e-TEP repair for midline primary and incisional hernia: technical considerations and initial experience

INTRODUCTION

The Enhanced-View Totally Extra Peritoneal Rives-Stoppa (e-TEP-RS) Technique for the repair of large, complex, ventral abdominal hernias has gained popularity especially in overcoming the disadvantages with Intra Peritoneal Onlay Mesh (IPOM) repairs and to enable siting of a large prosthetic mesh in an anatomical plane distinct from the abdominal cavity and its contents. Evolving variations of the original technique have allowed the definitive repair of such defects in a reproducible manner. We present our initial experience of this approach and detailed steps of our native technical modifications in overcoming the challenges in performing this complex and potentially challenging procedure.

MATERIALS AND METHODS

This is a retrospective review of the clinical data of midline, large, complex, ventral abdominal hernia patients who underwent e-TEP-RS with and without Transversus Abdominis Release (TAR). Patients, with or without Diastasis of Rectus Abdominis Muscle (DRAM) were included. Key outcomes measured were post-operative pain, operative morbidity, readmission, Quality of Life (QoL), hernia recurrence.

RESULTS

A total of 58 midline, ventral abdominal hernia patients who underwent e-TEP-RS with and without Transversus Abdominis Release (TAR), between March 2018 and December 2019 were studied. Mean defect area was 41.0 ± 28 cm² and the mean mesh surface area was 473.5 ± 165 cm². e-TEP-RS was done in 35 cases, e-TEP RS TAR in 15 cases and e-TEP-RS with e-TEP inguinal in 08 cases. There was no intraoperative morbidity. Mean duration of surgery was 156.2 ± 40 min and mean blood loss was 40.5 ± 26 cc. The CCS QoL scores improved from 34.6 (± 2) pre-operatively to 27.2 (± 4) at the end of 6 months. One patient had a supra-umbilical recurrence following bilateral TAR over the superior edge of the mesh. Follow-up ranged from 6 to 22 months, with a mean of 14 months. Major complications (n = 12; 20.7%) were seroma formation and prolonged ileus.

CONCLUSION

The e-TEP-RS technique for large, complex, midline, ventral abdominal hernias can be used with excellent results and acceptable morbidity. This technique is technically challenging and should be mastered in relatively smaller ventral hernias to achieve good results before attempting it in larger, complex ones.

Adiponectin in human pregnancy: implications for regulation of glucose and lipid metabolism

AIMS/HYPOTHESIS

Adiponectin is upregulated during adipogenesis and downregulated in insulin-resistant states. The mechanism(s) governing the re-arrangements from adipogenesis to facilitated lipolysis during pregnancy are unknown. Our purpose was to analyse the role of adiponectin relative to the metabolic changes in human pregnancy.

SUBJECTS, MATERIALS AND METHODS

Lean women (BMI <25 kg/m(2)) were evaluated longitudinally before conception, and in early (12-14 weeks) and late (34-36 weeks) pregnancy. Insulin sensitivity was measured using the glucose clamp technique. Venous blood and subcutaneous adipose tissue biopsies were obtained at each time point.

RESULTS

Adiponectin concentrations were lower in the third trimester than in the pregravid condition (9.9+/-1.4 vs 13.5+/-1.8 microg/ml). The hypoadiponectinaemia was reflected by a 2.5-fold decrease in white adipose tissue adiponectin mRNA. These changes were associated with a 25% increase in fat mass (23.7+/-2.9 vs 18.9+/-2.9 kg). Insulin infusion decreased high molecular weight adiponectin complexes in pregravid women (9.9+/-0.6 vs 6.2+/-0.06) and the suppressive effect of insulin was lost during pregnancy. The pregnancy-mediated changes in adiponectin were strongly correlated with basal insulin levels and insulin sensitivity (p<0.0001). The relationship between adiponectin and insulin sensitivity was related to the decreased insulin regulation of glucose utilisation (r=0.55, p<0.001) but not of endogenous hepatic glucose production.

CONCLUSIONS/INTERPRETATION

These data demonstrate that pregnancy is associated with adiponectin changes in lean women. Hypoadiponectinaemia is reflected by a lower amount of high molecular weight adiponectin and by the ratio of high to low molecular weight multimers. The adiponectin changes relate to decreased insulin sensitivity of glucose disposal rather than alterations of lipid metabolism.

Euglycemic clamp study in clozapine-induced diabetic ketoacidosis

OBJECTIVE

To describe the fifth case of clozapine-induced diabetic ketoacidosis (DKA) with complete resolution of abnormal glucose metabolism after discontinuation of clozapine as assessed by oral glucose tolerance testing (OGTT) and the first to be serially studied with markers of pancreatic autoimmunity; to demonstrate insulin resistance using the euglycemic clamp study and reduced pancreatic insulin reserve using intravenous glucose tolerance testing (IVGTT) in clozapine-induced diabetes mellitus and DKA, when the OGTT was normal; and to systematically review the previously described cases of clozapine-induced diabetes mellitus and DKA.

