Reconsidering Routine Repeat Group and Screens During Pregnancy-Personalizing Pregnancy Care

The group and screen (G&S) are performed in early pregnancy to identify clinically significant antibodies (CSA) that may necessitate fetal monitoring for hemolysis/anemia or affect RhIg eligibility. Guidelines vary, including differences between RhD-positive and negative patients, but typically, the G&S is repeated at 28 weeks, and sometimes pre-delivery. We reviewed data showing a low risk (0.01%-0.43%) of detecting a new CSA in late gestation (late alloimmunization) and the risk of late alloimmunization causing severe hemolysis/anemia is even lower at <0.01%. Routinely repeating a G&S at 28 weeks and delivery may not be necessary for healthy, low-risk pregnancies.

Achieving ultra-low and -uniform residual magnetic fields in a very large magnetically shielded room for fundamental physics experiments

High-precision searches for an electric dipole moment of the neutron (nEDM) require stable and uniform magnetic field environments. We present the recent achievements of degaussing and equilibrating the magnetically shielded room (MSR) for the n2EDM experiment at the Paul Scherrer Institute. We present the final degaussing configuration that will be used for n2EDM after numerous studies. The optimized procedure results in a residual magnetic field that has been reduced by a factor of two. The ultra-low field is achieved with the full magnetic-field-coil system, and a large vacuum vessel installed, both in the MSR. In the inner volume of ∼ 1.4 m 3 , the field is now more uniform and below 300 pT. In addition, the procedure is faster and dissipates less heat into the magnetic environment, which in turn, reduces its thermal relaxation time from 12 h down to 1.5 h .

Ethical and Legal Considerations for Sterilization Refusal in Nulliparous Women

We address the ethical and legal considerations for elective tubal sterilization in young, nulliparous women in Canada, with comparison with the United States and the United Kingdom. Professional guidelines recommend that age and parity should not be obstacles for receiving elective permanent contraception; however, many physicians hesitate to provide this procedure to young women because of the permanence of the procedure and the speculative possibility of regret. At the practice level, this means that there are barriers for young women to access elective sterilization; they are questioned or not taken seriously, or their desire for sterilization is more generally belittled by health care professionals. This article argues for further consideration of these requests and considers the ethical and legal issues that arise when preventing regret is prioritized over autonomy in medical practice. In Canada, there is a paucity of professional guidelines and articles offering practical considerations for handling such requests. Compared with the U.S. and U.K. policy contexts, we propose a patient-centered approach for practice to address requests for tubal sterilization that prioritizes informed consent and respect for patient autonomy. We ultimately aim to assure physicians that when the conditions of informed consent are met and documented, they practice within the limits of the law and in line with best ethical practice by respecting their patients' choice of contraceptive interventions and by ensuring their access to care.

A large 'Active Magnetic Shield' for a high-precision experiment: nEDM collaboration

We present a novel Active Magnetic Shield (AMS), designed and implemented for the n2EDM experiment at the Paul Scherrer Institute. The experiment will perform a high-sensitivity search for the electric dipole moment of the neutron. Magnetic-field stability and control is of key importance for n2EDM. A large, cubic, 5 m side length, magnetically shielded room (MSR) provides a passive, quasi-static shielding-factor of about 10 5 for its inner sensitive volume. The AMS consists of a system of eight complex, feedback-controlled compensation coils constructed on an irregular grid spanned on a volume of less than 1000 m3 around the MSR. The AMS is designed to provide a stable and uniform magnetic-field environment around the MSR, while being reasonably compact. The system can compensate static and variable magnetic fields up to ± 50 μ T (homogeneous components) and ± 5 μ T/m (first-order gradients), suppressing them to a few μ T in the sub-Hertz frequency range. The presented design concept and implementation of the AMS fulfills the requirements of the n2EDM experiment and can be useful for other applications, where magnetically silent environments are important and spatial constraints inhibit simpler geometrical solutions.

