± 0.1 (2.0-2.9) μm wide, located at the same level, but with divergent orientation and opening to opposite sides of the suture line. Sequencing of the SSU rRNA gene revealed a similarity of 100% between the analysed myxospores and triactinomyxon actinospores. The phylogenetic setting of O. labracis n. sp. shows subgrouping in correlation with tissue tropism, but identifies this parasite as another exception to the main division of Myxosporea into the main freshwater and marine lineages.

Paravertebral high cervical chordoma. A case report

Spinal chordomas are more often located on the midline and are associated with marked destruction of the vertebral bodies. We report a rare case of large cervical (C2-C3) right lateral paravertebral chordoma extending into the spinal canal through a very enlarged intervertebral foramen. The tumor was initially diagnosed as a mucous adenocarcinoma on a percutaneous needle biopsy. However, the neuroradiological features, including the well-defined tumor margins, the regular and sclerosing lytic bone changes with regular enlargement of the intervertebral C2-C3 foramen, were in favor of a more slowly growing lesion, such as schwannoma or neurofibroma. At surgery a well-demarcated capsulated tumor involving the nerve root was partially resected. Histology was in favor of a low-grade chordoma (Ki-67/MIB-1<1%). Postoperative proton beam therapy was also performed. The differential neuroradiological diagnosis is discussed.

Intracranial hypertension due to meningioma of the unique transverse sinus

We describe a 28-year-old woman with intracranial hypertension due to a meningioma invading the unique transverse sinus (with absent contralateral sinus). Clinical remission and normalization of orbital echography were obtained by resection of the intradural tumor and peeling of the dural attachment. In such cases, resection and reconstruction of the involved sinus segment is at high risk of venous infarction. Endovascular stenting of the obstructed sinus is a valid alternative when the stenosis is not remarkable. Single tumor removal may lead to partial sinus decompression and increased venous flow, resulting in long-term clinical remission.

Everolimus is an active agent in medullary thyroid cancer: a clinical and in vitro study

Everolimus, an mTOR inhibitor, which has been demonstrated to induce anti-tumour effects in different types of neuroendocrine tumours, has never been evaluated in patients with medullary thyroid cancer (MTC). The aim of this study was to evaluate the in vitro and in vivo effects of everolimus in combination with octreotide in MTC. Two patients with progressive metastatic MTC and high calcitonin levels were treated with everolimus 5–10 mg/day. Both patients were under treatment with octreotide LAR at the study entry. An in vitro study was also performed to assess everolimus effects on MTC cell lines (TT and MZ-CRC-1 cells). A tumour response was observed in both patients. Serum calcitonin decreased by 86% in patient 1 and by 42% in patient 2. In TT and MZ-CRC-1 cells, everolimus induced a significant dose-dependent inhibition in cell proliferation. This effect seems to be related to a cell cycle arrest in G₀/G₁ phase in both cell lines and to the induction of cellular senescence in TT cells. Everolimus in combination with octreotide may be active as anti-tumour therapy in patients with progressive metastatic MTC, suggesting to further evaluate this agent in MTC patients in a large prospective study.

Shortened interval of long-acting octreotide administration is effective in patients with well-differentiated neuroendocrine carcinomas in progression on standard doses

BACKGROUND

In patients with well-differentiated (WD) neuroendocrine tumors (NET), long-acting octreotide (LAR), conventionally administered at a dose of 30 mg every 28 days, has well-documented anti-secretive but limited antiproliferative effects.

AIM

The objective of this study was to evaluate a different schedule of LAR treatment consistent with a shorter interval between administrations (21 days) in WDNET patients with progressive disease at standard-dose interval.

SUBJECTS AND METHODS

Twenty-eight patients followed for diagnosis and therapy of WDNET who had tumor progression during therapy with LAR 30 mg every 28 days were enrolled. Clinical, biological, and objective tumor response was evaluated after LAR 30 mg every 21 days. Time to progression was also evaluated after LAR 30 mg every 21 days and compared to LAR 30 mg every 28 days.

RESULTS

The treatment with LAR 30 mg every 21 days resulted in complete and partial control of clinical symptoms in 40% and 60% of cases, respectively. Circulating neuroendocrine markers were significantly decreased in 30% of cases. A stabilization of disease was obtained in 93% and objective response in 7%. The median time to progression was significantly longer by using the shortened interval of LAR administration as compared to the standard one (30 vs 9 months, p<0.0001). The treatment was safe and well tolerated.

