Patient-specific affect-abdominal pain interactions in endometriosis: an experience sampling method (ESM) study

OBJECTIVES

Cross-sectional studies show that endometriosis-related pain is associated with affect. Measuring these symptoms in real-time in a longitudinal perspective yields the ability to analyze the temporal relationship between variables. The aim was to evaluate the association between affect and abdominal pain, using the Experience Sampling Method (ESM) as a real-time, randomly repeated assessment.

METHODS

Thirty-four endometriosis patients and 31 healthy subjects completed up to 10 real-time self-assessments concerning abdominal pain and affective symptoms during seven consecutive days.

RESULTS

Endometriosis patients experienced more abdominal pain and negative affective symptoms, and scored lower on positive affect compared to healthy controls. A significant association was found between abdominal pain and both positive and negative affect in endometriosis patients. For healthy controls, less strong or non-significant associations were found. When looking at abdominal pain as a predictor for affect and vice versa, we found that only in endometriosis patients, pain was subsequently accompanied by negative affect, and positive affect may alleviate pain in these patients.

CONCLUSIONS

This study confirms a concurrent and temporal relationship between affect and abdominal pain in endometriosis patients and supports the use of real-time symptom assessment to interpret potential influencers of abdominal complaints in patients with endometriosis.

Correlation between neonatal outcomes of twins depends on the outcome: secondary analysis of twelve randomised controlled trials

OBJECTIVE

To estimate the magnitude of the correlation between neonatal outcomes of twins and demonstrate how this information can be used in the design of randomised controlled trials (RCTs) in women with twin pregnancies.

DESIGN

Secondary analysis of data from 12 RCTs.

SETTING

Obstetric care in multiple countries, 2004-2012.

POPULATION OR SAMPLE

4504 twin pairs born to women who participated in RCTs to assess treatments given during pregnancy.

METHODS

Intraclass correlation coefficients (ICCs) were estimated using log-binomial and linear models.

MAIN OUTCOME MEASURES

Perinatal death, respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular haemorrhage, necrotising enterocolitis, sepsis, neonatal intensive care unit admission, birthweight, low birthweight and two composite measures of adverse neonatal outcome.

RESULTS

ICCs for the composite measures of adverse neonatal outcome were all above 0.5, indicating moderate to strong correlation between adverse outcomes of twins. For individual neonatal outcomes, median ICCs across trials ranged from 0.13 to 0.79 depending on the outcome. An example illustrates how ICCs can be used in sample size calculations for RCTs in women with twin pregnancies.

CONCLUSIONS

The correlation between neonatal outcomes of twins varies considerably between outcomes and may be lower than expected. Our ICC estimates can be used for designing and analysing RCTs that recruit women with twin pregnancies and for performing meta-analyses that include such RCTs. Researchers are encouraged to report ICCs for neonatal outcomes in twins in their own RCTs.

TWEETABLE ABSTRACT

Correlation between neonatal outcomes of twins depends on the outcome and may be lower than expected.

17-Hydroxyprogesterone caproate in triplet pregnancy: an individual patient data meta-analysis

BACKGROUND

Preterm birth complicates almost all triplet pregnancies and no preventive strategy has proven effective.

OBJECTIVE

To determine, using individual patient data (IPD) meta-analysis, whether the outcome of triplet pregnancy is affected by prophylactic administration of 17-hydroxyprogesterone caproate (17OHPc).

SEARCH STRATEGY

We searched literature databases, trial registries and references in published articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of progestogens versus control that included women with triplet pregnancies.

DATA COLLECTION AND ANALYSIS

Investigators from identified RCTs collaborated on the protocol and contributed their IPD. The primary outcome was a composite measure of adverse perinatal outcome. The secondary outcome was the rate of birth before 32 weeks of gestation. Other pre-specified outcomes included randomisation-to-delivery interval and rates of birth at <24, <28 and <34 weeks of gestation.

MAIN RESULTS

Three RCTs of 17OHPc versus placebo included 232 mothers with triplet pregnancies and their 696 offspring. Risk-of-bias scores and between-study heterogeneity were low. Baseline characteristics were comparable between 17OHPc and placebo groups. The rate of the composite adverse perinatal outcome was similar among those treated with 17OHPc and those treated with placebo (34 and 35%, respectively; risk ratio [RR] 0.98, 95% confidence interval [95% CI] 0.79-1.2). The rate of birth at <32 weeks was also similar in the two groups (35 and 38%, respectively; RR 0.92, 95% CI 0.55-1.56). There were no significant between-group differences in perinatal mortality rate, randomisation-to-delivery interval, or other specified outcomes.