Impact of free maternity services on outcomes related to hypertensive disorders of pregnancy at Moi Teaching and Referral Hospital in Kenya: a retrospective analysis

BACKGROUND

Preeclampsia is a major contributor to maternal and neonatal mortality worldwide. Ninety-nine percent of these deaths occur in resource limited settings. One of the greatest barriers to women seeking medical attention remains the cost of care. Kenya implemented a nation-wide policy change in 2013, offering free inpatient maternity services to all women to address this concern. Here, we explore the impact of this policy change on maternal and neonatal outcomes specific to the hypertensive disorders of pregnancy.

METHODS

We conducted a retrospective cross-sectional chart review of patients discharged or deceased with a diagnosis of gestational hypertension, preeclampsia, eclampsia or HELLP syndrome at a tertiary referral center in western Kenya one year before (June 1, 2012-May 31, 2013) and one year after (June 1, 2013-May 31, 2014) free maternity services were introduced at public facilities across the country. Demographic information, obstetric history, medical history, details of the current pregnancy, diagnosis on admission and at discharge, antepartum treatment, maternal outcomes, and neonatal outcomes were collected and comparisons were made between the time points.

RESULTS

There were more in hospital births after policy change was introduced. The proportion of women diagnosed with a hypertensive disorder of pregnancy was higher in the year before free maternity care although there was a statistically significant increase in the proportion of women diagnosed with gestational hypertension after policy change. Among those diagnosed with hypertensive disorders, there was no difference in the proportion who developed obstetric or medical complications. Of concern, there was a statistically significant increase in the proportion of women dying as a result of their condition. There was a statistically significant increase in the use of magnesium sulfate for seizure prophylaxis. There was no overall difference in the use of anti-hypertensives between groups and no overall difference in the proportion of women who received dexamethasone for fetal lung maturity.

CONCLUSIONS

Free maternity services, however necessary, are insufficient to improve maternal and neonatal outcomes related to the hypertensive disorders of pregnancy at a tertiary referral center in western Kenya. Multiple complementary strategies acting in unison are urgently needed.

Contraception use and HIV outcomes among women initiating dolutegravir-containing antiretroviral therapy in Kenya: a retrospective cohort study

INTRODUCTION

The rollout of dolutegravir (DTG) in low- and middle-income countries was disrupted by a potential association reported with periconceptional DTG exposure among women living with HIV (WLHIV) and infant neural tube defects. This prompted countries to issue interim guidance limiting DTG use among women of reproductive potential to those on effective contraception. Data to understand the potential impact of such guidance on WLHIV are limited.

METHODS

We conducted a retrospective cohort analysis of WLHIV 15-49 years initiating DTG-containing antiretroviral treatment (ART) in Kenya from 2017 to 2020. We determined baseline effective (oral, injectable or lactational amenorrhea) and very effective (implant, intrauterine device or female sterilization) contraception use among women who initiated DTG before (Group 1) or during (Group 2) the interim guideline period. We defined incident contraception use in each group as the number of contraceptive methods initiated ≤180 days post-guideline (Group 1) or post-DTG initiation (Group 2). We determined the proportions of all women who switched from DTG- to non-nucleoside reverse transcriptase inhibitor (NNRTI)- (efavirenz or nevirapine) containing ART ≤12 months post-DTG initiation, compared their viral suppression (<1000 copies/ml) and conducted multivariable logistic regression to determine factors associated with switching from DTG to NNRTI-containing ART.

RESULTS

Among 5155 WLHIV in the analysis (median age 43 years), 89% initiated DTG after transitioning from an NNRTI. Baseline effective and very effective contraception use, respectively, by the group were: Group 1 (12% and 13%) and Group 2 (41% and 35%). Incident contraception use in each group was <5%. Overall, 498 (10%) women switched from DTG to an NNRTI. Viral suppression among those remaining on DTG versus switched to NNRTI was 95% and 96%, respectively (p = 0.63). In multivariable analysis, incident effective and very effective contraception use was not associated with switching.

