Assessing knee joint biomechanics and trunk posture according to medial osteoarthritis severity

During progression of knee osteoarthritis (OA), gait biomechanics changes three-dimensionally; however, its characteristics and trunk posture according to OA severity remain unknown. The present study investigated three-dimensional knee joint biomechanics and trunk posture according to knee OA severity. Overall, 75 patients (93 knees) with medial knee OA [Kellgren-Lawrence grade ≥ 2, grade 2: 20 patients with 24 knees (mean 60.0 years old); grade 3: 25 with 28 knees (mean 62.0 years old); grade 4: 30 with 41 knees (mean 67.9 years old)] and 14 healthy controls (23 knees, mean 63.6 years old) underwent gait analysis using an optical motion capture system and point cluster technique. In grade 2 knee OA, the relative contribution of the knee adduction moment (KAM) increased significantly (P < 0.05), and that of the knee flexion moment decreased (P < 0.05) prior to significant progression of varus knee deformity. Grade 3 knee OA showed significant exacerbation of varus knee deformity (P < 0.01) and KAM increase (P < 0.001). The maximum knee extension angle decreased (P < 0.05) and trunk flexion increased during gait in grade 4 knee OA (P < 0.001). Our study clarified the kinematics and kinetics of medial knee OA with trunk flexion according to severity. Kinetic conversion occurred in grade 2 knees prior to progression of varus deformities, knee flexion contractures, and sagittal imbalance during gait in patients with severe knee OA.

Higher Association of Pelvis-Knee-Ankle Angle Compared With Hip-Knee-Ankle Angle With Knee Adduction Moment and Patient-Reported Outcomes After High Tibial Osteotomy

BACKGROUND

High tibial osteotomy (HTO) reduces the load distribution of the medial compartment by modifying leg alignment. Knee adduction moment (KAM), a surrogate measure of dynamic loading in the knee joint, decreases after HTO. However, leg alignment does not fully account for KAM.

PURPOSE

To assess the association between the pelvis-knee-ankle angle (PKA), a novel radiographic parameter reflecting leg alignment and pelvic width, and KAM and patient-reported outcomes after HTO.

STUDY DESIGN

Cross sectional study; Level of evidence, 3.

METHODS

PKA is the angle between the line from the midpoint of the anterior superior iliac spine to the center of the knee joint and the mechanical axis of the tibia. In this study, 54 patients with medial compartment knee osteoarthritis and varus alignment who underwent 3-dimensional gait analysis preoperatively and 2 years after medial open-wedge HTO were evaluated. The primary outcomes were hip-knee-ankle angle (HKA), PKA, KAM peaks, and Knee Society Score (KSS). Single and multivariate regression analysis including PKA and KAM peaks as well as other demographic and radiologic factors was performed.

RESULTS

HKA was weakly correlated with the first peak KAM (r = -0.33; P < .01) and second peak KAM (r = -0.27; P = .01) before HTO, but not significantly correlated after HTO. PKA was moderately correlated with the first peak KAM (r = 0.45; P < .01) and second peak KAM (r = 0.45; P < .01) before HTO and with the first peak KAM (r = 0.51; P < .01) and second peak KAM (r = 0.56; P < .01) after HTO. Multivariate linear regression revealed that postoperative PKA was still associated with the KAM peaks after HTO. Only postoperative PKA was correlated with the KSS satisfaction subscale (r = -0.30; P = .03).

CONCLUSION

Although HKA was not correlated with KAM peaks after HTO, PKA was significantly correlated with KAM peaks in patients with varus knee osteoarthritis after HTO.

Trainees between theoreticalknowledge and the initiative takingat the hospital

Introduction

The internshipis a period in which the studentimplements what they have learned from their training to obtain or certification and to promote their professionalintegration, the difficulty of taking initiative and the lack of self-esteemrepresenting an obstacle to their training

Objectives

This is a quantitative descriptive study conducted at the different placement departments among all 2nd-year students in all sections. Our data collection was done using two questionnaires administered, one for the supervisors and the other for the students.

Methods

Theoretical Framework: Theorist Patricia Benner

Results

According to the results found, in oursample, thereis a predominance of females 89.17%, with a sex ratio of 0.121. 88.34% are aged between 20 - 21 years and an averageage of 22.4 years. According to the interpretation of the Rosenberg Self-Esteem Scale scores, 17.5% of the trainees have a “Very Low Self-Esteem”, 47.5% have a “Low Self-Esteem”, 25.83% have an “Average Self-Esteem”, and only 9.17% have a “High Self-Esteem”. In addition, more than half of the respondents, 53.33%, state thatthey “often” have difficultytaking the initiative in the traineeshipenvironment, while 30.83% do not have such difficulty but “rarely”. Indeed, 53.33% of confirmedsupervisorssaythatthey “often” have difficultytaking the initiative in the placement environment

Conclusions

It isnecessary to take into account these obstacles to the trainee’s training through better psychological supervision, which could be the first steptowardssolving the problem

Disclosure

No significant relationships.

Changes in immune system and intestinal bacteria of cows during the transition period

•

Transitional high-energy diets reduce peripheral blood lymphocytes in dairy cows.

•

High-energy diets upregulate IL-1β and IL-2 and downregulate IL-10 expression.

•

Functional lactobacillus plantarum LP1 restores normal levels of lymphocytes subset.

•

Lactobacillus plantarum LP1-added diets reduce inflammatory cytokine expression.