CONCLUSION

Prophylactic 17OHPc given to mothers with triplet pregnancies had no significant impact on perinatal outcome or pregnancy duration.

TWEETABLE ABSTRACT

17-Hydroxyprogesterone caproate had no significant impact on the outcome or duration of triplet pregnancy.

Second-trimester cervical length as risk indicator for Cesarean delivery in women with twin pregnancy

OBJECTIVE

To determine whether second-trimester cervical length (CL) in women with a twin pregnancy is associated with the risk of emergency Cesarean section.

METHODS

This was a secondary analysis of two randomized trials conducted in 57 hospitals in The Netherlands. We assessed the univariable association between risk indicators, including second-trimester CL in quartiles, and emergency Cesarean delivery using a logistic regression model. For multivariable analysis, we assessed whether adjustment for other risk indicators altered the associations found in univariable (unadjusted) analysis. Separate analyses were performed for suspected fetal distress and failure to progress in labor as indications for Cesarean section.

RESULTS

In total, 311 women with a twin pregnancy attempted vaginal delivery after 34 weeks' gestation. Emergency Cesarean delivery was performed in 111 (36%) women, of which 67 (60%) were performed owing to arrest of labor. There was no relationship between second-trimester CL and Cesarean delivery (adjusted odds ratio (aOR): 0.97 for CL 26(th) -50(th) percentiles; 0.71 for CL 51(st)  - 75(th) percentiles; and 0.92 for CL > 75(th) percentile, using CL ≤ 25(th) percentile as reference). In multivariable analysis, the only variables associated with emergency Cesarean delivery were maternal age (aOR, 1.07 (95% CI, 1.00-1.13)), body mass index (BMI) (aOR, 3.99 (95% CI, 1.07-14.9) for BMI 20-23 kg/m(2) ; 5.04 (95% CI, 1.34-19.03) for BMI 24-28 kg/m(2) ; and 3.1 (95% CI, 0.65-14.78) for BMI > 28 kg/m(2) ) and induction of labor (aOR, 1.92 (95% CI, 1.05-3.5)).

CONCLUSION

In nulliparous women with a twin pregnancy, second-trimester CL is not associated with risk of emergency Cesarean delivery.

The effect of gestational age and cervical length measurements in the prediction of spontaneous preterm birth in twin pregnancies: an individual patient level meta-analysis

OBJECTIVE

To assess the effect of gestational age (GA) and cervical length (CL) measurements at transvaginal ultrasound (TVUS) in the prediction of preterm birth in twin pregnancy.

DESIGN

Individual patient data (IPD) meta-analysis.

SETTING

International multicentre study.

POPULATION

Asymptomatic twin pregnancy.

METHODS

MEDLINE and EMBASE searches were performed and IPD obtained from authors of relevant studies. Multinomial logistic regression analysis determined probabilities for birth at ≤28(+0) , 28(+1) to 32(+0) , 32(+1) to 36(+0) , and ≥36(+1) weeks as a function of GA at screening and CL measurements.

MAIN OUTCOME MEASURES

Predicted probabilities for preterm birth at ≤28(+0) , 28(+1) to 32(+0) , and 32(+1) to 36(+0) .

RESULTS

A total of 6188 CL measurements were performed on 4409 twin pregnancies in 12 studies. Both GA at screening and CL had a significant and non-linear effect on GA at birth. The best prediction of birth at ≤28(+0) weeks was provided by screening at ≤18(+0) weeks (P < 0.001), whereas the best prediction of birth between 28(+1) and 36(+0) weeks was provided by screening at ≥24(+0) weeks (P < 0.001). Negative prediction value of 100% for birth at ≤28(+0) weeks is achieved at CL 65 mm and 43 mm at ultrasound GA at ≤18(+0) weeks and at 22(+1) to 24(+0) weeks, respectively.

CONCLUSION

In twin pregnancies, prediction of preterm birth depends on both CL and the GA at screening. When CL is <30 mm, screening at ≤18(+0) weeks is most predictive for birth at ≤28(+0) weeks. Later screening at >22(+0) weeks is most predictive of delivery at 28(+1) to 36(+0) weeks. In twins, we recommend CL screening in twins to commence from ≤18(+0) weeks.

