The Combination of Gefitinib With ATRA and ATO Induces Myeloid Differentiation in Acute Promyelocytic Leukemia Resistant Cells

In approximately 15% of patients with acute myeloid leukemia (AML), total and phosphorylated EGFR proteins have been reported to be increased compared to healthy CD34⁺ samples. However, it is unclear if this subset of patients would benefit from EGFR signaling pharmacological inhibition. Pre-clinical studies on AML cells provided evidence on the pro-differentiation benefits of EGFR inhibitors when combined with ATRA or ATO in vitro. Despite the success of ATRA and ATO in the treatment of patients with acute promyelocytic leukemia (APL), therapy-associated resistance is observed in 5-10% of the cases, pointing to a clear need for new therapeutic strategies for those patients. In this context, the functional role of EGFR tyrosine-kinase inhibitors has never been evaluated in APL. Here, we investigated the EGFR pathway in primary samples along with functional in vitro and in vivo studies using several APL models. We observed that total and phosphorylated EGFR (Tyr992) was expressed in 28% and 19% of blast cells from APL patients, respectively, but not in healthy CD34⁺ samples. Interestingly, the expression of the EGF was lower in APL plasma samples than in healthy controls. The EGFR ligand AREG was detected in 29% of APL patients at diagnosis, but not in control samples. In vitro, treatment with the EGFR inhibitor gefitinib (ZD1839) reduced cell proliferation and survival of NB4 (ATRA-sensitive) and NB4-R2 (ATRA-resistant) cells. Moreover, the combination of gefitinib with ATRA and ATO promoted myeloid cell differentiation in ATRA- and ATO-resistant APL cells. In vivo, the combination of gefitinib and ATRA prolonged survival compared to gefitinib- or vehicle-treated leukemic mice in a syngeneic transplantation model, while the gain in survival did not reach statistical difference compared to treatment with ATRA alone. Our results suggest that gefitinib is a potential adjuvant agent that can mitigate ATRA and ATO resistance in APL cells. Therefore, our data indicate that repurposing FDA-approved tyrosine-kinase inhibitors could provide new perspectives into combination therapy to overcome drug resistance in APL patients.

Interleukin-8 is not a predictive biomarker for the development of the acute promyelocytic leukemia differentiation syndrome

Background

Differentiation syndrome (DS) is the main life-threatening adverse event that occurs in acute promyelocytic leukemia (APL) patients treated with all-trans retinoic acid (ATRA). Cytokine imbalances have been reported to play role during the developing of acute promyelocytic leukemia differentiation syndrome (APL-DS). However, the relationship between the plasma cytokine levels and their prognostic value for the prediction of DS developing in patients with APL during the treatment with ATRA and anthracyclines has not been previously reported.

Methods

In this study, we followed an APL cohort (n = 17) over 7 days of ATRA therapy in DS (n = 6) and non-DS groups (n = 11). Interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-12p70 and TNF-α were measured in the peripheral blood plasma from 17 patients with APL and 11 healthy adult controls by using the cytometric bead array method.

Results

In non-DS patients, IL-8 plasma levels were significantly reduced in the seventh day of ATRA treatment (34.16; 6.99 to 147.11 pg mL^− 1 in D0 vs. 10.9; 0 to 26.81 pg mL^− 1 in D7; p = 0.02) whereas their levels did not discriminate between DS and non-DS development during the entire induction period (all p > 0.05 in D0, D3, and D7). No significant differences were found in IL-6 levels between groups (p > 0.05 in D0-D7). Other cytokines tested were all undetectable in patients with APL or healthy controls.

Conclusions

We demonstrated that the modulation of IL-8 following ATRA treatment may occur regardless of the development of DS and, therefore, does not appear to be a predictive biomarker to monitor the APL-DS.