•

LP1 mitigates immune response imbalances caused by transitional high energy diets.

High-yield dairy cows need high energy feed during periods of increased milk production. The transitional feeding to high energy feed increases the risk of developing a variety of metabolic disorders. Here, five Holstein cows were fed a four-stage feeding protocol (3 weeks for each stage) ranging from 54.9 to 73.7% total digestive nutrients (TDN). The purpose of the study was to investigate the effect of lactic acid bacteria on high-energy-fed cows associated with transitional feeding, and to evaluate the effects of probiotics on intestinal bacterial changes and inflammatory responses. Three feed transition periods were established for five cows, and Lactobacillus plantarum RGU-LP1 (LP1) was fed as a probiotic during the high-energy feeding period. The number of lymphocyte subsets such as CD3-, CD4-, and CD8 positive cells decreased in response to the high energy feed. Lipopolysaccharide (LPS)-induced cytokine (IL-1β and IL-2) gene expression in peripheral blood mononuclear cells (PBMCs) was shown to increase in those animals receiving the high energy feed. However, supplementation with LP1 resulted in an increase in the number of lymphocyte subsets and the expression of IL-1β and IL-2 were returned to the level at low energy diet. These results suggest that high energy diets induce inflammatory cytokine responses following LPS stimulation, and that the addition of LP1 mitigates these results by regulating the LPS-induced inflammatory reaction. Therefore, the functional lactic acid bacteria LP1 is expected to regulate inflammation resulting from high energy feeding, and this probiotic could be applied to support inflammatory regulation in high-yield dairy cows.

Postural Stability and Muscle Activation Onset during Double- to Single-Leg Stance Transition in Flat-Footed Individuals

The effects of foot posture on postural stability and on muscular activation pattern for postural control remain unclear. This study aimed to investigate postural stability and muscular activation onset during the transition task from double- to single-leg stance in individuals with different foot postures. Twenty-seven healthy men (age: 21.5 ± 1.5 years) were divided into 3 groups using the Foot Posture Index: neutral foot (n = 10); flatfoot (n = 8); and high-arched foot (n = 9). Center of pressure (COP) data and muscle activation onset times of the tibialis anterior, peroneus longus, gastrocnemius medialis, and soleus during the transition task with eyes closed were compared among groups using one-way analysis of variance and a post-hoc Tukey honestly significant difference test (p < 0.05) when the data were normally distributed and the Kruskal-Wallis test and a post-hoc Mann-Whitney U-test with Bonferroni correction (p < 0.0167) when the data were not normally distributed. The COP displacements in the mediolateral and anteroposterior directions and the resultant COP displacement during the first 3 s after a stability time point, as determined by sequential estimation during the single-leg stance phase, differed significantly among the three groups (p < 0.05). Post-hoc tests showed that the displacements were significantly greater in the flatfoot group than in the neutral and high-arched foot groups (p < 0.05), and the effect sizes for these results were large. No muscular activation onset times showed significant intergroup differences. Postural stability was significantly decreased only in the flatfoot group, while muscle activation onsets did not differ significantly by foot posture during the transition task. Decreased postural stability may be one mechanism underlying the link between flatfoot and risk of lower limb injury, and foot posture represents a potential confounder for measuring postural stability during the transition task.

Nurse initiated thrombolysis in the accident and emergency department: safe, accurate, and faster than fast track

OBJECTIVE

To reduce the time between arrival at hospital of a patient with acute myocardial infarction and administration of thrombolytic therapy (door to needle time) by the introduction of nurse initiated thrombolysis in the accident and emergency department.

METHODS

Two acute chest pain nurse specialists (ACPNS) based in A&E for 62.5 hours of the week were responsible for initiating thrombolysis in the A&E department. The service reverts to a "fast track" system outside of these hours, with the on call medical team prescribing thrombolysis on the coronary care unit. Prospectively gathered data were analysed for a nine month period and a head to head comparison made between the mean and median door to needle times for both systems of thrombolysis delivery.

RESULTS

Data from 91 patients were analysed; 43 (47%) were thrombolysed in A&E by the ACPNS and 48 (53%) were thrombolysed in the coronary care unit by the on call medical team. The ACPNS achieved a median door to needle time of 23 minutes (IQR=17 to 32) compared with 56 minutes (IQR=34 to 79.5) for the fast track. The proportion of patients thrombolysed in 30 minutes by the ACPNS and fast track system was 72% (31 of 43) and 21% (10 of 48) respectively (difference=51%, 95% confidence intervals 34% to 69%, p<0.05).

CONCLUSION

Diagnosis of acute myocardial infarction and administration of thrombolysis by experienced cardiology nurses in A&E is a safe and effective strategy for reducing door to needle times, even when compared with a conventional fast track system.

Apoptotic epithelial cells in biopsy specimens from infants with streaked rectal bleeding

BACKGROUND

Histologic studies of rectosigmoidal mucosal biopsies of infants with isolated blood-streaked stool have shown many eosinophils and revealed aggregates of small dark granules (nuclear dust). However, no description of the nuclear dust has been made for this condition and the nature of the nuclear dust has not been thoroughly investigated. We determined the characteristics of these particles in biopsies from infants with streaked rectal bleeding.

METHODS

Nineteen infants who were younger than 6 months old and had isolated rectal bleeding were studied, as were six age-matched control infants. Rectosigmoidal mucosal biopsies were immunohistochemically assessed using anticarcinoembryonic antigen and macrophage-associated antibodies and examined for apoptotic cells by modified in situ TdT-mediated dUTP-biotin nick-end labelling. The number of apoptotic epithelial cells was compared between rectal bleeding and control groups.