CONCLUSIONS

Baseline, but not incident, effective contraception use was higher during the interim guideline period compared to before it, suggesting women already using effective contraception were preferentially selected to initiate DTG after the guideline was released. These findings reveal challenges in the implementation of policy which ties antiretroviral access to contraceptive use. Future guidance should capture nuances of contraception decision-making and support women's agency to make informed decisions.

Impacts of the COVID-19 pandemic on access to HIV and reproductive health care among women living with HIV (WLHIV) in Western Kenya: A mixed methods analysis

Introduction

The COVID-19 pandemic has impacted access to health services. Our objective was to understand the pandemic's impact on access to HIV, pregnancy, and family planning (FP) care among women living with HIV (WLHIV).

Methods

Data were collected after June 2020, when questions about the pandemic were added to two ongoing mixed methods studies using telephone surveys and in-depth interviews among WLHIV in western Kenya. The Chaguo Langu (CL) study includes primarily non-pregnant WLHIV receiving HIV care at 55 facilities supported by AMPATH and the Opt4Mamas study includes pregnant WLHIV receiving antenatal care at five facilities supported by FACES. Our outcomes were self-reported increased difficulty refilling medication, accessing care, and managing FP during the pandemic. We summarized descriptive data and utilized multivariable logistic regression to evaluate predictors of difficulty refilling medication and accessing care. We qualitatively analyzed the interviews using inductive coding with thematic analysis.

Results

We analyzed 1,402 surveys and 15 in-depth interviews. Many (32%) CL participants reported greater difficulty refilling medications and a minority (14%) reported greater difficulty accessing HIV care during the pandemic. Most (99%) Opt4Mamas participants reported no difficulty refilling medications or accessing HIV/pregnancy care. Among the CL participants, older women were less likely (aOR = 0.95, 95% CI: 0.92-0.98) and women with more children were more likely (aOR = 1.13, 95% CI: 1.00-1.28) to report difficulty refilling medications. Only 2% of CL participants reported greater difficulty managing FP and most (95%) reported no change in likelihood of using FP or desire to get pregnant. Qualitative analysis revealed three major themes: (1) adverse organizational/economic implications of the pandemic, (2) increased importance of pregnancy prevention during the pandemic, and (3) fear of contracting COVID-19.

Discussion

The two unique participant groups included in our study encountered overlapping problems during the COVID-19 epidemic. Access to HIV services and antiretrovirals was interrupted for a large proportion of non-pregnant WLHIV in western Kenya, but access to pregnancy/family planning care was less affected in our cohort. Innovative solutions are needed to ensure HIV and reproductive health outcomes do not worsen during the ongoing pandemic.

The very large n2EDM magnetically shielded room with an exceptional performance for fundamental physics measurements

We present the magnetically shielded room (MSR) for the n2EDM experiment at the Paul Scherrer Institute, which features an interior cubic volume with each side of length 2.92 m, thus providing an accessible space of 25 m³. The MSR has 87 openings of diameter up to 220 mm for operating the experimental apparatus inside and an intermediate space between the layers for housing sensitive signal processing electronics. The characterization measurements show a remanent magnetic field in the central 1 m³ below 100 pT and a field below 600 pT in the entire inner volume, up to 4 cm to the walls. The quasi-static shielding factor at 0.01 Hz measured with a sinusoidal 2 μT peak-to-peak signal is about 100 000 in all three spatial directions and increases rapidly with frequency to reach 10⁸ above 1 Hz.

The design of the n2EDM experiment: nEDM Collaboration

We present the design of a next-generation experiment, n2EDM, currently under construction at the ultracold neutron source at the Paul Scherrer Institute (PSI) with the aim of carrying out a high-precision search for an electric dipole moment of the neutron. The project builds on experience gained with the previous apparatus operated at PSI until 2017, and is expected to deliver an order of magnitude better sensitivity with provision for further substantial improvements. An overview is of the experimental method and setup is given, the sensitivity requirements for the apparatus are derived, and its technical design is described.