TWEETABLE ABSTRACT

An individual patient meta-analysis assessing gestation and CL in the prediction of preterm birth in twins.

Effectiveness of progestogens to improve perinatal outcome in twin pregnancies: an individual participant data meta-analysis

BACKGROUND

In twin pregnancies, the rates of adverse perinatal outcome and subsequent long-term morbidity are substantial, and mainly result from preterm birth (PTB).

OBJECTIVES

To assess the effectiveness of progestogen treatment in the prevention of neonatal morbidity or PTB in twin pregnancies using individual participant data meta-analysis (IPDMA).

SEARCH STRATEGY

We searched international scientific databases, trial registration websites, and references of identified articles.

SELECTION CRITERIA

Randomised clinical trials (RCTs) of 17-hydroxyprogesterone caproate (17Pc) or vaginally administered natural progesterone, compared with placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Investigators of identified RCTs were asked to share their IPD. The primary outcome was a composite of perinatal mortality and severe neonatal morbidity. Prespecified subgroup analyses were performed for chorionicity, cervical length, and prior spontaneous PTB.

MAIN RESULTS

Thirteen trials included 3768 women and their 7536 babies. Neither 17Pc nor vaginal progesterone reduced the incidence of adverse perinatal outcome (17Pc relative risk, RR 1.1; 95% confidence interval, 95% CI 0.97-1.4, vaginal progesterone RR 0.97; 95% CI 0.77-1.2). In a subgroup of women with a cervical length of ≤25 mm, vaginal progesterone reduced adverse perinatal outcome when cervical length was measured at randomisation (15/56 versus 22/60; RR 0.57; 95% CI 0.47-0.70) or before 24 weeks of gestation (14/52 versus 21/56; RR 0.56; 95% CI 0.42-0.75).

AUTHOR'S CONCLUSIONS

In unselected women with an uncomplicated twin gestation, treatment with progestogens (intramuscular 17Pc or vaginal natural progesterone) does not improve perinatal outcome. Vaginal progesterone may be effective in the reduction of adverse perinatal outcome in women with a cervical length of ≤25 mm; however, further research is warranted to confirm this finding.

Does 17-α-hydroxyprogesterone caproate affect fetal biometry and birth weight in twin pregnancy?

OBJECTIVE

Increasingly, maternal administration of 17-α-hydroxyprogesterone caproate (17-OHPC) is utilized to prevent preterm birth, but the fetal safety of 17-OHPC is still a matter of concern. This study aimed to assess whether exposure to 17-OHPC during the second and third trimesters of pregnancy affects fetal biometry in twin gestations.

METHODS

This study included a subset of women with a twin pregnancy who had been previously included in a randomized clinical trial comparing the effectiveness of 17-OHPC and placebo on neonatal outcomes and preterm birth rates in multiple pregnancy. In the present study, the individual growth patterns of femur length, head circumference and abdominal circumference were compared between fetuses of women who had been randomized to receive weekly injections of either 17-OHPC (n = 52) or placebo (n = 58) at between 16-20 and 36 weeks' gestation.

RESULTS

The three biometric variables assessed developed similarly in fetuses in both the group exposed to 17-OHPC and the placebo group during the second half of pregnancy. Birth weight adjusted for parity and fetal sex was also comparable between groups.

CONCLUSION

The use of 17-OHPC has no adverse effects on fetal biometry and birth weight in twins.

Effect of 17-alpha hydroxyprogesterone caproate on cervical length in twin pregnancies

OBJECTIVES

Previous studies on singleton pregnancies have indicated that progestogens may reduce the rate of cervical shortening during pregnancy. The aim of this study was to investigate whether treatment with 17-alpha hydroxyprogesterone caproate (17-OHPC) has an effect on cervical shortening in twin pregnancies.

METHODS

This was a secondary analysis of patients who had participated in a multicenter randomized clinical trial on the effectiveness of 17-OHPC in preventing preterm birth in multiple pregnancies (the AMPHIA-trial). We included all trial participants with a twin gestation who had undergone repeat cervical length measurements during pregnancy. We performed a separate analysis of women with repeat measurements in centers where this was standard protocol for multiple pregnancies. The rate of cervical shortening for both the 17-OHPC group and the placebo group was analyzed using a linear mixed model.