CASE SUMMARY

A 33-year-old white man without past or family history of diabetes mellitus presented with DKA after eight months of clozapine therapy (50 mg twice daily). After treatment of DKA and discontinuation of clozapine, glucose tolerance and concurrent serum insulin concentrations reverted to normal as measured by two OGTT performed 60 and 320 days after resolution of DKA.

DISCUSSION

Antiislet-cell antibodies, antiglutamic acid decarboxylase antibodies, and human insulin antibody were negative on two separate occasions. Euglycemic clamp study demonstrated insulin resistance manifested by a glucose disposal rate of approximately 55% of mean normal values. IVGTT demonstrated a low rate of glucose disappearance (KG = 0.95) and diminished first-phase insulin response when OGTT was normal, indicating impairment in insulin sensitivity and reduction in beta cell function 323 days after discontinuance of clozapine. This adverse reaction is considered probable according to the Naranjo probability scale.

CONCLUSIONS

The occurrence of cases of DKA and new or worsening diabetes mellitus in patients using clozapine suggests a causal relationship. We hypothesize that the mechanism by which clozapine may produce glucose intolerance may require a preexisting latent defect in insulin secretion and insulin action. With the administration of clozapine, some of these patients may develop worsening insulin resistance and may fail to mount an appropriate compensatory beta cell insulin secretion for the degree of insulin resistance. As a consequence, hyperglycemia develops and its persistence results in glucose toxicity, further suppressing beta cell insulin secretion. Such combined defects in insulin secretion and sensitivity are known to be synergistic, leading to the development of abnormal glucose tolerance, which can be clinically manifested as a spectrum ranging from impaired glucose tolerance through severe hyperglycemia to DKA. Patients being started on clozapine should be carefully followed for the development or worsening of diabetes mellitus, regardless of the dose of the drug.

Protein/amino acid metabolism and nutrition in very low birth weight infants

A large number of studies in recent years have described protein and nitrogen metabolism in the neonate. However, the majority of these data are difficult to interpret because of a number of confounding variables, particularly in very low birth weight (VLBW) infants. In contrast, application of state-of-the-art tracer isotopic and molecular biology methods in isolated cell system and whole animals has resulted in major advances in our understanding of the regulation of protein breakdown, synthesis, and protein accretion. The following workshop summary reviews the recent developments in basic physiology of protein metabolism in cellular and animal models in relation to human preterm infants, and identifies the important areas toward which future basic and clinical research should be directed to provide for optimal nitrogen accretion and growth of the VLBW infant.

Hypoglycemia: what is it for the neonate?

The definition of hypoglycemia in the newborn infant has remained controversial because of lack of significant correlation between plasma glucose concentration, clinical symptoms, and long-term sequelae. A threshold value for plasma glucose at which clinical intervention should be considered is important because of the potential for serious neurological injury. In this review, we have described threshold values for plasma glucose in the newborn infant, based upon available data, at which the clinician should consider close monitoring and therapeutic interventions aimed at increasing the glucose level. In clinically symptomatic infants, plasma glucose concentrations of 45 mg/dL (2.5 mmol/L) or less should be considered as threshold for intervention. In an asymptomatic baby and in those at risk for hypoglycemia, irrespective of gestational and postnatal age, plasma glucose values less than 36 mg/dL (2.0 mmol/L) should be considered as threshold levels. Variances from these criteria, as in breast-fed infants, are discussed. The threshold values described for surveillance and intervention should be separated from the targeted therapeutic values which should be in the range of 72-90 mg/dL (4-5 mmol/L).

Gluconeogenesis in the fetus and neonate

Gluconeogenesis (GNG), a key metabolic process, involves the formation of glucose and glycogen from non-glucose precursors via pyruvate. In the strict sense, it also includes the contribution of glycerol as well as recycled glucose carbon (Cori's cycle). The developmental expression of GNG in the fetus and newborn and the quantitative contribution of GNG to glucose has been extensively investigated in humans and other mammalian species. Data from studies in rodents, rabbits, and sheep fetuses show that the development of GNG is a well-orchestrated process that is regulated by the expression of specific factors involved in the transcription of the genes for specific regulating enzymes, which catalyze GNG. These transcription factors and the genes for gluconeogenic enzymes are expressed at specific time periods during development. Although the fetus has the potential for GNG, the actual formation of glucose from pyruvate is not apparent until after birth because the rate limiting enzyme phosphoenolpyruvate carboxykinase appears only after birth in the immediate newborn period. Several tracer isotope methods have been employed to quantify the contribution of GNG to glucose. Of these, the recently developed stable isotope techniques with deuterium labeled water and the mass isotopomer distribution analysis appear to be the most precise and easily applicable in human studies. The available data show that in the human newborn, GNG appears soon after birth and contributes 30% to 70% to glucose produced. Application of new molecular biology techniques, in combination with sensitive tracer isotopic methods, will allow us to identify and examine metabolic disorders that impact GNG and help develop intervention strategies.