Prevalence of Chlamydia and Gonorrhea Among Pregnant Adolescents Screened in the Third Trimester Using a Urine PCR Test: A Retrospective Review

OBJECTIVE

Our study assessed the rate of new and recurrent Chlamydia trachomatis and Neisseria gonorrhoeae infections in the third trimester at an adolescent obstetrics clinic.

METHOD

Between October 2016 and June 2020, routine third-trimester screening for C. trachomatis and N. gonorrhoeae was implemented according to new Canadian recommendations. Urine nucleic acid amplification was performed. Patient records were reviewed retrospectively, and demographic data; pregnancy and delivery characteristics; and information on screening at presentation to care, third-trimester screening (33-38 weeks), and other STI testing was recorded.

RESULTS

A total of 115 adolescents (mean age 17.90 ± 1.43 y) with 125 pregnancies presented for care. Twenty-three pregnancies were excluded (12 transferred out and 11 experienced a pregnancy loss). At presentation, screening was performed in 100 of 102 pregnancies: 64 of 100 at <13 weeks, 32 of 100 at 13-27 weeks, and 4 of 100 at 28-30 weeks. Nine tested positive for C. trachomatis and none tested positive for N. gonorrhoeae. In the third trimester, there were 3 positive C. trachomatis tests, but all were indicated: test of cure was due for 1 patient, 1 patient had a new sexual partner, and 1 patient presented with symptoms. The remaining 89 of 102 pregnancies were screened (with no other indication) and none were positive for C. trachomatis or N. gonorrhoeae. Ten patients could not be sampled (5 missed, 4 pre-term deliveries, and 1 non-compliant with testing).

CONCLUSION

No cases of C. trachomatis or N. gonorrhoeae infection were identified on third-trimester screening in our study. Adolescent obstetrics providers implementing Canadian screening guidelines may want to monitor their screening results to determine whether their yield warrants universal implementation.

nEDM experiment at PSI: Data-taking strategy and sensitivity of the dataset

We report on the strategy used to optimize the sensitivity of our search for a neutron electric dipole moment at the Paul Scherrer Institute. Measurements were made upon ultracold neutrons stored within a single chamber at the heart of our apparatus. A mercury cohabiting magnetometer together with an array of cesium magnetometers were used to monitor the magnetic field, which was controlled and shaped by a series of precision field coils. In addition to details of the setup itself, we describe the chosen path to realize an appropriate balance between achieving the highest statistical sensitivity alongside the necessary control on systematic effects. The resulting irreducible sensitivity is better than 1 × 10−26e cm. This contribution summarizes in a single coherent picture the results of the most recent publications of the collaboration.

Statistical sensitivity of the nEDM apparatus at PSI to n − n′ oscillations

The neutron and its hypothetical mirror counterpart, a sterile state degenerate in mass, could spontaneously mix in a process much faster than the neutron β-decay. Two groups have performed a series of experiments in search of neutron – mirror-neutron (n − n′) oscillations. They reported no evidence, thereby setting stringent limits on the oscillation time τnn′. Later, these data sets have been further analyzed by Berezhiani et al.(2009–2017), and signals, compatible with n − n′ oscillations in the presence of mirror magnetic fields, have been reported. The Neutron Electric Dipole Moment Collaboration based at the Paul Scherrer Institute performed a new series of experiments to further test these signals. In this paper, we describe and motivate our choice of run configurations with an optimal filling time of 29 s, storage times of 180 s and 380 s, and applied magnetic fields of 10 μT and 20 μT. The choice of these run configurations ensures a reliable overlap in settings with the previous efforts and also improves the sensitivity to test the signals. We also elaborate on the technique of normalizing the neutron counts, making such a counting experiment at the ultra-cold neutron source at the Paul Scherrer Institute possible. Furthermore, the magnetic field characterization to meet the requirements of this n − n′ oscillation search is demonstrated. Finally, we show that this effort has a statistical sensitivity to n − n′ oscillations comparable to the current leading constraints for B′ = 0.