CCAAT/enhancer-binding protein alpha (CEBPA) gene haploinsufficiency does not alter hematopoiesis or induce leukemia in Lck-CALM/AF10 transgenic mice

Although rare, CALM/AF10 is a chromosomal rearrangement found in immature T-cell acute lymphoblastic leukemia (T-ALL), acute myeloid leukemia, and mixed phenotype acute leukemia of T/myeloid lineages with poor prognosis. Moreover, this translocation is detected in 50% of T-ALL patients with gamma/delta T cell receptor rearrangement, frequently associated with low expression of transcription factor CCAAT/enhancer-binding protein alpha (CEBPA). However, the relevance of CEBPA low expression for CALM/AF10 leukemogenesis has not yet been evaluated. We generated double mutant mice, which express the Lck-CALM/AF10 fusion gene and are haploinsufficient for the Cebpa gene. To characterize the hematopoiesis, we quantified hematopoietic stem cells, myeloid progenitor cells, megakaryocyte-erythrocyte progenitor cells, common myeloid progenitor cells, and granulocyte-macrophage progenitor cells. No significant difference was detected in any of the progenitor subsets. Finally, we tested if Cebpa haploinsufficiency would lead to the expansion of Mac-1+/B220+/c-Kit+ cells proposed as the CALM/AF10 leukemic progenitor. Less than 1% of bone marrow cells expressed Mac-1, B220, and c-Kit with no significant difference between groups. Our results showed that the reduction of Cebpa gene expression in Lck-CALM/AF10 mice did not affect their hematopoiesis or induce leukemia. Our data corroborated previous studies suggesting that the CALM/AF10 leukemia-initiating cells are early progenitors with lymphoid/myeloid differentiating potential.

Topography-Guided PRK and Crosslinking in Eyes with Keratoconus and Post-LASIK Ectasia

Topography-guided photorefractive keratectomy (TG-PRK) combined with corneal collagen crosslinking (CXL) has been shown to potentially improve vision and stabilize progression in patients with keratoconus (KC). We attempted to reproduce the previously published results using a different laser platform (AMARIS 500E) in patients with KC and post-LASIK ectasia (PLE). All of the 9 included eyes showed improved topography (Kmax, Kmean, RMS HOA, vertical coma, cylinder; p < 0.05) and improved visual acuity (BCVA, UCVA; p < 0.05) after 18 months. Despite some still uncontrollable factors, the combination of TG-PRK and CXL may be a promising option to regularize and stabilize corneas with KC and PLE and improve visual acuity.

A single nucleotide deletion at the C1 inhibitor gene as the cause of hereditary angioedema: insights from a Brazilian family

BACKGROUND

Hereditary angioedema is an autosomal dominant disease characterized by episodes of subcutaneous and submucosal edema. It is caused by deficiency of the C1 inhibitor protein, leading to elevated levels of bradykinin. More than 200 mutations in C1 inhibitor gene have been reported. The aim of this study was to analyze clinical features of a large family with an index case of hereditary angioedema and to determine the disease-causing mutation in this family.

METHODS

Family pedigree was constructed with 275 individuals distributed in five generations. One hundred and sixty-five subjects were interviewed and investigated for mutation at the C1 inhibitor gene. Subjects reporting a history of recurrent episodes of angioedema and/or abdominal pain attacks underwent evaluation for hereditary angioedema.

RESULTS

We have identified a novel mutation at the C1 inhibitor gene, c.351delC, which is a single-nucleotide deletion of a cytosine on exon 3, resulting in frameshift with premature stop codon. Sequencing analysis of the hypothetical truncated C1 inhibitor protein allowed us to conclude that, if transcription occurs, this protein has no biological activity. Twenty-eight members of the family fulfilled diagnostic criteria for hereditary angioedema and all of them presented the c.351delC mutation. Variation in clinical presentation and severity of disease was observed among these patients. One hundred and thirty-seven subjects without hereditary angioedema did not have the c.351delC mutation.

CONCLUSION

The present study provides definitive evidence to link a novel genetic mutation to the development of hereditary angioedema in patients from a Brazilian family.

