Microscopic Hematuria as a Screening Tool for Urologic Malignancies in Women

INTRODUCTION

Most causes of microscopic hematuria (MH) are benign but may indicate an underlying malignancy. Current MH evaluation guidelines are reflective of male urologic malignancy risks. The objective of this systematic review was to evaluate whether the finding of MH predicts subsequent urologic malignancy in women.

METHODS

MEDLINE was searched between January 1990 and June 8, 2018. The positive predictive value (PPV) of MH as a screening tool for urologic malignancy was calculated for each study individually and collectively. The pooled relative risk of urologic malignancy associated with MH was calculated.

RESULTS

Seventeen studies were included. Eight studies included only women. In total, 300 urinary tract cancers were identified in 110,179 women with MH. The PPV of MH as a screening tool for cancer ranged from approximately 0.6% to 2.8%; confidence intervals (CIs) suggested this is a relatively unstable performance indicator because of small sample sizes. Average PPV across all studies was 2.13%, but the weighted average PPV was 0.24%. The risk of urologic malignancies among women with relative those without MH was 2.01 (95% CI, 1.61-2.51). Based on these limited data, we estimate that 859 (95% CI, 654-1250) women with MH would require complete evaluation to identify 1 urinary tract malignancy.

CONCLUSIONS

A very small proportion of women with MH are likely to have a urologic malignancy. Approximately 859 women require full screening to identify 1 malignancy. Current evidence is limited, and further studies, specifically in women, are needed.

Admixture mapping of pelvic organ prolapse in African Americans from the Women's Health Initiative Hormone Therapy trial

Evidence suggests European American (EA) women have two- to five-fold increased odds of having pelvic organ prolapse (POP) when compared with African American (AA) women. However, the role of genetic ancestry in relation to POP risk is not clear. Here we evaluate the association between genetic ancestry and POP in AA women from the Women’s Health Initiative Hormone Therapy trial. Women with grade 1 or higher classification, and grade 2 or higher classification for uterine prolapse, cystocele or rectocele at baseline or during follow-up were considered to have any POP (N = 805) and moderate/severe POP (N = 156), respectively. Women with at least two pelvic exams with no indication for POP served as controls (N = 344). We performed case-only, and case-control admixture-mapping analyses using multiple logistic regression while adjusting for age, BMI, parity and global ancestry. We evaluated the association between global ancestry and POP using multiple logistic regression. European ancestry at the individual level was not associated with POP risk. Case-only and case-control local ancestry analyses identified two ancestry-specific loci that may be associated with POP. One locus (Chromosome 15q26.2) achieved empirically-estimated statistical significance and was associated with decreased POP odds (considering grade ≥2 POP) with each unit increase in European ancestry (OR: 0.35; 95% CI: 0.30, 0.57; p-value = 1.48x10^-5). This region includes RGMA, a potent regulator of the BMP family of genes. The second locus (Chromosome 1q42.1-q42.3) was associated with increased POP odds with each unit increase in European ancestry (Odds ratio [OR]: 1.69; 95% confidence interval [CI]: 1.28, 2.22; p-value = 1.93x10^-4). Although this region did not reach statistical significance after considering multiple comparisons, it includes potentially relevant genes including TBCE, and ACTA1. Unique non-overlapping European and African ancestry-specific susceptibility loci may be associated with increased POP risk.

Genetic Determinants of Pelvic Organ Prolapse among African American and Hispanic Women in the Women's Health Initiative

Current evidence suggests a multifactorial etiology to pelvic organ prolapse (POP), including genetic predisposition. We conducted a genome-wide association study of POP in African American (AA) and Hispanic (HP) women from the Women's Health Initiative Hormone Therapy study. Cases were defined as any POP (grades 1-3) or moderate/severe POP (grades 2-3), while controls had grade 0 POP. We performed race-specific multiple logistic regression analyses between SNPs imputed to 1000 genomes in relation to POP (grade 0 vs 1-3; grade 0 vs 2-3) adjusting for age at diagnosis, body mass index, parity, and genetic ancestry. There were 1274 controls and 1427 cases of any POP and 317 cases of moderate/severe POP. Although none of the analyses reached genome-wide significance (p<5x10-8), we noted variants in several loci that met p<10-6. In race-specific analysis of grade 0 vs 2-3, intronic SNPs in the CPE gene (rs28573326, OR:2.14; 95% CI 1.62-2.83; p = 1.0x10-7) were associated with POP in AAs, and SNPs in the gene AL132709.5 (rs1950626, OR:2.96; 95% CI 1.96-4.48, p = 2.6x10-7) were associated with POP in HPs. Inverse variance fixed-effect meta-analysis of the race-specific results showed suggestive signals for SNPs in the DPP6 gene (rs11243354, OR:1.36; p = 4.2x10-7) in the grade 0 vs 1-3 analyses and for SNPs around PGBD5 (rs740494, OR:2.17; p = 8.6x10-7) and SHC3 (rs2209875, OR:0.60; p = 9.3x10-7) in the grade 0 vs 2-3 analyses. While we did not identify genome-wide significant findings, we document several SNPs reaching suggestive statistical significance. Further interrogation of POP in larger minority samples is warranted.