RESULTS

Immunohistochemistry showed that at least some of the nuclear dust consisted of apoptotic epithelial cells. Infants with rectal bleeding also showed nodular lymphoid hyperplasia (n = 16), abundant eosinophils (>20/high power field, n = 14) in the mucosa, and a significantly high number of apoptotic epithelial cells relative to the control group. Rectal bleeding disappeared at 6-month follow-up in 14 of 18 infants (one was lost to follow-up) who were fed a different milk formula or breast-fed (their mothers were restricted from having cow's milk and eggs).

CONCLUSIONS

The high number of apoptotic epithelial cells in rectosigmoidal mucosal biopsies of infants with streaked rectal bleeding is probably caused by accelerated epithelial cell turnover and apoptosis.

Haplotype-specific sequence encoding the protein kinase, interferon-inducible double-stranded RNA-dependent activator in the human leukocyte antigen class II region

The protein kinase, interferon-inducible double-stranded (ds)RNA-dependent activator (PRKRA) is a dsRNA-binding protein which activates a protein kinase participating in the antiviral activity of interferon. Our previous studies indicated that the nucleotide sequence encoding PRKRA, which appeared to be an intronless gene, was present in PAC HS265J14 containing the human leukocyte antigen (HLA) DR subregion. In this study, we further investigated and characterized the PRKRA gene on the human genome by means of Southern blotting and polymerase chain reaction with homozygous typing cell lines for HLA genes. Results indicated that the presence of PRKRA in the DR subregion was dependent on the DR53 group. Consistently, fluorescence in situ hybridization profiles with PRKRA as a probe showed that the hybridization signal on Chromosome (Chr) 6p21.3 was seen only in the samples carrying the DR haplotypes that belonged to the DR53 group. Interestingly, another hybridization signal, which was mapped on Chr 2q31.2-q32.1, was always detected in the samples examined, i.e., even in the samples negative for the DR53 group. The outcome of a sequence-database homology search further indicated that the PRKRA gene with introns appeared to be present in a recently opened draft-sequence, RP11-65L3 (GenBank accession number AC009948), which is located between D2S335 and D2S2257. Together, the data presented here indicate that the PRKRA gene in the DR subregion is a processed pseudogene (PRKRApsi), which could have been generated only on the DR53 common ancestor's genome, and that the master copy of PRKRApsi is most probably present on Chr 2q31.2-q32.1.

Closed-loop control using a stretch sensor for restoration of standing with functional electrical stimulation in complete paraplegia

A closed-loop control system for standing with functional electrical stimulation (FES) using percutaneous intramuscular electrodes in complete paraplegia is described. The system consisted of ultrafine percutaneous intramuscular electrodes, a 32-channel stimulator and a stretch sensor with active current control to detect knee buckling. The closed-loop control system was applied in a T8 completely paraplegic patient. Compared to the stretch sensor with a wide use flexible goniometer for direct current control during standing, the stretch sensor was superior to the flexible goniometer in both ease of use and response. The average time delay from the start of knee buckling until the sensor turned on was 0.56+/-0.19 seconds (Mean+/-S.D.) in the goniometer and 0.21+/-0.06 seconds in the stretch sensor. The average time delay from the start of knee buckling until the recovery from knee buckling was 1.01+/-0.05 seconds in the goniometer and 0.78+/-0.06 seconds in the stretch sensor. The continuous standing ability of the patient increased from 12 minutes with open-loop stimulation to 30 minutes with the closed-loop control. No complications such as falling occurred during clinical use. This system prevented falling due to knee buckling during standing and prolonged upright activities in complete paraplegics.

Telehealth in the Pacific: current status and analysis report (1999-2000)

From the summer of 1999 to the spring of 2000, we undertook an on-site investigation of the management and operational status of telehealth in the Pacific. The writers also gathered additional materials upon returning to Japan to provide as detailed a report as possible on the current status and analysis of telemedicine in the Pacific. Following the collapse of the Soviet Union, various regions around the world has sought a gentler alternative to "deterrence by arms." The writers of this paper believe one such means is telemedicine. We believe telemedicine services may help offset the emotional stress and sense of inequality experienced by "islanders and civilians living around military bases," which the financial benefits of the so-called "base-economy" alone has never been able to remedy. There are numerous medical support activities currently operating in the Pacific region, and telecommunications is the most effective tool for connecting and unifying such a vast region. We believe that projects for this region must have a clear focus and objective and be able to demonstrate concrete results in order to win subsidies or aid.

Molecular analyses of the possible RNA-binding protein gene located in the human leukocyte antigen (HLA)--DR subregion

We have previously found the sequence having potential for encoding a new protein in the human leukocyte antigen (HLA) class II region. The predicted amino acid sequence showed a significant sequence homology to the Xenopus double-stranded RNA-binding protein (Xlrbp) and the human cellular protein bound to the transactivation response (TAR) of human immunodeficiency virus type-1 (HIV-1) RNA (TRBP). Reverse transcription-polymerase chain reaction (RT-PCR) with poly(A)(+) RNA prepared from human peripheral lymphocytes and direct sequencing analyses in this study showed that the transcripts of the gene encoding the putative RNA-binding protein occurred in human cells: the gene was provisionally named Homo sapiens RNA-binding protein (hsRBP). From the result of Southern blot analyses, it appears that multiple copies of hsRBP are present in the human genome. Together with the known cDNAs having a high sequence homology to hsRBP, the data presented here suggest that the multigene family of the double-stranded RNA-binding protein exists in the human genome.