RESULTS

Of the 671 patients who participated in the trial, 282 (42%) had a twin pregnancy and underwent two or more cervical length measurements. Of these women, 140 were monitored in centers where repeat measurements were standard protocol. We observed an overall reduction of cervical length from 44.3 mm at 14-18 weeks to 30.0 mm at 30-34 weeks' gestation. In the 17-OHPC group, cervical length decreased by 1.04 mm each gestational week, while this was 1.11 mm per week for the placebo group (P = 0.6). For the overall group, each 10% decrease in cervical length led to an increase in the risk of preterm birth (hazard ratio, 1.14; 95% CI, 1.08-1.21).

CONCLUSION

In women with a twin pregnancy, there is progressive shortening of the cervix during pregnancy, regardless of 17-OHPC use.

Interactions of abiraterone, eplerenone, and prednisolone with wild-type and mutant androgen receptor: a rationale for increasing abiraterone exposure or combining with MDV3100

Prostate cancer progression can be associated with androgen receptor (AR) mutations acquired following treatment with castration and/or an antiandrogen. Abiraterone, a rationally designed inhibitor of CYP17A1 recently approved for the treatment of docetaxel-treated castration-resistant prostate cancer (CRPC), is often effective, but requires coadministration with glucocorticoids to curtail side effects. Here, we hypothesized that progressive disease on abiraterone may occur secondary to glucocorticoid-induced activation of mutated AR. We found that prednisolone plasma levels in patients with CRPC were sufficiently high to activate mutant AR. Mineralocorticoid receptor antagonists, such as spironolactone and eplerenone that are used to treat side effects related to mineralocorticoid excess, can also bind to and activate signaling through wild-type or mutant AR. Abiraterone inhibited in vitro proliferation and AR-regulated gene expression of AR-positive prostate cancer cells, which could be explained by AR antagonism in addition to inhibition of steroidogenesis. In fact, activation of mutant AR by eplerenone was inhibited by MDV3100, bicalutamide, or greater concentrations of abiraterone. Therefore, an increase in abiraterone exposure could reverse resistance secondary to activation of AR by residual ligands or coadministered drugs. Together, our findings provide a strong rationale for clinical evaluation of combined CYP17A1 inhibition and AR antagonism.

BCR-ABL1 kinase domain mutations: methodology and clinical evaluation

The introduction of tyrosine kinase inhibitors (TKIs), starting with imatinib and followed by second and third generation TKIs, has significantly changed the clinical management of patients with chronic myeloid leukemia (CML). Despite their unprecedented clinical success, a proportion of patients fail to achieve complete cytogenetic remission by 12 months of treatment (primary resistance) while others experience progressive resistance after an initial response (secondary resistance). BCR-ABL1 kinase domain (KD) mutations have been detected in a proportion of patients at the time of treatment failure, and therefore their identification and monitoring plays an important role in therapeutic decisions particularly when switching TKIs. When monitoring KD mutations in a clinical laboratory, the choice of method should take into account turnaround time, cost, sensitivity, specificity, and ability to accurately quantify the size of the mutant clone. In this article, we describe in a "manual" style the methods most widely used in our laboratory to monitor KD mutations in patients with CML including direct sequencing, D-HPLC, and pyrosequencing. Advantages, disadvantages, interpretation of results, and their clinical applications are reviewed for each method.

Cervical length measurement for the prediction of preterm birth in multiple pregnancies: a systematic review and bivariate meta-analysis

OBJECTIVES

To review the literature on cervical length as a predictor of preterm birth in asymptomatic women with a multiple pregnancy.

METHODS

We searched MEDLINE, Embase and reference lists of included articles to identify all studies that reported on the accuracy of cervical length for predicting preterm birth in asymptomatic women with a multiple pregnancy. We scored study characteristics and study quality, and extracted data in order to construct two-by-two tables cross-classifying cervical length and preterm delivery. Meta-analysis using a bivariate model was performed. Summary receiver-operating characteristics (ROC) curves were generated for various test characteristics and outcome definitions.

RESULTS

We found 21 studies reporting on 2757 women. There was a large variation in gestational age at measurement, cut-off point for cervical length and definition of preterm birth. The summary ROC curve indicated a good predictive capacity of short cervical length for preterm birth. Summary estimates of sensitivity and specificity for preterm birth before 34 weeks' gestation were 78% and 66%, respectively, for 35 mm, 41% and 87% for 30 mm, 36% and 94% for 25 mm and 30% and 94% for 20 mm.

CONCLUSIONS

In women with a multiple pregnancy, second-trimester cervical length is a strong predictor of preterm birth. In the absence of effective preventive strategies, there is currently no place in clinical practice for cervical length measurement in this population. However, future studies should evaluate preventive interventions in women with multiple pregnancies and a short cervix, and cervical length should be measured in any trial studying preventive strategies in multiple pregnancies.