CONCLUSIONS

The shortened schedule of LAR administration was able to re-institute control of clinical symptoms, to decrease level of circulating neuroendocrine markers and to increase time to progression in patients previously escaping from a standard schedule treatment.

Clinical and prognostic implications of the genetic diagnosis of hereditary NET syndromes in asymptomatic patients

Neuroendocrine tumors (NETs) can be sporadic or they can arise in complex hereditary syndromes. Patients with hereditary NETs can be identified before the development of tumors by performing genetic screenings. The aim of the study was to evaluate the clinical and prognostic impact of a preclinical genetic screening in subjects with hereditary NET syndromes. 46 subjects referred for hereditary NET syndrome [22 MEN1, 12 MEN2, 12 Familial Paragangliomatosis (FPGL)] were enrolled and divided in 2 groups (group A, 20 subjects with clinical appearance of NET before the genetic diagnosis; group B, 26 subjects with genetic diagnosis of hereditary NET syndromes before the clinical appearance of NETs). The main outcome measures were severity of disease, prognosis, and survival. The rate of surgery for MEN1-, MEN2-, FPGL4-related tumors was 90% in group A and 35% in group B (p<0.01). Both symptoms related to tumors and symptoms related to therapies were significantly less frequent in group B than in group A (p<0.05). Tumor stage was locally advanced or metastatic in 50% of group A and in no one of group B (p<0.01). The mortality rate was 25% in group A and 0% in group B (p<0.05). An early genetic screening for hereditary NET syndromes results in an improvement in clinical presentation and morbidity. A potential impact of the genetic screening on the mortality rate of these subjects is suggested and needs to be investigated in further and more appropriate studies.

Cinacalcet hydrochloride in combination with alendronate normalizes hypercalcemia and improves bone mineral density in patients with primary hyperparathyroidism

Cinacalcet is effective in controlling the biochemical abnormalities in patients with primary hyperparathyroidism (PHPT) but it seems to be less effective on bone mineral density (BMD). In the same patients, bisphosphonates are reported to be effective on bone resorption but less effective on calcium and PTH excess. In this study, the efficacy of cinacalcet in combination with alendronate has been retrospectively evaluated in patients with PHPT. Twenty-three patients with PHPT who had not been operated were retrospectively investigated. Cinacalcet was evaluated in combination with alendronate in 10 of the 23 patients, and in monotherapy in 13 other patients. Serum calcium, phosphorus and PTH, 24 h urine calcium and phosphorus as well as BMD, evaluated by DXA and expressed as T-score, were measured before and after treatment. In all patients serum calcium and phosphorus and urinary calcium excretion were effectively and stably controlled and PTH was significantly decreased after treatment. There was no difference in the rate of serum calcium and PTH decrease between subjects treated with cinacalcet plus alendronate and those treated with cinacalcet alone. T-score increased by 9.6% at lumbar spine and 3.9% at femur level in the cinacalcet plus alendronate subgroup and was unchanged in the cinacalcet subgroup (P < 0.01). In patients with PHPT, the biochemical abnormalities are rapidly improved by cinacalcet regardless from the administration in monotherapy or in combination with alendronate. BMD is significantly improved in patients receiving cinacalcet plus alendronate and stable in those receiving cinacalcet in monotherapy.

Thyroid function in Fabry disease before and after enzyme replacement therapy

AM: Patients with Fabry disease (FD), a genetic disorder caused by lysosomal a-galactosidase-A enzyme deficiency and characterized by a systemic accumulation of globotriaosylceramides, present high prevalence of subclinical hypothyroidism. The pathogenic mechanism is thought not to be related to anti-thyroid autoimmunity and may be dependent by intra-thyroid lipid accumulation. In this study, it was investigated whether thyroid function recovers in FD after long-term enzyme replacement therapy (ERT).

METHODS

Study population included 14 FD patients (7 females, 7 males, aged 21-62 years) and 14 sex- and age-matched normal subjects. Thyroid function was evaluated in each patient at baseline and after the beginning of ERT with rh-a-galactosidase-A (1 mg/kg/BW every 2 weeks) for three years.