Morphology and function of pulmonary surfactant inhibited by meconium

The pathophysiology of neonatal meconium aspiration syndrome (MAS) is related to mechanical obstruction of the airways and to chemical pneumonitis. It has also been suggested that meconium causes inhibition of surfactant function. To assess its in vitro effect on surfactant function and morphology, we used a pulsating bubble surfactometer to measure the dynamic surface tension of meconium-surfactant mixtures and observed their electron microscopic structures. The mixtures were prepared by adding serial dilutions of human meconium to various concentrations of Surfactant-TA (Surfacten) that had been used for the prevention and treatment of neonatal respiratory distress syndrome. Inhibition of the surface tension-lowering properties of Surfactant-TA was caused by the addition of meconium and depended on the concentration of the surfactant; the inhibition could be overcome by increasing the surfactant concentration. When meconium was added to Surfactant-TA, the characteristic ultrastructural features of the latter, the loosely stacked layers, changed to a spherical lamellar structure and folded linear structures. These results suggest that meconium inhibits surfactant function by altering surfactant morphology. Our morphologic and functional findings support the new concept that surfactant inhibition may play a role in the pathophysiology of MAS.

A case of congenital Listeria septicemia associated with high levels of inflammatory cytokines

A case of congenital Listeria septicemia is reported. A 2256 g male infant suffering from respiratory and circulatory failure with shock-like symptoms and high levels of inflammatory cytokines (tumor necrosis factor-alpha, interleukin-1 beta, -6, and -8), was admitted to the Morioka Red Cross Hospital. Listeria monocytogenes was cultured from cord blood, contents from the external ear canal, rectum and stomach. The infant was treated with surfactant replacement as well as conventional therapy. The high levels of interleukin-1 beta decreased with the improvement of the circulatory function, which might have been the major cause of the poor clinical state.

Surfactant proteins and stable microbubbles in tracheal aspirates of infants with respiratory distress syndrome: relation to the degree of respiratory failure and response to exogenous surfactant

Surfactant proteins (SP-A and SP-BC), albumin (ALB), and stable microbubble (SM) count were measured in tracheal aspirates from infants with respiratory distress syndrome (RDS) receiving single-dose Surfactant-TA (surfactant group, n = 32) or no surfactant (control group, n = 12), and those without RDS (non-RDS group, n = 8) to determine biochemical and biophysical status of surfactant in the course of RDS after surfactant replacement. Surfactant therapy resulted in immediate and sustained elevations of SP-BC/ALB and SM count with a rapid fall in ventilatory index to levels measured in the non-RDS group, whereas these indices improved slowly in the control group. The SP-A/ ALB was initially low in both RDS groups and increased to levels measured in the non-RDS group by age 48 h. Multiple regression analysis showed that SP-BC/ALB, postnatal age, SM count, SM count/SP-A plus SP-BC, and surfactant therapy were independently associated with the severity of RDS as assessed by ventilatory index (r = 0.75, P < 0.0001; number of samples = 256). Infants with a relapse response to surfactant (n = 9) had levels of SP-A/ALB and SP-BC/ALB similar to those measured in the sustained group (n = 23), but had significantly lower SM count and SM count/SP-A plus SP-BC between 24 and 96 h of age.

CONCLUSION

Surfactant therapy normalizes the surfactant and respiratory status of infants with RDS. Surfactant dysfunction rather than depletion may explain the relapse response seen in some surfactant recipients.

Is direct cell-to-cell contact needed to improve embryonic development in co-culture?

In vitro co-culture of embryos and somatic cells is used to obtain well-developed embryos of humans and other species. However, it is not known whether direct cell-to-cell contact is essential to embryonic development. To elucidate this mechanism, we cultured mouse embryos using rabbit oviductal cell as a somatic cell. To avoid the direct contact we used a microporous membrane cell-culture insert. This cell-culture insert permits only the liquid portion of the culture medium to pass through it and was interposed between mouse embryos and cultured rabbit oviductal cells. When mouse embryos were placed on the cultured oviductal cells directly, 52.2% of two-cell-stage embryos developed to the blastocyst stage. In contrast, when the cell-culture insert was interposed between the embryos and the cultured oviductal cells, 50.0% of two-cell-stage embryos developed to that stage. There was no difference between the rate of blastocyst development in co-culture system with and without cell culture insert. Results indicate that oviductal factor (s), rather than a direct contact with oviductal cells, is essential to the enhancement of embryonic development in vitro.

Application of a new perchloric acid treatment method to measure endotoxin in both amniotic fluid and cord blood by an endotoxin-specific chromogenic Limulus test in intra-amniotic infection

Endotoxin in both amniotic fluid and cord blood was measured to detect intra-amniotic fetal infection. Both amniotic fluid and cord blood plasma were pretreated by a perchloric acid treatment, and the endotoxin level was measured by Endospecy test. Cut off values for endotoxin in amniotic fluid and cord blood were 8.5 pg/mL and 7.6 pg/mL, respectively. Escherichia coli intra-amniotic infection caused respiratory distress syndrome (RDS)-mimicking pneumonia. Abnormally high values of endotoxin in both amniotic fluid and cord blood were detected. Intra-amniotic infection caused by Gram-positive bacteria (group B streptococci, Enterococcus fecalis) was shown to be endotoxin negative in both amniotic fluid and cord blood. In cases of negative amniotic fluid culture, measurement of the value of endotoxin in the amniotic fluid is useful in identifying intra-amniotic fetal infection.