Progress in Australian teledermatology

Because of their remoteness, the majority of rural towns in Australia are disadvantaged in terms of access to dermatological services. Telemedicine offers one solution. Since the mid-1990s, Australian dermatologists have experimented with telemedicine as an adjunct to clinical practice. The technical viability of teledermatology was first demonstrated in 1997. In 1999, the accuracy and reliability of teledermatology were demonstrated in a real-life urban setting. In 2001, Broken Hill (in western New South Wales), a location remote from dermatology services, served as a trial site for the institution of teledermatology as the primary method of accessing dermatological services. High patient and general practitioner acceptability and positive medical outcomes were demonstrated, but the study also revealed unexpected barriers and pitfalls in the effective operation of rural teledermatology.

Hybridization cross-reactivity within homologous gene families on glass cDNA microarrays

Glass cDNA microarrays can be used to profile the expression of thousands of gene targets in a single experiment. However, the potential for hybridization cross-reactivity needs to be considered when interpreting the results. Here, we describe hybridization experiments with a model array representing four distinct functional classes (families): chemokines, cytochrome P-450 isozymes, G proteins, and proteases. The cDNA clones selected for this array exhibited pairwise sequence identities ranging from 55% to 100%, as determined by a homology scoring algorithm (LALIGN). Targets for microarraying were amplified by PCR and spotted in 4-fold replication for signal averaging. One designated target from each family was further amplified by PCR to incorporate a T7 promoter sequence for the production of synthetic RNA transcripts. These transcripts were used to generate fluorescent hybridization probes by reverse transcription at varying input concentrations. As expected, hybridization signals were highest at the matching target elements. Targets containing less than 80% sequence identity relative to the hybridization probe sequences showed cross-reactivities ranging from 0.6% to 12%. Targets containing greater than 80% identity showed higher cross-reactivities (26%-57%). These cross-reactive signals were analyzed for statistical correlation with the length of sequence overlap, percent sequence identity, and homology score determined by LALIGN. Overall, percent sequence identity was the best predictor of hybridization cross-reactivity. These results provide useful guidelines for interpreting glass cDNA microarray data.

Accuracy and reliability of store-and-forward teledermatology: preliminary results from the St George Teledermatology Project

Teledermatology is the practice of dermatology across distances (and time) and involves the transfer of electronic information. To be effective and safe, the teledermatology process needs to demonstrate an acceptable level of accuracy and reliability. Accuracy is reflected by the degree of concordance (agreement) between the teledermatology and face-to-face diagnoses. Reliability is dependent on how consistently a set of results can be reproduced across different operators. Mean concordance (primary diagnoses) achieved by four dermatologists studying 53 store-and-forward diagnostic cases, originating from 49 referred patients, was 79% (range 73-85%). When the differential diagnoses were taken into account, the variation across individual dermatologists narrowed further, with a mean of 86% (range 83-89%). In contrast, the mean general practitioner (GP; n=11) concordance (GP face-to-face vs reference dermatologist store-and-forward diagnoses) was 49%. An interim review of all 49 teledermatology patients showed no adverse outcome at the end of 3 months. The ability to request face-to-face visits by dermatologists, combined with GPs maintaining primary care of the referred patient, serve as additional safeguards for patients using a telemedicine system. Our results indicate that teledermatology management of referred skin complaints is both accurate and reliable.

A case of mistaken identity. A rare presentation of gonadal dysgenesis

BACKGROUND

The incidence of gonadal dysgenesis (hermaphroditism) is recognised to be low. Rarer still is an initial late presentation in the general practice setting.

OBJECTIVE

To present a case study of a 35 year old man diagnosed as a hermaphrodite after routine investigations in general practice for lower abdominal pain. He has normal male external genitalia, a fully formed uterus and vagina, with no identifiable gonads.

DISCUSSION

This incidental finding in general practice is supported by a 46,X,i(Yp)/45,X karyotype and mosaicism for an isochromosome of the short arm of the Y. It is not unusual that with normal male genitalia, such patients are likely to survive undiagnosed or incorrectly diagnosed into adulthood.