RESULTS

TSH levels were higher in FD patients than in controls (P<0.05). In FD patients, TSH levels were higher before than after ERT (1.9±0.2 vs 1.2±0.2 mU/L, P<0.01) while fT3 and fT4 levels were normal at baseline and unchanged after ERT. At baseline, TSH levels were >3 mU/L in three patients and normalize after ERT. Anti-Tg and/or anti-TPO titres were positive in 14% of patients and 21% of controls. After ERT, the rate of autoimmunity was unchanged. At the thyroid ultrasonography, a slight hypoechoic pattern was found in 71% of patients at baseline and decreased to 43% after ERT.

CONCLUSION

Primary hypothyroidism in FD patients is reverted after long-term ERT. A screening of thyroid function and periodical re-evaluation during ERT is mandatory in all FD patients.

A decrease of calcitonin serum concentrations less than 50 percent 30 minutes after thyroid surgery suggests incomplete C-cell tumor tissue removal

CONTEXT AND OBJECTIVES

The prognosis of medullary thyroid carcinoma (MTC) depends on the completeness of the first surgical treatment. To date, it is not possible to predict whether the tumor has been completely removed after surgery. The aim of this study was to evaluate the reliability of an intraoperative calcitonin monitoring as a predictor of the final outcome after surgery in patients with MTC.

PATIENTS AND METHODS

Twenty patients underwent total thyroidectomy and central lymph node dissection on the basis of a positive pentagastrin test. In six cases a preoperative diagnosis of MTC was achieved at the cytological examination. During the surgical intervention, calcitonin was measured at the time of anesthesia, at the time of manipulation, and 10 and 30 min after surgical excision. At the histological examination, 10 patients had MTC and 10 had C cell hyperplasia.

RESULTS

As compared with calcitonin levels before thyroidectomy, a decrease of calcitonin greater than 50% 30 min after surgery was able to significantly distinguish patients who were cured from those who experienced persistence of disease. It was not possible to find a similar result when the decrease of calcitonin 10 min after surgery was considered.

CONCLUSIONS

A rate of calcitonin decrease less than 50% 30 min after thyroidectomy plus central neck lymph node dissection suggests the persistence of tumor tissue in patients operated for MTC. These results indicate that intraoperative calcitonin monitoring may be a useful tool to predict the completeness of surgery in patients with MTC.

Predictive value of pentagastrin test for preoperative differential diagnosis between C-cell hyperplasia and medullary thyroid carcinoma in patients with moderately elevated basal calcitonin levels

BACKGROUND AND OBJECTIVES

Medullary thyroid carcinoma (MTC) is a calcitonin (CT)-secreting neuroendocrine tumour originating from thyroid C cells. Serum CT concentrations are helpful in the early detection of MTC, while it is still unclear whether they can be used also for the differential diagnosis between MTC and C-cell hyperplasia (CCH), a precancerous condition in familial MTCs but with unclear clinical significance in sporadic MTCs. Nowadays, surgery is recommended in all patients with basal or pentagastrin (PG)-stimulated CT value of 100 pg/ml or more, without discriminating if they are affected with MTC or CCH only. The objective of this study was to investigate the utility of the PG test for CT in distinguishing CCH from MTC before surgery.

PATIENTS AND METHODS

Sixteen of 20 patients with thyroid nodules and basal CT levels between 15 and 100 ng/l had a positive PG test (>100 ng/l PG CT peak) and form the basis of the data analysis. A diagnosis of MTC was histologically proved on surgical samples in seven patients and of CCH in nine other patients. Four patients with neither FNAB nor PG test consistent with a diagnosis of MTC did not undergo thyroidectomy.

RESULTS

A peak of CT of 275 ng/l after PG was able to significantly distinguish patients with MTC from patients with CCH, with 100% sensitivity and 89% specificity (P = 0.002). PG-stimulated calcitonin levels >275 ng/l had a positive predictive value (PPV) value for diagnosis of MTC of 100%, and PG-stimulated calcitonin levels <275 had a PPV for the diagnosis of CCH of 89%.

CONCLUSIONS

A CT cut-off after PG of 275 ng/l is suggested to be highly predictive in distinguishing CCH from MTC before surgery, and this may be helpful in selecting patients for thyroid surgery.

Mediators of lifestyle behavior change in Native Hawaiians: initial findings from the Native Hawaiian Diabetes Intervention Program

OBJECTIVE

To examine the association of stage of change with diet and exercise behaviors in response to a lifestyle intervention for Native Hawaiians (NHs).