Prostaglandin-induced diarrhoea treated with loperamide or diphenoxylate. A double-blind study

Loperamide was compared double-blind with diphenoxylate and a placebo in 59 women with diarrhoea due to prostaglandin administration for mid-trimester abortion. Treatment was started with the intake of two capsules two hours before the first intramuscular injection of 15(S-)15 methyl prostaglandin F2alpha and was then adapted individually, i.e. one capsule after each unformed stool, with a maximum of ten per 24 hours. Both antidiarrhoeals were significantly more effective than the placebo in preventing diarrhoea, and loperamide was found to be more active than diphenoxylate. The course of abortion, BP and vital signs, or prostaglandin side-effects other than diarrhoea were not affected by either antidiarrhoeal, nor could any adverse experience be specifically attributed to them.

Vacancy island creation and coalescence using automated scanning tunneling microscopy

We demonstrate that scanning tunneling microscope tip-surface crash events can be utilized as an efficient means for the creation of predefined island configurations for diffusion studies. Using this method, islands of varying size can be created and placed in close proximity, increasing the probability of initiating and observing coalescence events. Data obtained from crash initiated events on a Ag(111) surface are presented. Relaxation time exponents extracted from these data confirm that our method gives results consistent with previous, sputter-obtained island coalescence studies. We also describe an instrument-control routine developed for these measurements that utilizes commercial imaging and off-the-shelf automation software to automate the tracking of islands or other features by the microscope.

[Juvenile cataract associated with microcornea and glucosuria: a new syndrome]

BACKGROUND

Predisposition is responsible for approximately 50% of age-related cataracts. Investigation of inherited forms of cataract provides the opportunity to identify the genes that may play a role in age-related cataract as well.

PATIENTS AND METHODS

We describe the phenotype of a Swiss family with juvenile cataract, associated with microcornea and renal glucosuria. 11 of 17 family members in three generations underwent ophthalmic assessment and urine analysis. Medical records or questionnaires were evaluated in the remaining six cases.

RESULTS

Eleven family members had progressive juvenile cataract. Eight affected members available for clinical examination had bilateral microcornea, not associated with microphthalmos. Furthermore, renal glucosuria was demonstrated in six of these persons. The mode of inheritance is autosomal-dominant.

CONCLUSIONS

We have defined a new syndrome, consisting of the association of juvenile cataract, microcornea and renal glucosuria. The pattern of inheritance is autosomal-dominant. Genotyping is ongoing.

[Pregnancy and drug abuse]

The antenatal care of pregnant women with drug abuse is very complex and costly both in money and in time. The women often live under different circumstances than non-abusing women, and their personal and social resources are often very small. Collaboration between the hospital and the social system is essential in order to obtain a positive outcome of the pregnancy. Retrospective records of pregnancy, outcome and follow-up on 18 morphine-abusing women referred for delivery at Glostrup hospital in Copenhagen county over the three year period 1992-1994 are reported here. The study show the children are born in relatively good condition, although almost all needed postnatal detoxification, since their mothers was not able to stop their drug abuse during pregnancy. The pregnancy was with few complications because of tight antenatal care for these women. The study also shows a need for defining a common goal for the care of these women and their children and binding political commitments in order to obtain this goal.

Folate and neural tube defects. Recommendations from a Danish working group

A working group was established to evaluate the need for an increased folate intake in Danish women to decrease the risk of neural tube defects (NTDs). NTD are birth defects which include anencephaly, encephalocele and spina bifida. In Denmark the incidence is about 1.4 per 1,000 pregnancies. Folate is a B-vitamin found in most food groups. In case-control studies and randomised studies, a protective effect of folic acid supplements on NTDs has been found. The studies show that a periconceptional folic acid supplement of 360 micrograms to 4 mg daily decreases the recurrence rate of NTDs. Likewise, in the few studies which calculate folate intake from the diet, a lower risk of NTD with higher intake of folate from the diet has been found. The folate intake can be increased by the diet, by folic acid supplements or by fortification of food with folic acid. It is concluded that the incidence of NTDs in Denmark will decrease if the folate intake in fertile women increases. All women planning pregnancy should receive dietary counselling. Women who do not eat according to the Nordic Nutrition Recommendations, and women with an increased risk due to diseases are recommended a supplement of 400 micrograms folic acid daily from a multivitamin/folic acid tablet. Women who have had a child with NTD and women who themselves have NTDs are recommended a supplement of 5 mg folic acid daily. Dietary changes and supplements should be initiated when pregnancy is planned.