The effect of polishing systems on microleakage of tooth-coloured restoratives. Part 2: composite and polyacid-modified composite resins

The purpose of this in vitro study was to investigate the effect of polishing systems on the microleakage of composite and polyacid-modified composite resins. Class V cavities were prepared at the cemento-enamel junction of 80 freshly extracted posterior teeth. The prepared teeth were randomly divided into two groups and restored with conventional or polyacid-modified composite resins. The restored teeth were stored in distilled water at 37 degrees C for 1 week after removal of excess restorative with diamond finishing burs. The restored teeth were then divided into four groups of ten and finished/polished using the following systems: Two Striper micron finishing system (MFS), Sof-Lex XT (Sof-Lex), Enhance composite finishing and polishing system (Enhance), and Shofu composite finishing kit (Shofu). The finished restorations were subjected to dye penetration testing. Results showed that the microleakage resistance at both enamel and dentin margins of composite and polyacid-modified composite resins are not significantly affected by the different polishing systems.

Australian teledermatology: the patient, the doctor and their government

Telemedicine is an emerging technology within Australia. We review the historical development of telemedicine and discuss the clinical and non-clinical issues surrounding its practice in this country. Teledermatology is one application of telemedicine. We discuss the potential impact of teledermatology on patients, doctors and third parties such as government. So far, teledermatology has received little attention from Australian dermatologists. By contrast, the Government and other organizations are showing keen interest in establishing infrastructure within this country. We believe it is time for dermatologists to become more involved in the practice and politics of telemedicine within Australia.

A role for Tlg1p in the transport of proteins within the Golgi apparatus of Saccharomyces cerevisiae

Members of the syntaxin protein family participate in the docking-fusion step of several intracellular vesicular transport events. Tlg1p has been identified as a nonessential protein required for efficient endocytosis as well as the maintenance of normal levels of trans-Golgi network proteins. In this study we independently describe Tlg1p as an essential protein required for cell viability. Depletion of Tlg1p in vivo causes a defect in the transport of the vacuolar protein carboxypeptidase Y through the early Golgi. Temperature-sensitive (ts) mutants of Tlg1p also accumulate the endoplasmic reticulum/cis-Golgi form of carboxypeptidase Y at the nonpermissive temperature (38 degrees C) and exhibit underglycosylation of secreted invertase. Overexpression of Tlg1p complements the growth defect of vti1-11 at the nonpermissive temperature, whereas incomplete complementation was observed with vti1-1, further suggesting a role for Tlg1p in the Golgi apparatus. Overexpression of Sed5p decreases the viability of tlg1 ts mutants compared with wild-type cells, suggesting that tlg1 ts mutants are more susceptible to elevated levels of Sed5p. Tlg1p is able to bind His6-tagged Sec17p (yeast alpha-SNAP) in a dose-dependent manner and enters into a SNARE complex with Vti1p, Tlg2p, and Vps45p. Morphological analyses by electron microscopy reveal that cells depleted of Tlg1p or tlg1 ts mutants incubated at the restrictive temperature accumulate 40- to 50-nm vesicles and experience fragmentation of the vacuole.

Rh(phen)2phi3+ as a shape-selective probe of triple helices

RNA pur*pur-pyr and pyr*pur-pyr (pur = purine, pyr = pyrimidine) triple helices consisting of a Watson-Crick base-paired 28mer hairpin duplex and a Hoogsteen base-paired purine or pyrimidine 12mer are targeted with photoactivated cleavage by the metal complex Rh(phen)2phi3+ (phen = phenanthroline, phi = 9, 10-phenanthrenequinone diimine). The metal complex interacts with these triple helices in a structure-specific manner. Different cleavage patterns are seen with the pyr*pur-pyr and pur*pur-pyr motifs. Cleavage is seen on both of the Watson-Crick strands of the former motif and primarily on the purine Watson-Crick strand of the latter motif. Little cleavage is seen on the Hoogsteen strand for either motif. Importantly, the metal complex shows no detectable cleavage on the A-form RNA duplex in the absence of the third Hoogsteen strand. The cleavage patterns are consistent with an intercalated model for the metal complex in the triple helix. Similar cleavage is seen on DNA triple helices, but over a background of duplex cleavage. Targeting of synthetic RNA triple helices, but not duplex regions, by Rh(phen)2phi3+ provides a basis for the chemical probing of triply bonded sites in folded RNA molecules.