RESEARCH DESIGN AND METHODS

A family ('ohana) support lifestyle intervention was compared with a standard intervention in NHs with or at risk for diabetes in two rural communities in Hawaii (n = 147). Stage of change, as a hypothesized mediator of behavior change, and dietary and exercise behaviors were measured at baseline and at 1 year postintervention.

RESULTS

Stage of change was significantly associated with positive dietary and exercise behaviors. NHs receiving the 'ohana support (OS) intervention were more likely to advance from pre-action to action/maintenance for fat intake and physical activity than the group who received the standard intervention. Participants in the OS group who advanced from pre-action to action/maintenance showed more improvement in fat intake and physical activity than those in the standard group.

CONCLUSIONS

These initial findings suggest that stage of change is an important factor in mediating lifestyle behavior changes in persons with or at risk for diabetes and merits further study among minority populations at high risk for diabetes.

Preinsertion local anesthesia at the trocar site improves perioperative pain and decreases costs of laparoscopic cholecystectomy

BACKGROUND

Local anesthesia at the trocar site in laparoscopic cholecystectomy is expected to decrease postoperative pain and hence expedite recovery. The aims of this prospective randomized study were to investigate the effect of local anesthesia and to discover whether it is cost effective.

METHODS

For this study, 100 patients undergoing laparoscopic cholecystectomy were randomized into two groups. The 43 study patients were injected with 0.5% bupivacaine hydrochloride at the trocar site before the trocars were inserted. They then were compared with 41 control patients who received no local anesthesia. The remaining 16 patients were excluded from the study. The postoperative pain was evaluated at the standard four trocar sites at 4 h and 24 h after surgery on a scale 1 (the mildest pain the patient had ever experienced) to 10 (the most severe pain the patient had ever experienced). Postoperative pain medications and their cost were evaluated.

RESULTS

There was no difference between the two groups with regard to gender, age, weight, operative time, estimated operative blood loss, and bile culture. The patients who received bupivacaine at the trocar site clinically had less pain (p < 0.001 for all four sites) both at 4 and 24 h after surgery. The treatment group patients used less mepiridine and promethzine than the control group (p = 0.001 and 0.002, respectively) postoperatively. Overall, the patients who had local anesthesia used less postoperative pain and antiemetic medication than the control patients (p = 0.02). This afforded a significant decrease in the costs and charges of these medications (p = 0.004 and 0.005, respectively). Three patients in the study group were discharged from the hospital the day of surgery.

CONCLUSION

Preinsertion of local anesthesia at the trocar site in laparoscopic cholecystectomy significantly reduces postoperative pain and decreases medication usage costs.

Safety and efficacy of radiofrequency thermal ablation in advanced liver tumors

HYPOTHESIS

Radiofrequency thermal ablation (RFA) can be performed safely and effectively to control local disease in patients with advanced, unresectable liver tumors.

DESIGN, SETTING, AND PATIENTS

Prospective study of 76 patients with unresectable liver tumors who underwent RFA at a private tertiary referral hospital.

INTERVENTIONS

Ninety-nine RFA operations were performed to ablate 328 tumors.

MAIN OUTCOME MEASURES

Complications and local recurrence.

RESULTS

There was 1 death (1%), major complications occurred in 7 operations (7%), and minor complications occurred in 10 operations (10%). Local recurrence was identified in 30 tumors (9%) at a mean follow-up of 15 months. Size (P<.001), vascular invasion (P<.001), and total volume ablated (P<.001) were associated with recurrence but the number of tumors was not (P =.39).

CONCLUSION

Radiofrequency thermal ablation provides local control of advanced liver tumors with low recurrence and acceptable morbidity.

Improved survival with screening for hepatocellular carcinoma

Hepatocellular cancer (HCC) is a frequent cause of cancer death worldwide. Although successful screening programs exist in Asian countries, the role for screening in the United States is not clear. The purpose of this study is to determine if screening has an effect on survival in a predominantly Asian population in Hawaii. We retrospectively reviewed cases of HCC from 1993 to 1998 for demographic data, risk factors, symptoms, stage, treatment, and survival. Patients were divided into 3 groups according to presentation: symptomatic (S), asymptomatic (A), and asymptomatic but screened for disease (A/Sc). Kaplan-Meier analysis was performed on overall survival by group. Ninety-one patients were referred for HCC. There were 56 patients in group S, 19 patients in group A, and 16 patients in group A/Sc. Patients in group A/Sc survived significantly longer than those in group S (P =.009), with the former group having a median survival of 1,399 versus 234 days for group S. Median survival for group A was 545 days and did not differ significantly from the other groups. Patients who are asymptomatic and screened for HCC have an increased survival compared with those patients who present with symptoms. This may justify the use of a formal screening program for HCC in Hawaii, but we would need to investigate this prospectively.