Abstract P4-02-20: Plasticity of the ER and HER2 Signaling Networks Results in Compensatory Escape Pathways Contributing to Treatment Resistance

Bidirectional crosstalk between the estrogen receptor (ER) and HER2 has been demonstrated in preclinical model systems. We have previously shown in HER2+ breast cancer cells with low ER that potent HER2- targeted therapy results in ER reactivation that functions as an escape pathway to evade therapeutic inhibition. Here we investigated the role of HER pathway components in resistance to endocrine therapies using UACC812 cells, which are endogenously amplified for HER2. Endocrine resistant (R) derivatives of the UACC812 line were developed through long-term (&gt;6 months) culturing with estrogen deprivation (ED) alone or with 4-OH-tamoxifen (Tam, 10-7M). Endocrine treatment [continued ED, estrogen (E2, 10-9M), Tam (10-7M), or fulvestrant (Ful, 10-7M)] of parental cells slowed cell growth compared to estrogen treatment (P&lt;0.01). EDR and TamR derivatives treated with any of the endocrine therapies, however, exhibited the same growth rates as with estrogen, validating the completely resistant phenotype of our clones. By immunoblot analysis, the resistant derivatives, TamR and EDR, showed a striking and complete loss of ER expression and its downstream gene products including PR, IGF-1R, and IRS-1. In contrast, both resistant lines exhibited significant upregulation of HER pathway components including marked increases in total and phosphorylated (p) EGFR, further upregulation of pHER2, and marked increases in the downstream signaling moieties pMAPK, pAkt, pFAK, pSrc, and pFOXO3a. In contrast, levels of pHER3 were markedly reduced at resistance. Since our in vitro data suggested that ER and HER2 compensate for inhibition of each other's pathways, we next examined whether simultaneous inhibition of both pathways can circumvent the development of resistance in an in vivo xenograft model. Athymic nude mice bearing UACC812 xenografts, established in the presence of E2 supplementation, were randomized to continued E2, endocrine therapies alone (ED, Tam, or Ful), anti-HER2 alone [lapatinib (L), trastuzumab (T), or L+T], or the combination of endocrine and anti-HER2 therapies (ED with L, T, or L+T). We found that tumors were stimulated by E2, as well as by Tam (as a mechanism of de novo resistance), while still being inhibited, though only temporarily (2-3 months), by ED and Ful. Anti-HER2 therapy alone only slowed down (L or T) or stabilized (L+T) tumor growth. In contrast, in the presence of both ED and anti-HER2 therapies, most tumors completely regressed. However, only the potent L+T plus ED regimen achieved continuous long term (&gt;200 days) complete regression in all mice. Our results further illustrate the plasticity of the ER and HER2 pathways and provide additional support for the role of the HER network, especially EGFR, in resistance to endocrine therapy in ER+/HER2+ breast cancer. The data emphasize the need for complete HER blockade for optimal therapy.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-02-20.

Sequence and structure continuity of evolutionary importance improves protein functional site discovery and annotation

Protein functional sites control most biological processes and are important targets for drug design and protein engineering. To characterize them, the evolutionary trace (ET) ranks the relative importance of residues according to their evolutionary variations. Generally, top-ranked residues cluster spatially to define evolutionary hotspots that predict functional sites in structures. Here, various functions that measure the physical continuity of ET ranks among neighboring residues in the structure, or in the sequence, are shown to inform sequence selection and to improve functional site resolution. This is shown first, in 110 proteins, for which the overlap between top-ranked residues and actual functional sites rose by 8% in significance. Then, on a structural proteomic scale, optimized ET led to better 3D structure-function motifs (3D templates) and, in turn, to enzyme function prediction by the Evolutionary Trace Annotation (ETA) method with better sensitivity of (40% to 53%) and positive predictive value (93% to 94%). This suggests that the similarity of evolutionary importance among neighboring residues in the sequence and in the structure is a universal feature of protein evolution. In practice, this yields a tool for optimizing sequence selections for comparative analysis and, via ET, for better predictions of functional site and function. This should prove useful for the efficient mutational redesign of protein function and for pharmaceutical targeting.

Uterosacral colpopexy at the time of vaginal hysterectomy: comparison of laparoscopic and vaginal approaches

OBJECTIVE

To compare the risk of ureteral compromise and of recurrent vault prolapse following vaginal vs. laparoscopic uterosacral vault suspension at the time of vaginal hysterectomy.

STUDY DESIGN

In this retrospective, cohort study, uterosacral ligament suspension was performed using either a vaginal or laparoscopic approach. The primary outcome was intraoperative ureteral compromise; secondary outcomes were postoperative anatomic result and recurrent prolapse. The Canadian Task Force Classification was II-2.

RESULTS

One hundred eighteen patients were included: 96 patients in the vaginal group and 22 patients in the laparoscopic group. Ureteral compromise was identified intraoperatively in 4 (4.2%) cases in the vaginal group; no ureteral compromise was observed in the laparoscopic group (p = 0.33). Failure at the apex, defined as stage > or = II for point C, was seen in 6.3% of patients in the vaginal group as compared with 0% in the laparoscopic group; this difference did not achieve statistical significance. Similarly, trends toward lower recurrent symptomatic vault prolapse (10% vs. 0%), any symptomatic prolapse recurrence (12.5% vs. 4.6%), and higher postoperative Pelvic Organ Prolapse Quantification point C were observed in the laparoscopic group (p > 0.05 for all).

CONCLUSION

Laparoscopic uterosacral vault suspension following vaginal hysterectomy is a safe alternative to the vaginal approach.

Management of stress urinary incontinence

Stress urinary incontinence (SUI) is a common disorder that does not require treatment unless bothersome to the patient. The evaluation includes a thorough history and physical in order to evaluate for other bladder and pelvic floor disorders. Multichannel urodynamics are not necessary for the diagnosis of SUI, but may be helpful when choosing among appropriate treatment options and for patient counseling. Behavioral and physical therapies are appropriate first-line treatments and should be discussed with all patients, even those desiring surgical treatment. Conservative treatments include the use of pessaries to improve urethral support. Multiple surgical options exist. While mid-urethral slings are commonly used today, there is a still a role for traditional pubovaginal slings and the Burch retropubic urethropexy.