The n2EDM experiment at the Paul Scherrer Institute

We present the new spectrometer for the neutron electric dipole moment (nEDM) search at the Paul Scherrer Institute (PSI), called n2EDM. The setup is at room temperature in vacuum using ultracold neutrons. n2EDM features a large UCN double storage chamber design with neutron transport adapted to the PSI UCN source. The design builds on experience gained from the previous apparatus operated at PSI until 2017. An order of magnitude increase in sensitivity is calculated for the new baseline setup based on scalable results from the previous apparatus, and the UCN source performance achieved in 2016.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Placental pathology associated with small for gestational age infants

Infants with intrauterine growth restriction (IUGR) are at an increased risk of perinatal disease, including death. Many, but not all small for gestational age infants (SGA) have IUGR. Placental disease is an important cause of IUGR, and gross and microscopic examination is critical in explaining such cases. Reports of placentas from infants with a birth weight < 2SD from the mean (approx 3rd centile) born between Jan 2004-Dec 2011 were evaluated. The principal pathology was determined in each case. Where two or more pathologic findings were present, they were ranked as principal and co-existing in terms of severity. There were 69,493 deliveries over the study period. 461 SGA cases were identified. No placenta was available in 44 cases, and 21 cases of known anomalies were excluded, leaving a study group of 396 cases. Pathology potentially causing or contributing to SGA and/or IUGR was identified in 84.1% of cases. Significant co-existing pathology was seen in 88 cases (22%). Placental examination provides key information in understanding abnormal fetal growth.

The Standardization of Uveitis Nomenclature (SUN) Project. Development of a clinical evidence base utilizing informatics tools and techniques

BACKGROUND

Given the recent increased focus on evidence-based medicine, it is critical that diseases and syndromes have accurate and complete descriptions, including standardized and widely accepted terminologies. Standardizing these descriptions and terminologies is necessary to develop tools such as computerized data entry forms and classification criteria. This need is especially true for diseases that are relatively uncommon, such as uveitis.

OBJECTIVES

To develop a standardized and internationally accepted terminology for the field of uveitis.

METHODS

The Standardization of Uveitis Nomenclature (SUN) Working Group (WG) is an international group of 79 uveitis experts from 18 countries and 62 clinical centers. Initial terminology was developed utilizing a "modified" green field approach, which was enhanced through web-based surveys and teleconferences via a "modified" Delphi technique. Terms were mapped provisionally into ontologic dimensions for each syndrome. The Working Group then met and utilized nominal group techniques as a formalized method of finalizing the mappings.

RESULTS

Mapping of terms into dimensions to describe 28 major uveitic diseases was confirmed using nominal group techniques (achieving super-majority consensus) for each of the diseases at a meeting of the entire WG.

CONCLUSIONS

The SUN WG utilized an informatics-based approach to develop a standardized and internationally accepted terminology for the uveitides.

Development, implementation, and evaluation of a student-initiated undergraduate medical education elective in HIV care

BACKGROUND

The literature indicates that medical students require more comprehensive HIV training.

AIM

Medical students at the University of Toronto developed and implemented the preclerkship HIV elective (PHE) with the aim to increase trainee HIV knowledge, address important issues in HIV care, and prepare students to serve affected populations.

METHODS

Developed in partnership with the Ontario HIV Treatment Network and in consultation with local AIDS service organizations and the University of Toronto Faculty of Medicine, the PHE was inaugurated in November 2008 as an elective supplement to medical curriculum content. Eighteen second-year medical students participated in the PHE, consisting of lectures, small group sessions, clinical observerships, community placements, reading assignments, and an HIV counseling and testing workshop. Participants completed a self-assessment of HIV knowledge prior to starting and after PHE completion.

RESULTS

Self-assessment scores of HIV knowledge among PHE participants significantly increased from 78.1% (pre-PHE) to 90.2% (post-PHE) (p = 0.0016). Common themes from feedback on participant satisfaction included enthusiasm for small group sessions, clinical observerships, community agency placements, and the diversity of topics covered.