Ethanol resistive microbubble test: a modification of the stable microbubble test used to predict respiratory distress syndrome

The stable microbubble (SM) test on gastric aspirate obtained at birth proved useful in identifying infants who would develop respiratory distress syndrome (RDS). This test involves only the count of stable microbubbles of < or = 15 microns in diameter. Larger bubbles (> 15 microns in diameter) are not necessary for the test and may interfere with stable microbubble counting. The aims of the present study were to determine: (i) if larger bubbles could be selectively removed by adding ethanol, a potent bubble breaker; and (ii) if the predictive value of this modified test, the ethanol resistive microbubble (ERM) test, on the development of RDS was similar to that of the SM test. Varying amounts of different concentrations of ethanol-water solutions were added to the top of the bubble crop generated by the SM test procedure, and the mean counts of stable microbubbles and larger bubbles in five regions were calculated. A volume of 10 microL of 47.5% ethanol was effective in defoaming larger bubbles generated by the SM test procedure without altering the stable microbubble counts. When concurrently performed on 43 samples of gastric aspirate obtained at birth from infants of less than 35 weeks gestation, the RDS predictive value of the ERM test was similar to that of the SM test. It was concluded that the ERM test may serve as an alternative to the SM test.

Effect of egg white on serum cholesterol concentration in young women

In a previous study we observed favorable effects of egg white on serum lipids in rats and mice. The present study was designed to elucidate these effects in 24 female university students with moderate hypercholesterolemia. About 30% of total protein was supplied with egg white, tofu or cheese. The experiment was conducted for a complete menstruation cycle of each subject. Lipid intake was about 30% of total energy intake. The energy intake of each subject was constant throughout the experiment. Body weight was measured every morning. Daily activity was measured by a pedometer. Blood was withdrawn after an overnight fast on the first, 15th and last days and serum lipids were measured. Body weight was measured every morning. Daily activity was measured by a pedometer. Blood was withdrawn after an overnight fast on the first, 15th and last days and serum lipids were measured. Body weight and daily activity were maintained in all the groups throughout the experiment. The egg white group showed a similar decrease in the total cholesterol (Total-C) concentration but a greater increase of high-density lipoprotein cholesterol (HDL-C) concentration as compared to the tofu group and a greater decrease in Total-C and low-density lipoprotein cholesterol (LDL-C) concentrations and a greater increase in the HDL-C concentration as compared to the cheese group (p < 0.05). The results indicate the favorable effects of egg white in the control of hypercholesterolemia.

[Molecular aspects of pulmonary surfactant in neonatal respiratory distress syndrome and surfactant replacement therapy]

A success in surfactant therapy for neonatal respiratory distress syndrome in Japan in 1980 has led to the introduction of scientific randomized controlled trials on the one hand, and a great interest in the constituents of the exogenous surfactant on the other. It contains 2% hydrophobic surfactant proteins B and C that are now known to be critical components in surface-active properties of lung surfactant. The application of molecular biology has fostered rapid progress in the elucidation of the structure, function and metabolism of the surfactant. The introduction of surfactant therapy has had a major impact on neonatal mortality and morbidity. Although various surfactant preparations are already in the market and a new generation of totally synthetic surfactant is under clinical evaluation, further studies are required to address the issue regarding optimization of surfactant therapy.

Application of a new perchloric acid treatment method to measure endotoxin by an endotoxin-specific chromogenic Limulus test in neonatal septicemia

The endotoxin in blood was measured to establish both the cut-off value and to detect Gram-negative septicemia. We employed a new perchloric acid treatment method using an endotoxin-specific chromogenic Limulus test (Endospecy test). The cut-off value of endotoxin in blood was 11.2 pg/mL. All cases of septicemia (n = 7) showed high values of endotoxin. Three cases were Group B streptococci, and two cases were Escherichia coli. The others were showed to be negative in blood cultures. The paired values of endotoxin titers during a 48 h interval were useful to evaluate the effectiveness of antibiotics.

Neonatal alloimmune thrombocytopenia involving HPA-5b (Br(a)): a rare Japanese case

Neonatal alloimmune thrombocytopenia (NAIT) is caused by platelet antigen incompatibility between the mother and fetus. The frequency of NAIT varies among ethnic groups. In Caucasians, HPA-5b (Br(a)) is the antigen that is second most frequently implicated. In Japan, NAIT due to anti-HPA-5b antibody is quite rare. The present case is the second case of Br(a)-NAIT in Japanese and the first case serologically confirmed by monoclonal antibody-specific immobilization of platelet antigens.

Treatment of severe ovarian hyperstimulation syndrome by ultrafiltration and reinfusion of ascitic fluid

Two severe OHSS patients were treated by ultrafiltration and reinfusion of their ascitic fluid. Improvement of symptoms was marked after this treatment with no complications, and termination of pregnancy was avoided. Treatment of OHSS with this ultrafiltration and reinfusion method may help to resolve serious cases of OHSS and become a useful treatment for severe OHSS.