Comparison of retropubic vs transobturator approach to midurethral slings: a systematic review and meta-analysis

To systematically review the literature and to quantitatively compare outcomes and complications following retropubic vs transobturator approach to midurethral slings. We searched PUBMED, OVID, EMBASE, CINAHL, POPLINE, Web of Science, Cochrane Collaboration resources, TRIP, Global Health databases, and abstracts from relevant meetings from 1990 to 2006. We included all studies that compared retropubic and transobturator approaches to midurethral slings and that defined outcomes. We used random-effects models to estimate pooled odds ratios and 95% confidence intervals for objective and subjective failure, complications, and de novo irritative voiding symptoms. Six randomized trials and 11 cohort studies compared transobturator and retropubic approaches to midurethral slings. There was insufficient evidence to support if one approach leads to better objective outcomes. We found no difference in subjective failure between the 2 approaches after pooling data from randomized trials (pooled odds ratio OR 0.85, confidence interval 95% CI 0.38-1.92). The transobturator approach was associated with a decreased risk of complications (pooled OR 0.40, 95% CI 0.19-0.83]). The transobturator approach to midurethral slings is associated with a lower risk of complications; however, it is still unclear if one approach results in superior objective or subjective outcomes.

Basic and translational research in neonatal pharmacology

Pharmacologic study is needed in the extremely immature newborns who currently survive. Study is needed of both the drug treatment previously established in more mature neonates and of novel drug therapy. Carefully controlled studies are needed to identify accurately both beneficial and harmful drug therapy and the mechanisms of that toxicity. Careful pharmacologic study of drug disposition and its mechanisms might lead to dosing paradigms or patient selection that minimize toxicity and maximize efficacy. In vivo, translational models of neonatal diseases are limited, but can be used to identify novel treatments and study mechanisms of established, successful therapy. Findings from such studies can generate hypotheses for study in humans leading to a continuing scientific interchange from bedside to bench to bedside. Similarly, clinical observations can generate hypotheses for study in translational models where more invasive analyses are possible. Specific areas of drug treatment should focus on neonatal disorders with long-term, adverse outcomes, such as chronic lung disease, that is amenable to translational study with animal models. National data show a progressive decrease in the clinician-scientist pool entering biomedical research. The future of neonatal pharmacology studies requires an increase in training programs for the physician-scientist whose clinical education in neonatology can be complemented by rigorous basic-science training. Success as a clinician-scientist will require collaboration with full-time basic scientists who can continue studies during periods of clinical work and provide critical study methodology to the overall study design. Such a work environment must be supported by academic institutions and may require more flexibility in the promotion and tenure schedule and process, such as the nature of what it rewards. To complement this, the NIH could modify its grant reporting process to identify co-investigators in studies who may provide unique input to the study concepts and design, such as clinical correlations or clinical investigations.

Viscosity of rice flour: a rheological and biological study

Rice breeders frequently use rapid visco analysis (RVA) as in index of rice quality. Potentially, viscosity curves could also be used to predict the sensory properties of a sample of rice or the processing properties of rice when used as an ingredient. The aim of this study is to determine the contribution of the main components of rice flour-starch and protein polymers and lipids-to the viscosity curve, accounting for biological and rheological contributions, and interactions with water. By deconstructing the rice flour, resistance to shear is generally the primary factor that affects rheological processes in the RVA, often masking the physical processes of cooking. Thus, higher concentrations of water reveal more about the true biological and physical processes of the transition from a powder to paste. Proteins contribute to peak height, offset thixotropy, and contribute to the final viscosity. Starch-lipid complexes can mask differences in the molecular structures of amylose and amylopectin, and removing lipids alters the structure of the paste significantly, which consequently alters viscosity curves.

Difficulties in the study of adverse fetal and neonatal effects of drug therapy during pregnancy

This article reviews the difficulties in studying adverse effects of drugs during pregnancy on the fetus and newborn. A study design should strive for prospective recording of drug intake during pregnancy, comparison to appropriate control groups adjusted for inherited traits, and single drug exposures for evaluation of specific syndromic causation, such as the Fetal Hydantoin Syndrome. Animal models are best used in mechanistic study of adverse drug effects on the fetus rather than for screening for adverse effects. Careful conclusions about causation of drug-induced adverse effects are needed to avoid false associations while providing appropriate safeguards to the fetus and newborn.

Albuterol delivery in a neonatal ventilated lung model: Nebulization versus chlorofluorocarbon- and hydrofluoroalkane-pressurized metered dose inhalers

The aim of this study was to compare albuterol delivery in a neonatal ventilated lung model, using three delivery methods: 1) jet nebulizer; 2) chlorofluorocarbon-pressurized metered dose inhaler (CFC-MDI) actuated into an ACE(R) spacer; and 3) hydrofluoroalkane-pressurized MDI (HFA-MDI) actuated into an ACE(R) spacer. The bench model consisted of a mechanically ventilated infant test lung with ventilator settings to simulate a very low birth weight neonate with moderate lung disease. Albuterol solution (0.5%) was nebulized at the humidifier and temperature port, 125 cm and 30 cm from the Y-piece, respectively. Albuterol metered dose inhalers (MDIs) were actuated into an ACE(R) spacer that was tested in two positions: 1) inline between the endotracheal (ET) tube and the Y-piece; and 2) attached to the ET tube and administered by manual ventilation. Albuterol was collected on a filter at the distal end of the ET tube and was quantitatively analyzed by high performance liquid chromatography. Albuterol delivery by CFC-MDI (position 1, 4.8 +/- 1.0%, vs. position 2, 3.8 +/- 1.6%, P > 0.05) and HFA-MDI (position 1, 5.7 +/- 1.6%, vs. position 2, 5.5 +/- 2.4%, P > 0.05) were significantly greater than delivery by nebulization at 30 cm (0.16 +/- 0.07%) and 125 cm (0.15 +/- 0.03%) from the Y-piece (P < 0.001). A single actuation of albuterol MDI delivered the equivalent of nebulizing 2.5-3.7 mg of albuterol solution. We conclude that albuterol administered by MDI and ACE(R) spacer resulted in more efficient delivery than by nebulization in this mechanically ventilated neonatal lung model. There was no significant difference in drug delivery between CFC-MDI and HFA-MDI; nor did the placement of the spacer significantly affect drug delivery.