Attempted limb lengthenings beyond twenty percent of the initial bone length: results and complications

In response to historic guidelines suggesting limits to the amount of limb lengthening, we report the results and complications of those patients in whom the initial goal of lengthening exceeded 20% of the initial segment length. Thirty-one patients underwent a total of 35 attempted lengthenings with a mean follow-up of 38.6 months. Limb-length discrepancy was the primary indication in all but one case. With an average goal of 35% of the original bone length, we achieved a mean gain of 33%. Lengthening to within 2.5 cm was achieved in 31 (89%) of 35 cases, and significantly more successful with goals extending < or =55% of the initial bone length (p<0.05). Treatment times extended a mean of 8.7 months with a healing index of 37 days/cm. By Paley's classification scheme, all had problems, in addition to an average of 1.3 obstacles and 0.9 complications per segment lengthened. In 23 patients with extended follow-up, good to excellent results were achieved in 78%, and were significantly more successful with goals < or =55% (< or =0.05).

Vaginal pH and parabasal cells in postmenopausal women

OBJECTIVE

To determine the vaginal pH level that correlates with elevated parabasal cells in vaginal smears.

METHODS

Postmenopausal women presenting to a gynecology office for routine annual and incontinence examinations were studied prospectively. Women were excluded if they had vaginal infections or pelvic organ prolapses past the hymen. pH was measured and cytology smears made from the midvagina. A pathologist who was not aware of pH results evaluated the smears. Spearman rho was used to correlate pH and percentage of parabasal cells. Logistic regression was used to analyze the relationship between pH and increased parabasal cells in vaginal smears. Predictive values were used to select a pH level as a cutoff point to predict increased parabasal cells.

RESULTS

Seventy-four women were enrolled and 70 completed the study. The correlation coefficient between pH and percentage of parabasal cells was 0.6 (P < .001). Logistic regression showed association of pH with 20% or more parabasal cells (P < .001). Positive and negative predictive values for pH level above 6.0 as a predictor of 20% or more parabasal cells were 96.3% and 87.5%, respectively. The prevalence of elevated parabasal cells was 22.9%.

CONCLUSION

Vaginal pH above 6.0 correlates with high levels of parabasal cells (20% or more) from the midvagina.

Number of nodes examined and staging accuracy in colorectal carcinoma

PURPOSE

The objective of this study was to determine the number of nodes that need to be examined to accurately reflect the histology of the regional lymphatics in colorectal carcinoma.

PATIENTS AND METHODS

Patients undergoing curative resection for T2 and T3 colorectal cancer between 1992 and 1996 were reviewed. Pathologic data from these patients were entered into a computerized database for storage, retrieval, and analysis. The major outcome measured was the number of nodes that need to be examined to achieve a node-positive rate consistent with that reported in the National Cancer Data Base (NCDB) report.

RESULTS

The number of nodes examined ranged from 0 to 78 (mean, 17 nodes). Node-negative patients had fewer nodes examined (mean, 14 nodes) than node-positive patients (mean, 20 nodes; P =.003). The entire sample had a node-positive rate of 38.8% (95% confidence interval [CI], 32% to 45.5%), not statistically different from that in the NCDB report. When at least 14 nodes were examined, the percent of patients with at least one positive node was 33.3% (95% CI, 24.6% to 42.3%), not statistically different from the NCDB report.

CONCLUSION

In a sample of patients statistically similar to the sample in the NCDB report, the examination of at least 14 nodes after resection of T2 or T3 carcinoma of the colon and rectum will accurately stage the lymphatic basin.