Targeting the Tat-binding site of bovine immunodeficiency virus TAR RNA with a shape-selective rhodium complex

The Tat-binding site of the bovine immunodeficiency virus TAR RNA hairpin has been targeted by Rh(phen)2phi3+ (phen = phenanthroline, phi = 9,10-phenanthrenequinone diimine), a photochemical probe of RNA tertiary structure. The primary site cleaved by the rhodium complex, upon photoactivation, is U24, a base which participates in the novel base triple (with bases A13 and U10) characteristic of this folded RNA. delta-Rh(phen)2phi3+ binds to this site with an affinity of 2 x 10(6) M-1. Upon mutation of U24 and A13 to A24 and U13, respectively, so that the RNA oligomer is unable to form the base triple, site-specific cleavage by the rhodium complex is abolished. Moreover, as determined through rhodium photocleavage, at a concentration of 20 microM, Rh(phen)2phi3+ inhibits specific binding of BIV-Tat peptide (2 microM) to its target site. Thus the rhodium complex, in matching its shape to the opened major groove of the properly folded RNA, specifically targets its site and is able to compete for its target with the BIV-Tat peptide.

Detrusor hyperreflexia in strokes

Urodynamic evaluation via water cystometry was undertaken in 27 patients from 12 to 120 days after cerebrovascular accidents. Seven patients had urinary symptoms--five with urge incontinence, one with frequency and one with sensation of incomplete bladder emptying. The remaining 20 were asymptomatic. Cystometry revealed normal bladder function in 15 patients (55.6%), detrusor areflexia in one patient (3.7%) and detrusor hyperreflexia in 11 patients (40.7%). Of the 11 patients with detrusor hyperreflexia, six (54.5%) were asymptomatic and the remaining five (45.5%) had urge incontinence. The former group had a statistically significant higher first sensation and functional cystometric capacity than the latter. Urge incontinence was also found to be an accurate predictor of detrusor hyperreflexia.

Chemical probing of tDNAPhe with transition metal complexes: a structural comparison of RNA and DNA

The three-dimensional folding of tDNAPhe has been examined and compared to native tRNAPhe using a series of shape-selective transition metal complexes as chemical probes of nucleic acid structure. Rh(phen)2 phi 3+ (phen = phenanthroline, phi = 9,10-phenanthrenequinonediimine), which targets sites of tertiary interaction in tRNAPhe, cleaves specifically at similar sites on tDNAPhe. However, this rhodium complex also targets 5'-pyr-pyr-pur-3' sites within the acceptor and anticodon stems of tDNA;Rh(phen)2 phi 3+ generally targets 5'-pyr-pyr-pur-3' sites in B-form duplex DNA. On tRNAPhe, Rh(DIP)3(3+) (DIP = 4,7-diphenyl-1,10-phenanthroline) specifically cleaves C70, which neighbors a GU mismatch, and targets psi 55 as well, within the hydrophobic region of tRNAPhe. On tDNAPhe no specific cleavage by Rh(DIP)3(3+) is observed. The cleavage studies, taken together, indicate that globally the tertiary folding of tDNAPhe resembles that of tRNAPhe. However, the double helical regions of the DNA analog differ from tRNAPhe, likely in adopting a more B-like conformation. As a consequence, the GT mismatch within the acceptor stem of tDNA does not present the same recognition elements as in tRNA, and the GT mismatch is no longer recognized by the shape-selective rhodium complex. The present work underscores the utility of applying DNA analogs to studies of RNA structure and function, since the general folding characteristics of the two polymers are likely to be similar. However, structural probing with transition metal complexes offers a valuable companion to such experiments, since the shape-selective probes, with sensitivity, may be used to delineate locally on the polymer those regions which may differ in structure.

Lower limb paralysis: its effect on the recanalization of deep-vein thrombosis

Fifty patients with lower limb deep-vein thrombosis (DVT) confirmed by venography were studied prospectively to determine the time required for recanalization. The patients were anticoagulated with heparin and warfarin for at least three months; impedance plethysmography, Doppler, and duplex scans were repeated at scheduled intervals. The 24 patients who were paralyzed took longer for recanalization than did the 26 nonparalyzed patients; this difference was statistically significant between the paraplegic-quadriplegic and nonparalyzed groups (54 vs 33 days; t = 2.12, p = .04). Patients with motor complete paraplegia or quadriplegia took longest for recanalization (57 days). Although most variables were not statistically significant on comparison, a somewhat longer recanalization time was seen in men and in those with DVTs located more proximally. Because of delay in recanalization, patients with lower limb paralysis may have persistent swelling due to venous insufficiency and may be at greater risk for development of the postphlebitic syndrome.