[Hysterectomy in a Danish population. Weight-related factors, psychological factors and life style variables]

The aim was to assess risk factors for hysterectomy performed for benign conditions. In a prevalence study, 2301 Danish women were selected at random in 1982. Information about weight and slimming history, life-styles, psychological factors, gynaecological history, and social background were obtained. In an incidence study, the cohort was followed from 1982 to 1990 to assess the incidence of hysterectomy. In the prevalence study, weight cycling (recurrent weight loss and weight gain of more than 5 kg) was associated with hysterectomy for benign disease (adjusted odds ratio 1.77, 95% confidence interval 1.05-2.99) independently of overweight, smoking, oral contraceptives, psychological and social factors. In the incidence study, weight cycling was the only significant weight-related risk factor for hysterectomy performed for benign disease (adjusted relative risk 2.49, 95% confidence interval 1.10-5.60), explaining the relation between hysterectomy and psychological factors. Weight cycling might be an important risk factor for premenopausal hysterectomy performed for benign conditions.

Gynaecological correlates of hysterectomy in Danish women

BACKGROUND

The aim has been to assess the gynaecological characteristics of importance for hysterectomy performed for benign diseases.

METHODS

In a prevalence study, 2301 Danish women aged 30, 40, 50, or 60 years, were selected at random in 1982, and self-report questionnaires were collected from 77%. Information about gynaecological and obstetric history, social background, weight and dieting history, and various lifestyles were recorded. Weight and height were measured. In an incidence study, the cohort was followed during 1982-1990 via central registers to assess the incidence of hysterectomy. Logistic and Cox regression were used to analyse data.

RESULTS

In the prevalence study, 85% of the hysterectomies were performed for benign conditions. Early menarche (< or = 11 years old) and short-term use of oral contraceptives (OC) (1-4 years) were independent correlates of these hysterectomies by multivariate analyses, whereas multiparity (> or = 4 childbirths) was confounded by education and weight-related factors. Long-term use of OC was associated with lower prevalence of hysterectomy. In the incidence study, short-term use of OC and ever use of progestogen-only minipills were independent risk factors for hysterectomy performed recently for benign diseases in women under 50 in the multivariate analyses. Abortions did not reach significance, and neither multiparity, long-term use of OC, nor early menarche were important.

CONCLUSION

The most important gynaecological characteristics related to premenopausal hysterectomy performed for benign diseases are hormonal contraceptives. These findings imply that the decision-making process concerning hysterectomy might depend on women's choice of contraception and compliance with OC as medical treatment.

Hysterectomy in Danish women: weight-related factors, psychologic factors, and life-style variables

OBJECTIVE

To assess weight-related risk factors, psychologic factors, and life-styles of importance for hysterectomy performed for benign conditions.

METHODS

In a prevalence study, 2301 Danish women aged 30, 40, 50, or 60 years were selected at random in 1982, and self-report questionnaires were collected from 77%. Information about weight and dieting history, life-style, psychologic factors, gynecologic history, and social background were recorded. Weight, height, and plasma lipids were measured. In an incidence study, the cohort was followed during 1982-1990 via central registers to assess the incidence of hysterectomy. Logistic and Cox regression were used to analyze the data.

RESULTS

In the prevalence study, weight cycling (recurrent weight loss and weight gain of more than 5 kg) was associated with hysterectomy for benign disease (odds ratio 1.77, 95% confidence interval [CI]1.05-2.99) by multivariate analysis independent of overweight, smoking, psychologic factors, social factors, and gynecologic characteristics. In the incidence study, all the weight-related factors except slimming diets were significant risk factors for hysterectomy performed recently for benign disease in women under age 50. In the multivariate analysis, weight cycling was the only significant weight-related factor (relative risk 2.49, 95% CI 1.10-5.60), explaining the relation between hysterectomy and psychologic factors. Coffee, tea, alcohol, smoking, and plasma lipids were not related to hysterectomy in either study.