Development and outcomes of the multiple-choice format national certification examination in nurse-midwifery and midwifery

The national certification examination in nurse-midwifery and midwifery now is offered exclusively in the multiple-choice format. The strategies used to develop equivalent examination forms are described. The manner of criterion-referenced standard setting is explained. Outcomes of the first five multiple-choice examination forms include an aggregate first-time failure rate of 8.3%. Multiple- and logistic-regression analyses indicate that examination scores of African-American and Hispanic ethnic candidates, and older candidates, are lower with regard to statistical significance; however, these differences are too modest to be of practical significance. No substantive relationship was observed between any demographic or academic variable and the probability of passing the examination. The experience gained by the ACNM Certification Council during development, administration, and evaluation of these first five multiple-choice examination forms has provided strong support for the transition to multiple-choice testing for the assessment of entry into practice of this competency-based profession.

Frequency of mortality and myocardial infarction during maximizing oxygen delivery: a prospective, randomized trial

OBJECTIVES

To determine the frequency of myocardial infarction and mortality during treatment that increased oxygen delivery (DO2) to > or = 600 mL/min/m2. To define the characteristics of patients achieving a high DO2 without inotropes in order to guide future studies.

DESIGN

A prospective, randomized, controlled trial.

SETTING

Two surgical intensive care units at The Queen's Medical Center in the University of Hawaii Surgical Residency Program.

PATIENTS

Eighty-nine surgical patients (> or = 18 yrs of age), who were admitted to a surgical intensive care unit and who required pulmonary artery catheter monitoring, were selected for the study. Diagnoses included sepsis, septic shock, adult respiratory distress syndrome, or hypovolemic shock. Patients facing imminent death were excluded from the study.

INTERVENTIONS

The treatment group received fluid boluses, blood products, and inotropes, as needed, to achieve a DO2 of > or = 600 mL/min/m2 in the first 24 hrs. Using the same interventions, we treated the control group to reach a DO2 of 450 to 550 mL/min/m2.

MEASUREMENTS AND MAIN RESULTS

Hemodynamic measurements were obtained every 4 hrs until the pulmonary artery catheter was removed. DO2 and oxygen consumption were calculated by standard formulas. Serial creatine kinase myocardial fraction and electrocardiograms were documented for the first 48 hrs after study entry and for any new onset of arrhythmia or increasing hemodynamic instability. The patients who generated a high DO2 (> or = 600 mL/min/m2) with only preload treatment were reflective of patients with better cardiac reserve and low mortality rates. These patients, from both treatment and control groups, were excluded in the final analysis. The treatment group who received inotropes to achieve the high DO2 had a 14% mortality rate. Those patients who failed to achieve the high DO2 had a 67% mortality rate, and the control group who achieved a normal DO2 had a 62% mortality rate (p = .005). The frequency of myocardial infarction after study entry was 5.6% (five of 89 patients). This rate was not higher among the groups who received inotropes. Logistic regression analysis showed that age of > or = 50 yrs could be used to classify patients as not self-generating, with an 83% chance of being correct.

CONCLUSIONS

The group that required catecholamines to achieve a DO2 of > or = 600 mL/min/m2 had a lower mortality rate, with no increase in the frequency of myocardial infarction. Future prospective, controlled trials examining select groups of patients (age > or = 50 yrs) may demonstrate a difference between control and treatment groups by eliminating the majority of patients who generate the high DO2 with only preload augmentation.

The effect of nursing interventions on transcutaneous oxygen and carbon dioxide tensions

The objectives for this study were to (a) establish reference values for transcutaneous oxygen tension (PtcO2) and carbon dioxide tension (PtcCO2) in response to three common patient events (a nurse-administered bed bath, passive range-of-motion exercises, and turning from side to side), and (b) determine if these physiological parameters vary according to the order in which the interventions are administered. A convenience sample of 30 healthy men and women were randomly assigned to one of three treatment groups, which designated the order in which the interventions were administered. Instrumentation included a Novametrix Model 840 transcutaneous monitor, a Dinamap BP monitor, a BoMed NCCOM3 cardiovascular monitor, and YSI 44008 thermistors. Analysis of ambient temperature at baseline revealed that the room was significantly cooler for men than for women. Analysis of covariance revealed no significant difference between men and women, except at baseline. The mean PtcO2 for each activity, as well as the post-activity period, was significantly higher than at baseline. There was a significant interaction between gender and activity for PtcO2 and PtcCO2. For both men and women, the mean changes in PtcCO2 were statistically significant but clinically insignificant. The order in which interventions were administered did not have a significant effect on either PtcO2 or PtcCO2. The results suggest that the physical activity associated with nursing interventions may significantly improve oxygen levels in the skin by stimulating overall cutaneous circulation.