CONCLUSIONS

Student-run initiatives can supplement medical curriculum content and program feedback may be used to advocate for curriculum changes. Factors influencing success include student leadership and interest, community partnerships, and faculty mentorship.

Clinical presentation of adult coeliac disease

The mode of presentation of coeliac disease has been changing to more atypical or silent disease. Few studies described the clinical presentation of adult coeliac disease in Ireland in recent years. We retrospectively collected the clinical data for all patients who had a diagnosis of coeliac disease made in our centre between January 07 and December 08. Forty seven adults, predominantly females (n = 30), had a confirmed diagnosis of coeliac disease made during the study period. In our patient cohort, the presenting symptom was diarrhoea in 19 (40%) patients, while 16 patients (34%) did not have any G.I. symptoms, 10 (21%) presented with anaemia. Females presented at a significantly younger age compared to males, with median ages at diagnosis of 44.5 and 57 years, respectively (p = 0.04). Females also presented more commonly with non G.I. symptoms (p = 0.07). The reasons behind this gender difference need further study.

Profile of sudden death in an adult population (1999-2008)

Sudden death is the sudden and unexpected death of an individual within 24 hours of symptom onset. The vast majority of these cases are found, at autopsy, to be due to underlying ischaemic cardiac disease. We retrospectively reviewed all adult post mortems performed at Beaumont Hospital over a decade (1999-2008). Our aim was to identify all sudden death cases (natural and accidental) and subclassify them according to age profile and organ system involved. We identified 1230 sudden death cases in the review period with 775 (63%) deaths attributable to ischaemic heart disease. The rate of sudden death remained constant over the decade with 663 (54%) deaths occurring in the first five years. Our negative autopsy rate was 2.8% corresponding to 35 cases. This is the first Irish study to retrospectively review all adult sudden deaths within a defined catchment area and analyse them as outlined above.

Non-haemorrhagic subdural collection complicating rupture of a middle cranial fossa arachnoid cyst

Arachnoid cysts are a common incidental finding on routine brain imaging and, for the most part, their presence is uneventful. Occasionally they may be associated with haemorrhage into the subdural compartment. Rarer still is simple rupture of the contents of the arachnoid cyst into the extra-axial space. MRI can help distinguish between these two rare occurrences--an important distinction to make as this may assist in directing the treating clinician toward the most appropriate management plan.

A study of prenatal ultrasound and postnatal magnetic imaging in the diagnosis of central nervous system abnormalities

Accurate prenatal diagnosis of central nervous system (CNS) abnormalities is essential in counselling parents, as they are the most common developmental abnormalities causing considerable mortality. Currently, the standard in prenatal imaging is ultrasound scanning (USS). The introduction of fast acquisition magnetic resonance imaging (MRI) has lead to increased diagnostic confidence and information available for parents. Frequently USS initially identifies CNS abnormalities as ventriculomegaly alone. However, it is known that ventriculomegaly is commonly associated with other CNS pathology, which may adversely affect the prognosis. As MRI has superior soft tissue resolution and can be used at any time postnatally, it is expected to identify disorders of myelination that may result from prenatal ventriculomegaly. This study will evaluate the role of MRI as a postnatal imaging tool in patients that had a prenatal USS diagnosis of isolated ventriculomegaly. This was a retrospective review of patient notes and scan reports. The postnatal MRI study group consisted of 9 patients that had been diagnosed initially with prenatal isolated ventriculomegaly on USS, and followed up with postnatal MRI (cases of spina bifida and Dandy-Walker malformations were excluded). Findings from the scan reports were recorded and analysed. Both MRI and prenatal USS gave the same information in 55.6 % of the patients. In the remaining 44.4 %, MRI added to the information provided by the prenatal USS. An interesting finding was that MRI missed a small fluid-filled cyst and an arachnoid cyst in 2 cases. 55.6 % of patients went on to develop other CNS abnormalities prenatally, whereas 33.3 % showed prenatal regression of VM with no other pathology. 11.1 % showed postnatal persistence of isolated VM. As USS has the advantage of being cheap and easy to perform, it will remain as the primary imaging tool in obstetric care. MRI can provide significant additional information that can affect parent counselling, prenatal intervention, and postnatal management. Postnatally, MRI can give some idea of prognosis by evaluating myelination patterns, which is not possible with USS.