Ten guiding principles for teaching children and adolescents about medicines. US Pharmacopeia

In 1996, an open conference sponsored by the US Pharmacopeia (USP) and attended by more than 100 health care professionals established the need and rationale for teaching children and adolescents about medicines. After the conference, a public, iterative, consensus-development process including participation by 35 health-professional organizations was undertaken. This process resulted in a USP position statement, "Ten Guiding Principles for Teaching Children and Adolescents About Medicines," which supports the right of children and adolescents to receive developmentally appropriate information and direct communications about medicines that are consistent with their health status, capabilities, and culture. The position statement is intended to stimulate activities that will help children become active participants in the process of appropriate use of medicines and prepare them for the day they begin to use medicines independently.

Cisapride: a survey of the frequency of use and adverse events in premature newborns

OBJECTIVE

This survey estimated the frequency of use and adverse events associated with cisapride treatment of premature newborns in intensive care units. It was initiated in response to a warning issued in Canada cautioning against cisapride treatment of premature infants of <36 weeks' gestation and <3 months of age.

METHODOLOGY

Surveys were mailed to 105 neonatology training program directors to obtain the total number of neonatal intensive care unit (NICU) admissions, the number of admissions of infants of <36 weeks' gestation, the number of years that cisapride had been used, the estimated percent/number of premature patients treated with cisapride per year, and the frequency and nature of arrhythmias or other adverse events associated with cisapride treatment. Of 105 programs, 46 responded to a single mailing of the first survey. A second survey mailed to the 45 respondents to the first survey sought to determine the indications, diagnostic tests, and dosages used with cisapride treatment of premature newborns. Of the 45 programs, 26 responded to the second survey.

RESULTS

More than 58 000 premature newborns of <36 weeks' gestation were admitted to the NICUs we surveyed, and approximately 19% were treated with cisapride. No deaths attributable to cisapride were reported among >11 000 preterm newborns treated. Three nonfatal arrhythmias were reported; two associated with 10-fold dosing errors and one with co-treatment with erythromycin, a macrolide antibiotic that reduces the metabolism of cisapride. Diarrhea was reported in 12 patients, and reversible liver enzyme changes were noted in one patient. Typically, cisapride treatment was started in dosages of 0.1 to 0.2 mg/kg/dose, repeated every 6 to 8 hours. Treatment usually was begun empirically, without a preceding study to document gastroesophageal reflux. The most frequent indications for cisapride treatment were choking or gagging, with associated apnea, bradycardia, and desaturation. Approximately 50% of patients had discontinued cisapride treatment before discharge. Eighty-four percent of clinicians judged cisapride to be effective for the problems being treated.

CONCLUSIONS

Cisapride treatment of premature infants of <36 weeks' gestation and <3 months of age in NICUs appears to be widespread in the United States. Complications and adverse events were seen when cisapride was administered in excessive dosages or in combination with a drug that inhibits its metabolism and leads to increased serum concentrations. Severe toxicities such as arrhythmias were reported with a frequency of <1/11 000 NICU admissions. However, in a retrospective survey, episodes of toxicity, including mortality, attributable to cisapride may not have been recognized or reported.

Congenital malformations presenting during the neonatal period

Discharge of the newborn within 24 to 48 hours after birth makes it more difficult to detect some congenital malformations and increases the need for careful examination and review of the history of the pregnancy, delivery, and nursery course. Progressive physiologic changes after birth, especially in the cardiovascular system, precede the development of signs indicative of disease for certain congenital malformations. Discharge before these changes occur may delay their detection because the newborn is not being monitored by medical or nursing caregivers. The AAP Committee on the Fetus and Newborn has published guidelines for criteria for safe discharge and follow-up evaluation to help create a safe situation for such early discharges. Some specific observations at birth may lead to earlier diagnosis. Careful attention to subtle differences between the initial and follow-up examination, such as a changing cardiac murmur or quality of pulses or abdominal fullness, may provide clues to the diagnosis of congenital malformations. Coordinated suck and swallow with successful feeding and passage of stool and urine within 24 hours after birth should occur before discharge. Reports of feeding difficulties should be reviewed. Although a thorough examination is facilitated by a sleeping infant, documentation of a normal pitched cry helps in the evaluation of the upper airway. Parents should be counseled about signs of illness that warrant medical attention, and early follow-up is needed to detect problems early enough to intervene effectively. In addition, although passage of a feeding tube through each nare and to the stomach with aspiration and measurement of gastric volume is not a routine procedure in the well, term newborn, this may be a useful early diagnostic tool in infants with signs or a maternal or nursery history suggestive of nasal or GI obstruction.

Visual search for a tilted target: tests of spatial uncertainty models

We report that spatial cueing of a parafoveal target in the presence of distractors enhances orientational acuity for that target. When no distractors were present, orientation thresholds were in the range 1-4 degrees. For long exposure times, distractors increased threshold by the amount predicted from a winner-takes-all spatial uncertainty model. For short (100-msec) exposures followed by a random dot mask, the rise in threshold with distractors was considerably greater than that predicted from spatial uncertainty. For brief exposures the effect of distractors was greater when the target and distractors were spatially crowded rather than widely spaced. Adding a tilt to the distractors in the opposite direction to the target increased thresholds still further. Cueing the target with a spatial pointer decreased the effect of distractors, even when they were crowded. We suggest that when attention cannot be appropriately focused, discrimination is carried out by a relatively coarse texture analyser, which averages over several elements, and that focused attention permits the analysis of the target over a smaller area of space.