Stable microbubble test for predicting the risk of respiratory distress syndrome: II. Prospective evaluation of the test on amniotic fluid and gastric aspirate

We determined prospectively if the stable microbubble (SM) test on gastric aspirate obtained at birth was as useful as that on amniotic fluid in predicting respiratory distress syndrome (RDS). One hundred and five paired samples of amniotic fluid obtained at delivery from 105 consecutive women with gestation of 35 weeks or less and gastric aspirates from their neonates obtained within 30 min of birth were studied. The SM test with the predefined cut-off value of less than 5 bubbles/mm2 for amniotic fluid and less than 10 bubbles/mm2 for gastric aspirate signified the risk of RDS with the positive predictive value of 100% and 96% and with the negative predictive value of 91% and 84%, respectively. We conclude that the SM test on both amniotic fluid and gastric aspirate obtained at birth is a rapid (< 10 min), simple and reliable procedure for predicting neonates who will develop RDS. It may be used as a bedside test to define a population of neonates with surfactant deficiency in clinical trials of prophylactic surfactant therapy.

Stable microbubble test for predicting the risk of respiratory distress syndrome: I. Comparisons with other predictors of fetal lung maturity in amniotic fluid

With the advent of surfactant replacement therapy, there is an increasing need for a rapid test of predicting the development of respiratory distress syndrome (RDS). We evaluated the clinical usefulness of the stable microbubble (SM) test in predicting the development of RDS by comparison with other tests in amniotic fluid samples obtained within 12 h before delivery from 40 pregnancies between 23-35 weeks of gestation. These tests included the lecithin/sphingomyelin (L/S) ratio, disaturated phosphatidylcholine/sphingomyelin (DSPC/S) ratio, concentrations of lecithin, DSPC, and surfactant-associated proteins A and B, C (SP-A, SP-B,C). The cut-off value of each test for predicting RDS was determined at a point of maximum diagnostic accuracy. The overall diagnostic accuracy of the SM test was similar to that of other tests. However, both the SM test and the SP-B,C concentration had positive predictive values of 100%. We conclude that the rapid (< 10 min) and reliable information obtained by this test should encourage its use in defining a population of neonates with surfactant deficiency in a multicentre trial of prophylactic surfactant therapy.

Neonatal adrenal hemorrhage detected antenatally

This report describes two cases of neonatal adrenal mass detected antenatally by routine ultrasound (US) examination of pregnant women. Case 1 was recognized by the fetal US at 31 weeks gestation. The mass, located near the right upper pole of the kidney, was echolucent on US examination. A serial US of the mass showed changes of the internal echoes from a cystic lesion to a mixed lesion, and finally to a hyperechogenic lesion due to a neonatal adrenal hemorrhage (NAH). At 33 days, laparotomy was performed, and the pathological finding revealed an NAH owing to the mass bleeding into the adrenal cyst. Case 2 was also detected by fetal US just before birth. The mass of the right upper pole of the kidney was hyperechogenic on US examination. The baby clinically deteriorated after birth because of hypovolemia owing to NAH. A serial US of the mass showed the change from a hyperechogenic to a cystic lesion. Four months later, the mass spontaneously resolved. From the US spectrum, the mass was diagnosed as NAH. These are the second known cases of NAH detected before birth in Japan.

Surfactant replacement therapy in premature babies with respiratory distress syndrome: factors affecting the response to surfactant and comparison of outcome from 1982-86 and 1987-91

The impact of surfactant therapy on chronic lung disease remains uncertain. During the past decade (1982-91), over 300 babies with respiratory distress syndrome (RDS) weighing 501-2,500 g at birth were consecutively treated with surfactant-TA at our neonatal intensive care unit. Data on 95 RDS babies treated in the first 5 year period (Period 1, 1982-86) were compared with those on 158 RDS babies treated in the second 5 year period (Period 2, 1987-91). Overall respiratory improvement was better in Period 2 than in Period 1. In Period 2, surfactant therapy converted 98% of the babies with moderate/severe RDS to those with 'near normal' lung by 72 hr post-treatment. In Period 2, 95% of the surfactant-treated babies weighing 501-1,750 g at birth survived, 97% of which required no supplemental oxygen at 40 weeks corrected gestational age. Increased survival rate in the surfactant-treated babies during the past decade has not been followed by a parallel increase in chronic lung disease. The severity of the initial pulmonary disease per se was not the significant risk factor for chronic lung disease. Several other variables affecting the response to surfactant therapy and outcome have been identified by stepwise logistic regression analysis and include factors related to perinatal events such as birth asphyxia and infection, and other complications of prematurity.

A prospective, randomized trial of early versus late administration of a single dose of surfactant-TA

Thirty-two neonates weighing 500-1500 g with documented surfactant deficiency and without evidence of severe birth asphyxia, infection, prolonged rupture of membranes greater than or equal to 72 h, or oligohydramnios were randomly assigned to receive a single intratracheal dose of surfactant-TA (100 mg/kg) either within 30 min of birth (n = 16, early group) or at 6 h of age (n = 16, late group). By 6 h of age, all neonates of the late group had moderate/severe RDS, while none of the neonates of the early group had either clinical or radiological respiratory distress syndrome. The incidence of bronchopulmonary dysplasia was significantly lower in survivors of the early group than those of the late group (1/15 versus 7/14, a 43% reduction with a 95% confidence interval of 14-72%, P = 0.025). These beneficial effects of early surfactant treatment remained after controlling for the various confounding factors in the logistic models.