CONCLUSION

Weight cycling might be an important risk factor for premenopausal hysterectomy performed for benign conditions. Whether weight cycling causes menstrual irregularities and leiomyomas, these results give us a better understanding of the pathways to hysterectomy.

[Do pregnant women need supplementation of folic acid?]

Neutral tube defects (NTDs) occur at an incidence of about 0.01 per cent, and in Denmark 40-50 new cases are recorded annually. Although the metabolism of folic acid increases during pregnancy, the dietary supply is marginal. Finding in recent studies suggest that folic acid supplementation as prophylactic treatment of gravidae reduces the incidence of NTDs. Folic acid prophylaxis is already being recommended as a general policy, with treatment starting before conception.

Secretory endometrial protein PP14 in women with early pregnancy bleeding

The decidualized endometrium produces secretory proteins of which secretory endometrial protein PP14 is the major product during the first trimester of pregnancy. The protein is secreted into the uterine lumen as well as into the peripheral blood. The purpose of this study was to examine whether decidual function, evaluated by the serum concentration of PP14, was different in women with early pregnancy bleeding compared to normal pregnant women. A reference range for serum PP14 was established on the basis of single samples from 236 normal pregnant women with ultrasonically confirmed gestational age. All the women were delivered of a normal child at term. The study comprised 128 pregnant women admitted because of vaginal bleeding between 6 and 18 weeks gestation. At ultrasonography, intrauterine fetal heart activity was either present or was confirmed at a subsequent examination. No difference was found in the serum level of PP14 compared to that in normal pregnancies, but women with vaginal bleeding and depressed PP14 levels appeared to have a 5-fold higher risk of preterm delivery than women with bleeding and normal PP14 levels.

A perinatal audit of stillbirths in three Danish countries

All stillbirths in 1985 and 1986 in three Danish counties were assessed in a perinatal audit. The aim was to investigate if departure from generally accepted standards of satisfactory perinatal care might have contributed to stillbirths, and also to investigate if differences in the structure of antenatal care and the delivery systems might have any influence on the rate of stillbirths. 119 cases evaluated, 70 were classified as unavoidable deaths, in 48 cases a different treatment might have improved the infant's possibility of survival and in one case consensus was not reached. The most frequent cause of suboptimal care was inadequate antenatal care of obvious signs of intrauterine growth retardation. Directives for visitation between surgical and obstetric departments were essential to the rate of stillbirth. The results indicate that it might be possible to achieve a further decrease in the number of stillbirths by intensifying the postgraduate training of the professionals and by issuing guidelines for the sharing of care responsibilities.

[The quality of registration of causes of death in perinatal and neonatal deaths]

The quality of registration of the causes of death in 273 perinatal and neonatal deaths was assessed. The present authors classified the causes of death according to WHO classification of disease. The authors classification was compared with the Danish Health Department's original classification of deaths and a classification undertaken by one of the staff of the Danish Health Department, the coding of which was based exclusively on information from the original death certificates (death certificate classification). Agreement between the respective forms of classification was assessed by the observed agreement for positive diagnosis and the kappa coefficients calculated by the three-figure level in the ICD diagnosis for categories and between categories of causes of perinatal and neonatal death, respectively. The investigation revealed that the deaths were classified with great accuracy by coding by the staff member when the death certificates were correctly completed. Comparison between the "authors classification" and the "Danish Health Department's original classification" and the "death certificate classification", respectively revealed that the observed agreement for positive diagnoses were 52% and 50% and that the kappa coefficients were between 0.80-0.07 and 0.81-0.04, respectively, on comparison with the three-figure levels in the ICD diagnoses and 0.93-0.32 and 0.85 and 0.32 on comparing the categories in between. It is concluded that considerable improvement in registration of perinatal and neonatal deaths may be obtained if the Danish Health Departments states precisely what information is required on the death certificate in connection with perinatal and neonatal deaths. Correspondingly, local efforts should be made to complete death certificates more correctly.