Genetic studies into inherited and sporadic hemolytic uremic syndrome

Hemolytic uremic syndrome (HUS) in adults carries a high morbidity and mortality, and its cause remains unknown despite many theories. Although familial HUS is rare, it affords a unique opportunity to elucidate underlying mechanisms that may have relevance to acquired HUS. We have undertaken a genetic linkage study based on a candidate gene approach. A common area bounded by the markers D1S212 and D1S306, a distance of 26 cM located at 1q32 segregated with the disease (Z max 3.94). We demonstrate that the gene for factor H lies within the region. Subsequent mutation analysis of the factor H gene has revealed two mutations in patients with HUS. In an individual with the sporadic/relapsing form of the disease we have found a mutation comprising a deletion, subsequent frame shift and premature stop codon leading to half normal levels of serum factor H. In one of the three families there is a point mutation in exon 20 causing an arginine to glycine change, which is likely to alter structure and hence function of the factor H protein. Factor H is a major plasma protein that plays a critical regulatory role in the alternative pathway of complement activation. In light of these findings and previous reports of HUS in patients with factor H deficiency, we postulate that abnormalities of factor H may be involved in the etiology of HUS.

Acute response to inhaled nitric oxide in newborns with respiratory failure and pulmonary hypertension

OBJECTIVE

Systemic oxygenation is improved by inhaled nitric oxide therapy in some newborns with respiratory failure and pulmonary hypertension. Our results with inhaled nitric oxide were reviewed to determine factors associated with an acute improvement in systemic oxygenation.

METHODS

Newborns with oxygenation indices of 25 to 40 were prospectively randomized to receive conventional therapy with or without 20 ppm inhaled nitric oxide. All newborns with oxygenation indices greater than 40 were treated with inhaled nitric oxide. Hemodynamic, blood gas, and Doppler ultrasound measurements were performed before and after 30 to 60 minutes of observation or therapy. The severity of lung disease was classified by the chest radiograph as: (1) normal or focal disease; (2) moderate diffuse disease-diffuse lung disease with well-defined heart borders; or (3) severe diffuse disease-diffuse lung opacification with indistinct heart borders.

RESULTS

Heart rate, blood pressure, and ductal diameters did not change. Blood gases and ductal shunting acutely improved only in patients treated with inhaled nitric oxide. Patients with normal lung fields or focal disease had the greatest degree of improvement in systemic oxygenation. Changes in oxygenation were not influenced by gestational age, baseline blood gases, the proportion of right-to-left ductal shunting, prior treatment with a surfactant, or the use of conventional or high-frequency jet ventilation. Collectively, blood gases and ductal shunting did not improve with inhaled nitric oxide in patients with lung hypoplasia or severe diffuse lung disease. Sustained improvement in oxygenation occurred in 87% of patients with oxygenation indices greater than 40 in whom oxygenation indices less than 40 acutely developed after exposure to nitric oxide, whereas 90% of patients in whom oxygenation indices less than 40 did not acutely develop were treated with extracorporeal membrane oxygenation or ultimately died.

CONCLUSIONS

Inhaled nitric oxide acutely improves systemic oxygenation in many newborns with respiratory failure and pulmonary hypertension. The diagnosis and chest radiograph are helpful in identifying patients who will have favorable acute responses to therapy. In patients with severe hypoxemia, the need for invasive support with extracorporeal membrane oxygenation may be determined by an acute trial of inhaled nitric oxide.

Pharmacologic enhancement of fetal lung maturation

During the 22 years since the first clinical reports of prenatal corticosteroid treatment to enhance fetal lung maturation, this treatment has been studied in thousands of preterm newborns. These studies demonstrated that prenatal steroid treatment reduces RDS among premature newborns at 26 to 33 weeks gestation. The potent fluorinated steroids, betamethasone and dexamethasone, are more effective in accelerating lung maturation than are the less potent corticosteroids, cortisol, cortisone, and prednisone. No immediate or long-term adverse effects have been demonstrated for the newborn or fetus. With PROM, mothers may have an increased risk of endometritis without a clear increase in overall frequency of infection, at the same time steroids significantly decrease the frequency of RDS in the newborns. During these 22 years of evaluation and application of prenatal steroid treatment to reduce RDS, the survival of the very low birth weight (< 1501 g) newborn has increased dramatically. Major morbidities, however, impact significantly on the quality of life for these survivors with birth weights as low as 500 g and gestations as short as 22 to 23 weeks. Prenatal steroid treatment reduces the frequency of PDA, intraventricular hemorrhage, NEC, and bronchopulmonary dysplasia. These are the most important and frequent morbidities that reduce the quality of life for the very low birth weight survivor. Without clearly demonstrable and major adverse effects for the mother or child from corticosteroid treatment, the cost/benefit ratio strongly and clearly favors treatment when preterm delivery is anticipated. Hopefully, obstetricians will use corticosteroids more often in the management of preterm labor because this treatment may markedly improve the quality of survival for many premature newborns.

Motion displacement thresholds for compound stimuli predicted by the displacement of centroids

Minimum displacement thresholds were measured using a compound motion stimulus, in which a single bar split into oppositely moving components, having different luminances and absolute displacements. The results fit a simple model in which observers detect the movement of the centroid of the combined luminance pattern of the two components. This was so even when the two components were separated by more than the static spatial resolution limit of 30 sec arc.

Neonatal glucose determinations obtained from an umbilical artery catheter: evaluation for accuracy using an in vitro model

Accuracy of glucose values is crucial in the management of the critically ill neonate. Sampling for these values may be obtained from an umbilical artery catheter (UAC), but dextrose solutions infused through these catheters may contaminate samples obtained for glucose determination. An in vitro study was conducted to evaluate the effect of blood withdrawal amount and normal saline irrigation on the accuracy of glucose measurements obtained from a UAC. Methods included randomization of blood withdrawal amounts and irrigation with normal saline solution prior to obtaining the blood for glucose measurement. Two hundred and eighty glucose samples were obtained. Results revealed a significant difference between measured and baseline glucose values for all withdrawal amounts and varying flush volumes. This inability to approximate the baseline glucose values could mean that a UAC sample may not reflect the neonate's actual glucose value.