Surfactant proteins and anti-surfactant antibodies in sera from infants with respiratory distress syndrome with and without surfactant treatment

The presence of surfactant protein antigenemia and of surfactant protein antibodies was determined in serum from surfactant-treated and control infants with respiratory distress syndrome who were enrolled in a prospective randomized clinical trial. The surfactant used for treatment (surfactant TA) contained surfactant proteins (SPs) B and C and no SP-A. Enzyme-linked immunosorbent assays (ELISAs) that identify surfactant-associated proteins and ELISAs that identify IgG or IgM directed against surfactant proteins were used to investigate sera from these infants obtained prior to treatment, at 1 week of age, and at 2 months of age. There were no significant differences between average values in the surfactant-treated and control groups at each time period. However, in the control group, averaged results from ELISAs that identify SP-A and that identify IgM antibodies to SP-A or to SP-B, C showed significant differences between pretreatment sera and sera obtained at 1 week of age. No significant differences were noted in averaged results for IgG. Positive ELISA values were more frequently found in the control group than in the surfactant-treated group with regard to SP-A, and IgM against SP-A and SP-B, C in sera from neonates at 1 week of age. No positive ELISA values were found in sera from infants at 2 months of age. It is concluded that some patients with severe respiratory distress syndrome presumably leak surfactant proteins into the circulation and that this induces transient low titers of IgM antibody. This occurrence is decreased with surfactant treatment. Surfactant treatment may reduce leak of surfactant proteins into the vascular space by reducing lung damage.

Precision and reliability of stable microbubble test as a predictor of respiratory distress syndrome

The precision and reliability of the stable microbubble test as a predictor of respiratory distress syndrome (RDS) were studied. In blind experiments, the stable microbubble test was performed by three analysts in quadruplicate on six different amniotic fluid samples obtained from pregnant women whose babies developed RDS and on three samples prepared from mature controls. Three-way analysis of variance revealed that there were statistically significant differential effects of the analyst, observer, and sampling on the stable microbubble values, and also that there were statistically significant interactions between the analyst and observer as well as between the analyst and sampling. However, the magnitude of these effects was not large enough to modify the interpretation of the test results. We conclude that the rapidity, simplicity and reliability of the stable microbubble test allow for its use as a bedside procedure in identifying infants who are likely to develop RDS.

[Factors affecting clinical response to surfactant therapy in neonates with severe respiratory distress syndrome]

Clinical data from a multicenter, nonrandomized clinical trial (phase II) of surfactant therapy in 206 neonates with severe respiratory distress syndrome were evaluated by logistic risk models to identify factors that might affect response to surfactant therapy as well as outcome. Based on the magnitude and duration of initial response to a single post-ventilatory dose of Surfactant-TA, the response patterns were classified into three categories: A) immediate and sustained response, B) immediate response, relapse, and recovery, and C) poor or no response. Neonates with response A had significantly better outcome than those with response C. When the neonates with response A were combined with those with response B, surfactant treatment was successful in 89% of the neonates, with a 90% survival rate in this series. The risk variables strongly associated with "non responders" were low pretreatment values for arterial pH (less than or equal to 7.25), blood pressure, and a 5-minute Apgar score (less than or equal to 6). All of these factors are known to be related to perinatal events including an intercurrent episode of hypoxia during the first hours of life, and modify the course of "pure" respiratory distress syndrome, in which the surfactant deficiency is the primary factor. Some of these factors affecting the response to the surfactant can be eliminated by improving perinatal care including maternal transport, prevention of birth asphyxia and initial stabilization of the neonates with respect to the cardiocirculatory system, and by treating with surfactant at or soon after birth.

Surfactant replacement therapy with a single postventilatory dose of a reconstituted bovine surfactant in preterm neonates with respiratory distress syndrome: final analysis of a multicenter, double-blind, randomized trial and comparison with similar trials. The Surfactant-TA Study Group

The effects of a single dose of surfactant TA were assessed in premature neonates (birth weight 750 to 1749 g) with respiratory distress syndrome (RDS) in a multicenter, double-blind, randomized clinical trial. Only neonates with surfactant deficiency and without ultrasonographic evidence of intracranial hemorrhage greater than or equal to grade II were enrolled. Fifty-four patients received surfactant (100 mg of phospholipid per kilogram of body weight) and 46 patients received an air placebo within 8 hours of life. Treatment with this surfactant resulted in a significant reduction in the severity of RDS with a concomitant increase in the proportion of neonates with mild disease. The frequency of pulmonary interstitial emphysema and of pneumothorax was significantly lower in treated neonates compared with control neonates (2% vs 26%, P = .0008, and 7% vs 39%, P = .0004, respectively). The frequency of intracranial hemorrhage was significantly lower in the surfactant group compared with the control group (20% vs 54%, P = .0008) and was also reduced for the smallest neonates in the surfactant group (13% vs 73%, P = .00008). When categorized according to severity of intracranial hemorrhage and severity of bronchopulmonary dysplasia, the surfactant group was at a significant advantage (adjusted Cochran-Mantel-Haenszel X2 = 10.72, P less than .001 and X2 = 4.43, P = .036, respectively). The proportion of neonates surviving without intracranial hemorrhage and/or bronchopulmonary dysplasia was 63% in the surfactant group vs 26% in the control group (P = .0004); as for the smallest neonates, it was 58% in the surfactant group vs 4% in the control group (P = .0002). There were no differences between the groups with respect to the frequency of patent ductus arteriosus (46% vs 37%), pulmonary hemorrhage (6% vs 7%), necrotizing enterocolitis (0% vs 2%), sepsis (4% vs 2%), retinopathy of prematurity (13% vs 22%), or death (15% vs 22%). It is concluded that treatment with the single-dose surfactant regimen used in this study reduces the severity of respiratory distress during the 48 hours after treatment and decreases the major pulmonary morbidity and intracranial hemorrhage in premature neonates with RDS. Further studies are needed to determine whether (1) treatment at birth or as soon as after RDS is diagnosed and (2) the use of multiple dose of this surfactant would result in any additional benefits.