Factors that predict performance on the national certification examination for nurse-midwives

The ACNM Certification Council is responsible for determining that the national certification examination in nurse-midwifery is not biased toward any protected group. Educational programs of nurse-midwifery have an interest in knowing that their admissions criteria and educational design have validity. Policy makers have an interest in both of these issues. Nine demographic and preadmission factors were investigated to identify their ability to predict performance on the nurse-midwifery national certification examination. This retrospective analysis included 1,046 candidates who took any one of five criterion-referenced, modified essay forms of the examination between January 1988 and April 1994. Multiple-regression analysis revealed that five factors explained 16.2% of the variance in certification examination performance. These factors included age (as age increased, scores decreased slightly), ethnicity (white and Hispanic candidates received higher scores compared with other groups), years of nursing practice prior to nurse-midwifery education (a slight positive influence for each additional year), highest educational degree obtained (those whose highest degree was the baccalaureate performed slightly better than candidates with no degree and candidates with graduate degrees), and academic level of the nurse-midwifery education program (certificate, master's, and doctoral level candidates all performed better than candidates from precertification programs; certificate candidates performed slightly better than master's candidates). However, even though these variables contributed to a statistically significant model, the actual degree of predicted difference in scores was of little practical significance. Variables that were not predictive of performance included marital status, U.S. versus foreign education either in nursing or in midwifery, and academic level of the registered nursing educational program [corrected].

In-hospital care for low-risk childbirth. Comparison with results from the National Birth Center Study

The largest prospective study of freestanding birth centers was reported in 1989. This article reports on data from a comparison group of over 2,000 low-risk women who were admitted to hospital-care settings during the same period. The data on the hospitalized women were collected using the research methodology and data collection instruments developed for the birth center study. Consequently, these data offer the opportunity to observe differences that can be associated with birth site. Both groups of women experienced similar rates of serious antepartum and intrapartum health problems and maternal morbidity. However, even when controlling for complications and differences in sociodemographic characteristics, women in hospitals were more likely to receive an interventive style of labor and birth management. Neonatal outcomes were also similar, although the incidence of sustained fetal distress, prolapsed cord, and difficulty in establishing respirations were significantly greater in the hospital sample. Hospital care did not offer any advantage for women at lowest risk, and it was associated with increased intervention. The results of this study provide support for the National Birth Center Study's conclusion that birth centers offer a safe and acceptable alternative for selected pregnant women.

Morning glory syndrome with chronic simple glaucoma

A 42-year-old woman had morning glory syndrome of the fundus of the right eye. The finding was related to chronic simple glaucoma and without pulsation of the staphyloma. The clinical symptoms and echographic pattern during the endocular hypertensive phase with normal intraocular pressure was studied after appropriate medication. This associated disease is attributed to the presence of a congenital malformation of the anterior chamber angle.

HLA antigens in insulin dependent and non-insulin dependent Spanish diabetic patients

HLA-A, -B, -C, -DR and Bw4, Bw6 antigens and Bf and GLO alleles have been studied in a sample of Spanish insulin dependent (IDD) and non-insulin dependent (NIDD) diabetic patients. In IDD's there was no significant increase of B8 and B15; an increase of B18 secondary to that of DR3 has been found. DR4 was also increased in our sample. The GLO-S/DR2 haplotype was found to be decreased in IDD. It was observed that (Aw30)-B18-Cw5-Bw6-DR3-BfF1 is the commonest ID diabetic haplotype in our population. A relationship between DR4 and early IDD onset was also found. No association was found between HLA, or Bf, and age of onset, macroangiopathy, microangiopathy, retinopathy, nephropathy and peripheral or autonomic neuropathy. In NIDD's, DR3 was increased and DR3-non BfF1 and DR3-non B18 RRs were higher than DR3 RR.Aw30 and Cw5 tended to be decreased, although not significantly. These findings further support the hypothesis that several closely linked diabetic susceptibility factors may exist within an HLA haplotype (i.e.: (Aw30)-B18-Cw5-Bw6-DR3-BfF1 in our population) and that all of them may be necessary for developing an IDD form; lack of one or several factors might lead to the acquisition of the NIDD form.