Drug therapy of the fetus

The fetus has become an intended object of drug therapy administered through the mother with the successful prevention of hyaline membrane disease with glucocorticoids. Maternal drug treatment has now been undertaken for a variety of fetal problems, including arrhythmias, congestive heart failure, infections, and inborn errors of adrenal metabolism. Interestingly, this planned maternal drug exposure during pregnancy coincided with increasing concerns during the last two decades about inadvertent transplacental exposure of the fetus to licit and illicit drugs. Efforts to direct drug therapy to the fetus have pointed out important gaps in knowledge of the pharmacology of the maternal-placental-fetal-unit (MPFU), whereas other observations illustrated recognized principles of the pharmacology of the MPFU. Many of these principles fit the basic framework of pharmacokinetics: absorption, distribution, metabolism and excretion. Rapid changes in maternal-placental physiology and fetal development during gestation, however, lead to dramatic variations in these processes throughout pregnancy.

Factors modifying the use of anaesthetic drugs in the elderly

The elderly are forming an ever greater proportion of our hospital population. The process of ageing produces a gradual erosion of all the body's margins of safety coupled with a decreasing ability to adapt. This has significant effects on the physiological responses to the surgical and pharmacological trespass encountered during anaesthesia. In addition elderly people often suffer from multiple pathology and polypharmacy, both of which play important roles in the selection of the optimal anaesthetic regimen.

Continuous arteriovenous hemofiltration in experimental iron intoxication

This study evaluated continuous arteriovenous hemofiltration (CAVH) as a method for removing the iron-deferoxamine complex in experimental iron intoxication. Five anesthetized dogs were instrumented for hemodynamic monitoring and then given 600 mg/kg of elemental iron as ferrous sulfate. After a 3-h absorption period, CAVH was begun from the femoral artery to femoral vein. Deferoxamine was infused into the arterial lines of the CAVH cartridge at increasing doses. We found a dose-dependent increase in the ultrafiltrate excretion of iron. However, most of the deferoxamine was excreted unbound. The efficiency of complex formation was greater at lower BP and ultrafiltrate formation rate, suggesting that inadequate mixing of deferoxamine with blood may occur when arterial administration is used. Iron excretion in the urine over the same time period was not significantly greater than that removed by CAVH. We conclude that CAVH can remove iron using deferoxamine as a chelating agent.

Maternal-placental-fetal unit: unique problems of pharmacologic study

Fetal exposure to different drugs has increased, but few prospective, controlled, blinded trials have been conducted of adverse fetal effects following fetal drug exposure. The quantitative exposure of the fetus to drugs varies during pregnancy with changes in the MPFU. Prospective, controlled, blinded studies of adverse fetal effects of drugs are very difficult; investigators therefore have used alternative study designs that make the conclusions more tentative. Such studies may be limited by accuracy of recall of drug intake and its timing, oversimplification of complex drug exposure, separating the effects of drugs from that of the underlying disease, and a lack of correlation between human and animal effects of fetal drug exposure. Intentional drug treatment of the fetus has begun but should proceed from thorough laboratory study to clinical applications, not the reverse.

Serial renal function in an ovine model of unilateral fetal urinary tract obstruction

Renal tubular and glomerular function following ovine fetal urinary tract obstruction has been studied predominantly in anesthetized, exteriorized fetuses immediately after relief of obstruction. Since surgery and anesthesia may alter fetal cardiovascular and renal physiology, we developed a chronically catheterized, ovine model of unilateral fetal urinary tract obstruction to compare function of the unobstructed and obstructed kidneys repeatedly after relief of obstruction. Split renal function of the previously obstructed kidneys and unobstructed kidneys was measured serially in 7 fetal sheep after obstruction at 55 to 85 days per 147 days of gestation for 30 to 49 days. Seventy-five split clearances were determined on days 1, 2, 3 to 4 and 5 to 6 postoperatively. Not every fetus was studied each day. By 2-way ANOVA, renal function was stable on day 1 after surgery and did not change with time. Previously obstructed kidneys had lower creatinine clearance (0.16 versus 0.71 ml. per minute, p equals 0.0001), higher fractional sodium excretion (33.04 versus 6.02 per cent, p equals 0.0001) and higher urine sodium/creatinine ratio (4.80 versus 0.90 mEq. per mg., p equals 0.0001). Urine flow in the unobstructed kidneys did not differ significantly from that of the obstructed kidneys (0.122 versus 0.083 ml. per minute, p equals 0.35). Obstruction reduced kidney weight (4.7 versus 9.7 gm., p equals 0.0006), cortical thickness (-39 per cent) and nephrogenic zone (-59 per cent), and it increased collecting duct dilatation and medullary fibrosis. No cysts or dysplasia was noted. Fetal urinary tract obstruction for 39.7 days alters renal histology, glomerular function and tubular function. Renal function is stable by 1 day after catheterization and does not change from days 1 to 6 following relief of obstruction.

Management of posthemorrhagic hydrocephalus in the low-birth-weight preterm neonate

Over a period of 34 months from 1987 to 1990 we inserted ventricular catheter reservoirs (VCR) into 20 premature low-birth-weight infants who had developed progressive, symptomatic posthemorrhagic hydrocephalus following grade III or IV intraventricular hemorrhages. The mean estimated gestational age was 27.7 +/- 5.3 weeks and mean birth weight was 1,041 +/- 699 g. The ventricular catheter reservoirs were placed on day of life 30.7 +/- 29.7 and tapped for a total of 3-34 days at varying frequencies and for varying volumes. Of the 20 patients, 4 died on days of life 25, 76, 88, and 187. There were two reservoir infections, both occurring in infants who eventually died. The 16 survivors have been followed from 2 to 24 months (adjusted age). Four (25%) remain shunt-free and 3 have undergone VCR removal. There have been two shunt infections in the 12 shunted patients; ten shunt revisions have been performed overall. At the time of last follow-up, 14 patients were old enough to undergo neurodevelopmental evaluation. Five patients (36%) were 'normal' on gross neurological screening examination, 5 (36%) had 'mild developmental delay' and 4 (28%) had 'significant developmental delay'. We feel these data support the continued use of ventricular catheter reservoirs in the management of posthemorrhagic hydrocephalus and offer hope that some of these patients might remain shunt-free and most will have a normal or mildly delayed neurodevelopmental outcome.