Monozygous double inner cell masses in mouse blastocysts following fertilization in vitro and in vivo

The incidence of human identical twins after in vitro fertilization and embryo transfer (IVF-ET) is estimated to be higher than the commonly accepted incidence after conception in vivo. This paper reports that 8 mouse blastocysts which had double inner cell masses in 261 blastocysts (3.1%) were identified after fertilization in vitro and they developed into trophoblastic outgrowth formation with two inner cell masses. In contrast, only 3 monozygous double inner cell masses were observed in 526 blastocysts (0.6%) which were fertilized in vivo and cultured from the two-cell stage in vitro. It is therefore possible that fertilization in vitro predisposes to monozygous twinning.

Effects of indomethacin, prostaglandin E2 and prostaglandin F2 alpha on mouse blastocyst attachment and trophoblastic outgrowth in vitro

A study was performed in order to investigate the participation of prostaglandins (PGs) during implantation. The effects of indomethacin on mouse blastocyst attachment and trophoblastic outgrowth were examined in vitro. Studies were also carried out on cultures supplemented with PGE2 and/or PGF2 alpha along with indomethacin. (1) Blastocyst attachment and trophoblastic outgrowth were inhibited by indomethacin dose-dependency. (2) In the cultures supplemented with indomethacin and PGE2 or PGF2 alpha, respectively, the inhibitory effects of indomethacin were reduced. (3) In the cultures supplemented with all three substances with treatment (1) and (2), inhibition of indomethacin was partially reversed, but still lower than control group without indomethacin. The above results indicate that both PGE2 and PGF2 alpha have a promoting effect on implantation, and PGF2 alpha was more effective than PGE2.

Surfactant-associated proteins in tracheal aspirates of infants with respiratory distress syndrome after surfactant therapy

We have developed enzyme-linked immunoassays (ELISAs) that measure major proteins that are associated with pulmonary surfactant. Using these ELISAs, we tested sequential tracheal aspirates from infants severely ill with respiratory distress syndrome (RDS) who had been treated either with exogenous surfactant or with placebo within 8 h of birth. On average, we found low concentrations of surfactant proteins in tracheal aspirates on Day 1 of life, with increases evident by Day 3. The surfactant used in this study (TA surfactant) contains only the low molecular weight (6 kDa) surfactant proteins and not the 35 kDa surfactant protein. As we expected, those who were treated with TA surfactant more frequently had detectable concentrations of low molecular weight surfactant protein on the second day of life when compared with control infants. No differences were evident in the concentrations of surfactant proteins between the 2 groups by Day 3, nor were differences evident between the 2 groups evident for 35 kDa surfactant protein during the first 3 days of life. Increased low molecular weight surfactant proteins in tracheal aspirates 1 to 2 days after surfactant therapy may occur either because of persistence of exogenous surfactant proteins and/or enhanced surfactant protein production. Comparisons with measurements from other groups of patients with RDS confirm that absence of both surfactant proteins reflects alveolar surfactant deficiency.

[Pharmacokinetic and clinical studies on latamoxef in the field of obstetrics and gynecology]

Latamoxef (LMOX) 1 g was administered twice daily for 5 days to patients undergoing operation for myoma uteri and the time course of tissue concentrations of the drug and the prophylactic effect of the treatment on postoperative infection were studied. 1. Area under concentration-time curve (AUC) of LMOX was the highest in the perimetrium (45.3%), followed by the cervix uteri (39.2%), endometrium (35.9%), oviduct (35.1%), myometrium (29.5%), and ovary (24.4%). 2. Cmax was the highest in oviduct (46.9 micrograms/g), followed by Cmax's in perimetrium (44.2 micrograms/g), cervix uteri (35.8 micrograms/g), myometrium (26.9 micrograms/g), endometrium (25.6 micrograms/g), and ovary (24.3 micrograms/g). 3. Serum half-lives were T1/2(alpha) = 0.27 hour and T1/2(beta) = 1.81 hours. 4. Prophylactic efficacy against postoperative infections was 94.3%, and febrile morbidity was 5.7%. The preoperative and postoperative laboratory tests did not show appreciable changes, no adverse reaction was observed. In the present study, LMOX showed good transfer into gynecological tissues, suggesting its very high usefulness in the treatment of infection and in the postoperative management.

[Establishment of mouse embryo culture system on collagen gel layer]

In order to study the morphological features of mouse embryos in the early developmental stage, we first established an in vitro culture system applying a collagen gel layer, and then observed the morphology of the embryos cultured in this system. Embryos after hatching were attached to the collagen gel layer and grew to the egg cylinder stage. By means of morphological analysis of embryos cultured for 3 or 4 days, some interesting characteristics, such as processes and villi of the mural trophoblast, lacunae formation in the mural trophoblast, steroid synthesis of the mural and polar trophoblasts and desmosome or intermediate junctions between the mural and the polar trophoblasts, were revealed. Moreover, no morphological difference was observed between cells derived from the inner cell mass. From those findings, it has been concluded that the established culture system is useful in observing the morphology of early embryonal development and also in maintaining the viability of the embryo.