[Classification of perinatal and neonatal deaths. Fetal, obstetrical and neonatal causes]

A new method of classification of causes of death which may be employed in connection with perinatal and neonatal deaths is presented. The classification of causes of death proposed by the authors identifies the factor which probably initiated the train of events leading to death. This classification includes nine main categories and illustrates foetal conditions, happenings in pregnancy, the course of delivery and also the neonatal period. Employment of classification is proposed in regional registration of perinatal and neonatal deaths and as an aid in the current assessment of the quality of antenatal, obstetric and neonatal care as these are employed in medical audits of the perinatal and neonatal deaths in many Danish counties.

[Quality assurance in antenatal, perinatal and neonatal care. A medical audit]

Formalized quality assessment of prophylaxis, diagnosis, treatment, and care has recently been introduced in the Danish health service. A review is presented of quality assessment undertaken by the medical audit method and a model is described for quality assurance of prophylaxis, diagnosis, treatment and care during the ante-, peri and neonatal periods. The information is based partly on results from a medical audit project and also experience from work in a perinatal committee in the County of Copenhagen. The method of medical audit is reviewed, including here the specialists participating, the extent of the work and the material forming the basis for assessment of the quality. In addition, examples are quoted of criteria for satisfactory prophylaxis, diagnosis, treatment and care in the perinatal period and for how assessment by the specialists is carried out. A new classification of causes of death and review of the results of assessments of quality is presented. Finally, quality assessment as seen from the patients' point of view is discussed.

Polyhydramnios with maternal lithium treatment

Severe polyhydramnios, probably due to fetal lithium toxicity, is described. The mother had been treated with lithium because of manic-depressive psychosis. The plasma lithium level during the pregnancy was in or below the therapeutic range. From the 26th week of gestation, polyhydramnios developed. In the 35th week, 11.5 L of amniotic fluid was removed over a period of 12 hours by transabdominal amniocentesis. A cesarean delivery was performed in the 39th week of gestation because of fetal distress. The infant presented with the following symptoms, which in previous reports have been associated with lithium toxicity: asphyxia, apnea, cardiac decompensation, respiratory distress, hypoglycemia, thrombocytopenia, diabetes insipidus, hypotonia, and convulsions. The polyhydramnios was probably caused by fetal diabetes insipidus, possibly combined with cardiac decompensation. Lithium can be toxic to the infant and the fetus even though the mother is not affected and has a normal or low plasma lithium level. Polyhydramnios may be a sign of fetal lithium toxicity.

Breast-feeding in a Danish alternative birth center compared with the obstetrical ward

In 1984 an Alternative Birth Clinic (ABC) was opened at the Copenhagen County Hospital in Glostrup. The ABC was opened on a trial basis to evaluate the demand for a different and more peaceful birth and nursing environment. The study was performed to illustrate how the place of birth can influence the delivery and the duration of breast-feeding. During the observation period of seven months there were 125 uncomplicated births at the ABC, and 170 uncomplicated births at the obstetrical ward. It was not possible to perform this study as a randomized one as delivering at the ABC was on offer to all women in this part of Copenhagen County. The newborn children at the ABC were nursed during the first 30 min after birth by 73.1% of the mothers compared to only 48.1% of the mothers at the obstetrical ward. On the fifth day after delivery 79.7% of the mothers at the ABC breast-fed without supplementary infant formula, while 95.1% of the mothers at the obstetrical ward breast-fed without supplement. Fourteen weeks after delivery 68.4% of the mothers who delivered at the ABC were breast-feeding without supplement, compared to 51.8% of the mothers who delivered at the obstetrical ward. The success of breast-feeding was found to have a positive correlation to higher social groups, delivering at the ABC, the number of antenatal care visits and increasing maternal age. The significance of these factors was tested in a regression analysis which revealed that birthplace and social group were the two factors that could explain the differences in the course of breast-feeding. Women referred to the obstetrical ward because there were no vacancies at the ABC (ABC-refused) followed in all aspects the mothers at the obstetrical ward. In spite of the groups not being randomized we feel that we can conclude, especially taking into consideration the results from the ABC-refused group, that the differences in the success of breast-feeding can be explained by the place of birth, and that making the birthplace and the surroundings more inviting will be very profitable for the length of breast-feeding. If possible the staff should spend more time with the delivering women and later assist them in getting a good start of breast-feeding.