Spatial properties of mechanisms for detection of moving dot targets in dynamic visual noise

The maximum displacement threshold for direction discrimination (dmax) was determined for single or paired dot targets moving discretely against a background of dynamic visual noise. dmax rose as the spatial density of noise was reduced, or when the interframe interval was decreased. dmax was greater for dot pairs than for single dots, and rose progressively as the distance between the dots was reduced. dmax was also greater if the orientation of the target dot pairs differed from the orientation of paired dots in the background noise. Dichoptic presentation of the target and background noise allowed the target to be detected with an accuracy that did not depend on displacement.

Developmental pharmacology and toxicology: principles of study design and problems of methodology

Pharmacologic investigations in the fetus, neonate and child are difficult for the various reasons outlined above, ranging from ethical constraints to difficulties with microanalytic techniques. Attempts to circumvent these difficulties through animal studies, retrospective analyses, and prospective surveys have provided only partial answers. These studies have often helped to guide subsequent similar studies in humans. Results of developmental pharmacologic studies applied to the human must be conducted in humans. The alternatives to randomized, controlled trials presented above may help with these studies, but these innovative study designs must be applied carefully to avoid biasing the results. Although difficult, definitive studies in developmental pharmacology are possible with investigators willing to work within the ethical constraints outlined above, to sensitively consider the needs of perinatal and pediatric patients, and to adhere to the strictest standards of study design.

Antibodies to P. acnes and P. acnes exocellular enzymes in the normal population at various ages and in patients with acne vulgaris

Total serum IgM and IgG agglutinins to P. acnes and neutralizing antibodies to P. acnes lipase, hyaluronate lyase and acid phosphatase were measured in normal individuals of different age groups. Agglutinins to P. acnes were detected in infants at 4 months of age and were present at a high level throughout life. A switch from predominantly IgM agglutinins in children, to IgG agglutinins in adults, occurred during adolescence. Anti-P. acnes lipase antibodies were present in 20% of teenagers and 17-42% of adults. Anti-P. acnes hyaluronate lyase antibodies were found in adults only (4-17%). Antibodies to acid phosphatase were not detected. Agglutinins to P. acnes were measured in individuals with mild, moderate and severe acne, and in normal controls. Only patients with severe acne had significantly higher titres than the controls. IgM and IgG agglutinins were determined in 13-14-year-olds with mild, moderate and severe acne, and in normal controls. Thirty-three per cent, 60% and 100% of the acne patients, respectively, but none of the normal controls, had predominantly IgG agglutinins. No difference in the prevalence or titre of antibodies to P. acnes exocellular enzymes was observed when patients with severe acne were compared with normal controls. There was no evidence to suggest a role for antibodies to P. acnes exocellular enzymes in the initiation of inflammatory acne.

Quantitative determination of tolazoline in human serum by high performance liquid chromatography

A micro high performance liquid chromatography assay is reported for the measurement of tolazoline in newborn infants. Pharmacokinetic data are presented for a single infant receiving tolazoline therapy. Tolazoline and the internal standard, clonidine, are extracted from alkaline serum into butylchloride/isopropanol (95/5). The organic layer is then back extracted with 50 mM phosphoric acid. A portion of the phosphoric acid layer is injected onto a 15-cm CN-bonded phase column. A mobile phase consisting of acetonitrile and phosphate buffer (pH 3) is used to elute tolazoline and the internal standard in less than 5 min. The effluent is monitored with a fixed wavelength detector at 214 nm. Using 50 microliters of serum, concentrations as low as 0.25 mg/L can be routinely determined with a coefficient of variation (CV) of 7.2%. However, when a 100-microliters sample is used, and the injection volume increased, a concentration of 0.05 mg/L can be routinely monitored with a CV of 1.2%. Interference from other drugs that are often used concurrently with tolazoline therapy was not observed.

The detection of deviation from straightness in lines

A wide range of differently shaped perturbations were introduced into long thin straight lines, and threshold amplitude for their detection was measured. This amplitude threshold varies over a 20-fold range, depending on the shape of the cue, but can be economically expressed as just one numerical value, irrespective of the cue shape. This quantity is the area of the largest bump in the target around a least squares regression line axis, and its value is 0.3 arc min2. This value can be related to a fundamental spatial error of 3 arc sec (standard deviation) which is the limiting constraint on shape sensitivity.

Cystosarcoma phyllodes. A clinicopathologic study of 26 cases

Twenty-six cases of cystosarcoma phyllodes diagnosed at M. D. Anderson Hospital were reviewed. The following criteria were evaluated for possible correlation with local recurrence, uncontrolled local recurrence, metastasis, and tumor death: tumor size, stromal overgrowth, tumor necrosis, mitotic rate, stromal cellularity, nuclear size and pleomorphism, the presence of specialized stroma, and initial therapy. Of the 26 tumors, seven caused death. Five patients developed metastatic spread, and all of them died of tumor. Five patients had local recurrence, which was uncontrolled in three (two patients died with uncontrolled recurrence alone, and one with uncontrolled recurrence and metastasis). Stromal overgrowth was present in eight cases. Six of the seven patients who died of tumor had stromal overgrowth, including all five with metastasis. Correlation of stromal overgrowth with metastatic spread and tumor death was significant at P levels of 0.0014 and 0.02, respectively. It is concluded that stromal overgrowth is a significant histologic indicator of malignant behavior in cystosarcoma phyllodes.