Immunolocalization of 5alpha-reductase isozymes in acne lesions and normal skin

BACKGROUND

Dihydrotestosterone mediates androgen-dependent diseases, such as acne, hirsutism, and androgenetic alopecia. This hormone is produced from testosterone by the 5alpha-reductase enzyme. There are 2 isozymes of 5alpha-reductase (types 1 and 2) that differ in their localization within the body and even within the skin. Activity of the type 1 isozyme predominates in sebaceous glands, where it may be involved in regulation of sebum production. Since specific inhibition of 5alpha-reductase type 1 may represent a novel therapeutic approach to acne, it is important to define the localization of these isozymes in normal sebaceous follicles and acne lesions.

OBSERVATIONS

Skin biopsy specimens were obtained from the backs of 11 subjects: 8 with acne and 3 without acne. Sections of normal follicles, open comedones, closed comedones, and inflammatory lesions were incubated with antibodies to types 1 and 2 5alpha-reductase. In all samples, the type 1 antibody localized specifically to sebaceous glands, and the type 2 antibody localized to the companion layer of the hair follicle (the innermost layer of the outer root sheath) and granular layer of the epidermis. Localization of the type 2 isozyme was also noted within the walls of open and closed comedones and in endothelial cells from sections of inflammatory lesions.

CONCLUSIONS

The immunolocalization of 5alpha-reductase isozymes in normal sebaceous follicles and acne follicles is similar to the pattern described in terminal hair follicles and corresponds with the findings of biochemical studies that have demonstrated predominance of type 1 activity in sebaceous glands. The function of type 2 5alpha-reductase in comedones or endothelial cells in inflammatory lesions is unknown.

Low grade pilocytic astrocytoma presenting as a spontaneous intracerebral haemorrhage in a child

A girl aged 13 years presented with spontaneous intracerebral haemorrhage. Initially, no cause could be found but she was later found to have a low grade pilocytic astrocytoma. This very uncommon presentation was not considered before surgery.

Analysis of protein fractions by micropreparative capillary isoelectric focusing and matrix-assisted laser desorption time-of-flight mass spectrometry

In this study, the use of capillary isoelectric focusing (cIEF) as a micropreparative tool for protein analysis by matrix-assisted laser desorption time-of-flight mass spectrometry (MALDI-TOF-MS) is demonstrated. A newly designed, automated, collection interface equipped with a fiber-optic UV detector and a sheath flow connection was employed for collection of protein fractions. Multiple fractions were collected during a single cIEF run and further analyzed by MALDI-TOF-MS for mass assignment. The feasibility of the method was tested with a mixture of model proteins with different isoelectric points and molecular masses, and with variants of human hemoglobins differing in pI, but with negligible difference in M(r). Some practical considerations of the collection procedure and subsequent TOF analysis are presented.

Lidocaine diffusion in five tissue expanders: an in vitro and in vivo study

Previous work in our laboratory has demonstrated that tissue expanders are permeable to lidocaine. In this two-part study, we assessed the in vitro lidocaine diffusion in the following five common tissue expanders: Dow Corning, McGhan, Cox-Uphoff, Hyer-Schulte (Mentor), and Surgitek. In part 1, we demonstrated that wall thickness appeared to be the major determinant for diffusion. Part 2 reports an in vivo study of lidocaine diffusion from tissue expanders used for breast reconstruction. We initially determined that there is incomplete mixing between the valve and connecting tubing and the contents of the expanders, over the period of 1 week. We subsequently examined the lidocaine diffusion from seven tissue expanders placed in a submuscular position for breast reconstruction. The rate of lidocaine diffusion was highly variable, but on average was about 3% per day.