Can pregnancy-associated plasma protein A (PAPP-A) predict the outcome of pregnancy in women with threatened abortion and confirmed fetal viability?

Depressed pregnancy-associated plasma protein A (PAPP-A) concentrations have been found in patients with threatened abortion, often weeks before spontaneous abortion while the fetus was still alive. In order to extend these findings we have developed a highly sensitive PAPP-A radio-immunoassay and have established a reference range in early pregnancy for PAPP-A between week 7 and week 20 of pregnancy, based on blood samples from 240 pregnant women. The gestational age was determined by ultrasound. PAPP-A was measured in 128 women admitted to hospital because of vaginal bleeding in the 7th to 20th gestational week. The viability of the fetus was confirmed by ultrasonography. The serum values of PAPP-A were significantly lower (p = 0.002) in the group of women with vaginal bleeding than in the group of normally pregnant women. However, with regard to abortion later on, the predictive value of an abnormal blood test on admission was only 18.7%. Serial determinations showed increased PAPP-A values corresponding to the centile expected in the 12 women who aborted, as well as in the 116 women who gave birth. Consequently, the test is of no clinical value in the assessment of the prognosis in patients with symptoms of threatened abortion.

[Delivery at an alternative clinic or a special department]

With the object of assessing the safety of deliveries in the Maternity Clinic in Glostrup Hospital, consecutive registration of all 196 deliveries which commenced in the clinic during a period of seven months was undertaken. On account of various complications, 36.2% of these were transferred to the Special Department during delivery. As a control material, 313 so-called "no risk" deliveries which occurred in the Maternity Department of the Special Department during the same period were employed. The corresponding number of "complicated" deliveries in this material was 45.7%. Interventions such as early rupture of the membranes and stimulation of contractions with intravenous oxytocin were employed significantly more frequently in the Special Department. Delivery with vacuum-extractor or caesarean section was employed in 12.3% of the deliveries which commenced in the Clinic as compared with 16.6% in the Special Department. This difference was not significant. No differences could be demonstrated in the conditions of the infants on delivery and in the neonatal period which could be attributed to the choice of place of delivery. It is concluded that, with the rules for referral, monitoring during delivery and transfer to the Special Department which hold for the Maternity Clinic, the safety for deliveries corresponds to that which the Maternity Unit of the Special Department can offer.

[The significance of the place of delivery and other factors for the course of breast feeding]

A prospective investigation of the course of delivery and postpartum period in the maternity clinic and special department in Glostrup Hospital was undertaken and data concerning establishing of breast feeding and its course were registered. In order to assess the significance of various factors for the course of breast feeding, two materials of 125 deliveries in the maternity clinic and 170 deliveries in the special department, respectively, were compared, all of which were characterized by uncomplicated deliveries. Fourteen weeks after delivery 78.6% of the women from the maternity clinic and 57.7% of the women from the special department breast fed their infants. Breast feeding without supplements was employed by 69.1% from the maternity clinic and 52% from the special department, respectively. The social status of the women and the place of delivery were the only variables investigated which could explain the statistically significant differences in the course of breast feeding. The differences in the physical and mental environments in the two places of delivery which may be considered to have contributed to the difference in the course of breast feeding demonstrated here are discussed.

[The significance of the place of delivery for an uncomplicated delivery]

As part of an extensive prospective consecutive investigation of the course of delivery in the Maternity Clinic and Special Department in Glostrup Hospital, the results of the uncomplicated deliveries in both of these institutions are described in this article. Women who were delivered in the Maternity Clinic were, on the whole, a few years older and belonged to higher social groups than those who were delivered in the Special Department. Electronic monitoring was rarely employed in the Maternity Clinic, the parturient women were mobilized to a greater extent, the administration of analgesics was less and early rupture of the membranes was undertaken on fewer occasions. Patients appeared to be more satisfied with the physical surroundings in the Clinic than in the Special Department. It is not possible to isolate any single factor which was responsible for the differences encountered. However, there can scarcely be any doubt that the physical surroundings and the environment in the Maternity Clinic exerted a positive influence on the course of the delivery. The arrangements in the Maternity Clinic have probably also permitted the midwives to give the individual women more personal attention than is normally possible in a busy Special Department. Finally, differences in attitudes and knowledge in the parturient women may well have contributed to the differences encountered. Only randomized controlled investigations will be capable of revealing the roles played by the individual factors in the course of delivery.