Adaptation of fetal pulmonary blood flow to local infusion of tolazoline

Although tolazoline is the most commonly used drug in the treatment of neonatal pulmonary hypertension, its mode of action and efficacy remain incompletely understood. In order to study the effects of tolazoline on a high resistance pulmonary circulation and to better understand mechanisms that control pulmonary vascular tone and reactivity in the fetus, we infused tolazoline either continuously or as bolus into the left pulmonary artery of 15 chronically instrumented, normoxic fetal lambs during late gestation. The vasodilatory effects of bolus injections of tolazoline (2.5 mg) were inhibited by the prior administration of the histaminergic receptor blockers, cimetidine (56%), diphenhydramine (56%), or both (100%). During the continuous infusion of tolazoline (4.5 mg/h for 9 min), pulmonary blood flow to the left lung increased from 61 +/- 6 ml/min (mean +/- SE; control) to 100 +/- 10 (peak) at 30 min (p less than 0.001). However, following this initial vasodilatation, pulmonary blood flow steadily decreased toward control values by 90 min, despite the continued infusion of tolazoline (p less than 0.001). Although the calcium channel blocker, verapamil, and the alpha-adrenergic blocker, phentolamine, had little effect on fetal pulmonary blood flow when infused alone, both drugs increased the vasodilatory response to tolazoline (p less than 0.001). We conclude that tolazoline effects pulmonary vasodilatation by a histaminergic mechanism and that subsequent refractoriness to the drug is a calcium-dependent process which may be partially mediated by an alpha-adrenergic mechanism.

Renal function in the fetal lamb: a chronic model to study physiological effects of ureteral ligation and deligation

Between 53 and 98 days of gestation 11 fetal lambs were subjected to unilateral ureteral ligation. In 8 fetuses re-exploration was performed 35 to 41 days after ligation. Chronic catheterization of the obstructed kidney, bladder and fetal vascular system was used for analysis of physiological data. Average creatinine clearance was 1.35 +/- 0.067 ml. per minute in the control kidney and 0.226 +/- 0.057 ml. per minute in the obstructed kidney after diversion. Free water clearance, osmolar clearance and fractional sodium excretions were not statistically significantly different in control and obstructed kidneys.

Oliguria and tolazoline pharmacokinetics in the newborn

Tolazoline treatment of neonates has been reported since 1965. Dosages increased from pulse doses of 1 to 2 mg/kg to continuous infusions of 10 mg/kg X h before neonatal plasma tolazoline concentrations were measured. We developed a microassay for tolazoline and determined neonatal distribution volume, 1.61 +/- 0.21 L/kg, and disposition rate constant (beta), 0.0027 +/- 0.005 min-1 (mean +/- SEM). Half-life (gamma) ranged from 1.47 to 41.25 (median = 4.43) hours and correlated inversely with urine output (x); y (h) = -0.46 + 7.63/x (mL/kg X h), r = .61, P less than .05. The highest plasma tolazoline concentration in a neonate was 20.3 mg/L. Lethal tolazoline concentrations in lambs ranged from 21.8 to 56.8 mg/L. Initial tolazoline concentrations during infusions and after 1- to 2-mg/kg pulse doses ranged from 0.35 to 2.3 mg/L and PaO2 increased greater than or equal to 15 mm Hg in 64% of 14 treatments. The average neonatal pharmacokinetics predict that each 1 mg of tolazoline HCl per kilogram pulse dose will increase the plasma concentration of tolazoline base by 0.5 mg/L. The plasma concentration should remain constant with infusion dose increments of 0.16 mg of tolazoline HCl per kilogram per hour for every 1.0-mg/kg loading dose. Tolazoline dose requirements for specific patients will vary, especially with renal dysfunction. Reduced tolazoline doses were used to treat two patients, concentrations remained constant, and PaO2 was maintained. Tolazoline doses derived from neonatal kinetics are less than current infusion doses and may avoid high concentrations.

Is Werdnig-Hoffmann disease a pure lower motor neuron disorder?

It is not widely recognized that the pathology of Werdnig-Hoffman disease (WHD) may include cells other than the lower motor neuron. In the early infantile (acute) forms of this degenerative disease, neuropathologic involvement may extend well beyond the lower motor neuron territory to include neurons in spinal sensory ganglion and thalamus. The present report describes the neuropathologic findings of four patients with early infantile degenerative motor neuron disease, compares them to other reported patients, and discusses the relationship of these patients to those with classic WHD. We found involvement of thalamic and primary sensory neurons, although mild, to be a common finding in classic WHD. We suggest that early infantile forms of degenerative lower motor neuron disease which show prominent involvement of thalamic, primary sensory, and other neurons are but one end of the spectrum of WHD.

Pharmacology of tolazoline

Tolazoline's complex pharmacologic effects likely represent the algebraic sum of primary, secondary, and possibly tertiary interactions with histamine and adrenergic receptors. Oxygenation improves initially in the majority of neonates with PPHN treated with tolazoline. Preliminary studies of tolazoline pharmacokinetics in the newborn indicate current doses are excessive and lead to accumulation, which may contribute to adverse effects, including cardiotoxicity.

Evaluation of a QRS scoring system for estimating myocardial infarct size. IV. Correlation with quantitative anatomic findings for posterolateral infarcts

This study correlated the location and size of posterolateral myocardial infarcts (MIs) measured anatomically with that estimated by quantitative criteria derived from the standard 12-lead ECG. Twenty patients were studied who had autopsy-proved, single, posterolateral MIs and no confounding factors of ventricular hypertrophy or bundle branch block in their ECG. Left ventricular anatomic MI size ranged from 1 to 46%. No patient had a greater than or equal to 0.04-second Q wave in any electrocardiographic lead and only 55% had a 0.03-second Q wave. A 29-point, simplified QRS scoring system consisting of 37 weighted criteria was applied to the ECG. Points were scored by the ECG in 85% of the patients (range 1 to 8 points). MI was indicated by a wide variety of QRS criteria; 19 of the 37 criteria from 8 different electrocardiographic leads were met. The correlation coefficient between MI size measured anatomically and that estimated by the QRS score was 0.72. Each point represented approximately 4% MI of the left ventricular wall.