A second traumatic spinal cord injury: associated risk factors. Case report and review

Despite advances in acute care and long term management, traumatic spinal cord injury remains a devastating and disabling event. This report describes the case of a second traumatic spinal cord injury in a previously rehabilitated and functionally independent paraplegic. Factors potentially associated with the second spinal cord injury in this patient include wheelchair use, previous spinal fusion, alcohol use and sensation-seeking behavior. These factors, which are common to many spinal cord injured patients, could potentially be risk factors for a second traumatic spinal injury.

[Meniscal repair with autogenous periosteum and fibrin adhesive system]

It is well recognized that meniscal tear in the avascular portion is difficult to heal. The purpose of this study is to evaluate the ability of periosteum and fibrin adhesive system (FAS) in promoting the meniscal repair in the avascular zone. Full-thickness defects of 1 x 3 mm were created in the avascular portion of lateral menisci in adult mongrels. The control menisci were left without any treatment. The experimental defects were either repaired with autogenous periosteum or the combination of periosteum and FAS. Histologic and ultrastructural evaluation of the reparative tissue were compared at 4, 8, and 16 weeks postoperatively. The reparative tissue in the control group remained fibrous even at week 16, whereas that in the grafted and graft/FAS groups resembled normal adjacent fibrocartilage. Moreover, the regenerated chondrocytes in the graft/FAS group appeared more mature than those in the grafted group. Our results suggest that periosteum is a potential source of primitive cells from which chondrocytes could be differentiated and developed during the reparative process of meniscal fibrocartilage. As to FAS, it not only acted as a hemostatic agent and a fixant, but also could indirectly accelerate the chondrogenesis of periosteum in the meniscal defects. It is sufficient to conclude that the combination of periosteum and FAS in promoting meniscal defects or severe tears in the avascular portion bears its potential in future clinical application.

Carpal tunnel syndrome, subclinical median mononeuropathy, and peripheral polyneuropathy: common early complications of chronic peritoneal dialysis and hemodialysis

Nerve conduction velocity studies were done in median, ulnar, and peroneal nerves, one time each in 46 patients who had been on chronic peritoneal dialysis or hemodialysis for varying lengths of time. Only six patients had normal findings; 37 had peripheral polyneuropathy (15 had isolated polyneuropathy; 22 had median nerve dysfunction in addition); 16 had subclinical median mononeuropathy (14 with polyneuropathy, two without); and nine had overt carpal tunnel syndrome (eight with polyneuropathy, one without). Abnormalities were present in seven of the 11 patients studied after one year of dialysis and in 19 of the 24 patients studied after two years of dialysis. Seventeen patients studied after five years of dialysis all had polyneuropathy. Nine patients studied after seven years of dialysis all had median nerve dysfunction. Abnormalities were as common with peritoneal dialysis as with hemodialysis. Nerve dysfunction was independent of the disease underlying renal failure, the side of the dialysis access shunt, and the presence or absence of osteodystrophy. Dialysis patients need frequent nerve conduction studies from the onset of dialysis to identify carpal tunnel syndrome early and to avoid irreversible nerve damage.

Prevention of thromboembolism after spinal cord injury using low-molecular-weight heparin

OBJECTIVE

To examine the safety and effectiveness of a low-molecular-weight heparin in the prevention of thromboembolism in patients with recent spinal cord injury and complete motor paralysis.

DESIGN

Randomized evaluation of two heparin regimens in 41 consecutive patients meeting eligibility requirements for anticoagulant prophylaxis. Daily bedside examinations were supplemented by serial venous flow studies; suspicious or positive tests were confirmed by venography.

INTERVENTION

Standard heparin, 5000 units subcutaneously three times a day; low-molecular-weight heparin 3500 anti-Xa units subcutaneously once daily.

MEASUREMENTS AND MAIN RESULTS

Five patients in the standard heparin group had thrombotic events, including two patients with fatal pulmonary embolism; two other patients had bleeding severe enough to necessitate withdrawing the heparin. The cumulative event rate was 34.7% (95% CI, 13.7% to 55.2%). None of the patients treated with low-molecular-weight heparin had thrombosis or bleeding (CI, 0% to 14%). The difference between the two groups was significant (P = 0.006, log-rank test).

CONCLUSIONS

Low-molecular-weight heparin is safe and effective in the prevention of thromboembolism in selected patients with spinal cord injury and complete motor paralysis, and is superior to standard heparin in fixed doses of 5000 units three times a day.