Random blood glucose sampling as an early antenatal screening test for diabetes mellitus

Random blood glucose was measured on 1,992 pregnant women during the initial attendance at our antenatal clinic. The visit usually took place during the first part of the second trimester. Women with a random blood glucose concentration in excess of 6.1 mmol/l within 2 hours of the last meal and 5.6 mmol/l more than 2 hours after the last meal were referred for a fasting blood glucose measurement. A 75 g oral glucose tolerance test was performed in those cases where the fasting blood glucose exceeded 4.0 mmol/l. The cut-off levels were exceeded in 22 cases, but only one of these women was found to be suffering from previously unsuspected diabetes mellitus, based on the criteria of WHO (1). Five other cases of gestational diabetes were not detected by the random blood glucose method. It is concluded that random blood glucose measurements cannot be recommended as a safe and reliable screening procedure during the early part of the second trimester.

Ritodrine in the treatment of preterm labor: second Danish Multicenter Study

In a randomized trial intramuscular ritodrine followed by oral ritodrine treatment and bed rest was compared with placebo and bed rest in the treatment of 99 cases of preterm labor. The ritodrine treatment did not have a statistically significant effect on birth weight, gestational age, or the incidence of low birth weight. However, it did inhibit preterm labor in the initial stage, resulting in a gain of a few days to a few weeks in length of gestation. This gain may be valuable. Where necessary, advantage can be taken of it to transfer the mother before delivery to a more specialized hospital with a neonatal intensive care unit or to administer steroid treatment to promote fetal lung maturation. No serious side effects were recorded. The intramuscular route is recommended because large fluid infusions are avoided and treatment can easily be started before the patient is transported from home to hospital.

15(S)-15-methyl-prostaglandin F2 alpha used for induction of delivery in the case of intra-uterine fetal death

102 pregnant women with intra-uterine fetal death after the 12th week of gestation were treated with 15(S)-15-methyl-prostaglandin F2 alpha intramuscularly with doses of 125-250 micrograms at 2-3 hourly intervals. In all cases abortion or delivery was completed within 30 hours. The average time in primigravidae was 9 hours 43 minutes, and in multigravidae 9 hours and 59 minutes. In approximately two-thirds of the patients, mild or moderate gastrointestinal side effects were recorded in spite of prophylactic treatment with Retardin or Loperamide + Diphenoxylate. The therapy was found to be effective, easy to administer and the side effects acceptable. No serious side effects were recorded.

Elevated maternal serum alpha-fetoprotein caused by midtrimester amniocentesis: a prognostic factor

In a prospective investigation, 247 patients underwent ultrasonically guided midtrimester amniocentesis. Maternal serum alpha-fetoprotein (AFP) was measured before and after the procedure. In 229 patients, preamniocentesis AFP exceeded 19 micrograms/liter. Forty-eight (21.0%) of these displayed a significant elevation of AFP induced by the procedure, indicating fetal-maternal bleeding. This event was correlated with anterior placental location (P less than .025) and was followed by a significantly reduced mean fetal birth weight (3143 versus 3385 g, P less than .05). In addition, a nonsignificant (.10 less than P less than .20) doubling of the risk of giving birth to a child small for gestational age was observed. These findings suggest that amniocentesis represents a potential hazard to the fetus. The implications in relation to the widening indications for amniocentesis are discussed.

Smoking habits and maternal serum alpha-fetoprotein levels during the second trimester of pregnancy

In a prospective study the influence of cigarette smoking on maternal serum alpha-fetoprotein levels at 16 weeks gestation was examined. Significantly higher levels were found in 120 smokers compared with 138 non-smokers (median 54.0 and 44.3 micrograms/1 respectively, P less than 0.001). No difference in maternal body weight between the two groups could account for the results. The possibility of smoking-induced increased permeability of the placental barrier is discussed.