Quantification of gluconeogenesis in cirrhosis: response to glucagon

BACKGROUND & AIMS

Accelerated starvation and early recruitment of alternate fuels in cirrhosis have been attributed to reduced availability of hepatic glycogen. The aim of this study was to measure gluconeogenesis (as a marker of protein oxidation) in relation to total glucose production and glucagon-stimulated glycogenolysis.

METHODS

Glucose and urea production, gluconeogenesis, and glycogenolysis were calculated using stable isotope methods before and during glucagon infusion (3 ng. kg-1. min-1) in 5 cirrhotic patients and 5 matched controls before and after glycogen repletion.

RESULTS

In the basal state, cirrhotic patients had a normal rate of glucose production, but the contribution of gluconeogenesis was increased (74.3% +/- 4.1% vs. 55. 6% +/- 12.1%; P < 0.005). Glycogen repletion normalized the rate of gluconeogenesis. The glycemic response to glucagon (3 ng. kg-1. min-1) was blunted in cirrhotic patients because of a lower rate of glycogenolysis (0.63 +/- 0.23 vs. 1.22 +/- 0.23 mg. kg-1. min-1; P < 0.01) and was not affected by glycogen repletion. Despite increased gluconeogenesis, the simultaneously measured rate of urea synthesis was lower in cirrhotic patients (3.11 +/- 1.02 vs. 5.0 +/- 1.0 mg/kg; P < 0.05).

CONCLUSIONS

These data show that in cirrhosis, glucose production is sustained by an increased rate of gluconeogenesis. The hepatic resistance to glucagon action is not caused by reduced glycogen stores.

Glucose turnover and gluconeogenesis in human pregnancy

The rate of appearance (Ra) of glucose in plasma and the contribution of gluconeogenesis were quantified in normal pregnant women early ( approximately 10 wk) and late ( approximately 34 wk) in gestation. Their data were compared with those of normal nonpregnant women. Glucose Ra was measured using the [U-13C]glucose tracer dilution method. Gluconeogenesis was quantified by the appearance of 2H on carbon 5 and 6 of glucose after deuterium labeling of body water pool. Weight-specific glucose Ra was unchanged during pregnancy (nonpregnant, 1.89+/-0.24; first trimester, 2.05+/-0.21; and third trimester 2.17+/-0.28 mg/kg.min, mean+/-SD), while total glucose Ra was significantly increased (early, 133.5+/-7.2; late, 162.6+/-16.4 mg/min; P = 0.005). The fractional contribution of gluconeogenesis via pyruvate measured by 2H enrichment on C-6 of glucose (45-61%), and of total gluconeogenesis quantified from 2H enrichment on C-5 of glucose (i.e. , including glycerol [68-85%]) was not significantly different between pregnant and nonpregnant women. Inasmuch as total glucose Ra was significantly increased, total gluconeogenesis was also increased in pregnancy (early pregnancy, 94.7+/-15.9 mg/min; late pregnancy, 122.7+/-9.3 mg/min; P = 0.003). These data demonstrate the ability of the mother to adapt to the increasing fetal demands for glucose with advancing gestation. The mechanism for this unique quantitative adjustment to the fetal demands remains undefined.

Glucose and lactate kinetics during a short exercise bout in pregnancy

Pregnancy is considered diabetogenic. Although exercise has been advocated to assist in metabolic control of the nonpregnant diabetic individual, there is a paucity of data about the metabolic effects of exercise during pregnancy. To examine whether moderate exertion may be beneficial in the maintenance of maternal carbohydrate homeostasis, glucose and lactate kinetics were measured in the third trimester in five pregnant nondiabetic women (gestational age, 34.2 +/- 0.1 weeks [mean +/- SE]) by infusion of 45 microg x kg(-1) x min(-1) [6,6-2H2]glucose and 70 microg x kg(-1) x min(-1) [U-13C]lactate tracers. Subjects were observed at rest for determination of baseline steady-state kinetics over a 30-minute period, and then they exercised for 30 minutes at 60% maximum oxygen consumption (VO2max) and were evaluated for 30 minutes postexercise. Glucose and lactate kinetics and lactate oxidation were measured throughout the exercise protocol. This study was repeated postpartum in all individuals at least 6 weeks after delivery. Compared with the steady-state preinfusion period, plasma glucose concentration was not elevated during exercise in either group, nor was plasma lactate concentration significantly different in either group. Glucose kinetics did not change during exercise, but lactate kinetics increased in both groups. V02 and percent of lactate C contribution to CO2, an indication of lactate oxidation, increased proportionally in both groups during exercise. Metabolic perturbations, as measured by glucose and lactate kinetics, do not appear to be different during the third trimester of pregnancy during a relatively short bout of exercise compared with the nonpregnant state.

Determination of body composition in children and adolescents: validation of bioelectrical impedance with isotope dilution technique

The determination of body composition as part of the clinical and auxologic follow up of childhood growth disorders necessitates the use of a quick, portable, reliable and simple non-invasive method. The present study was undertaken to validate bioelectrical conductance, height2/resistance (Ht2/R), against isotopically determined total body water (TBW) using heavy water tracer H2[18O]. The subjects (n = 56) consisted of normal children, children with various endocrine disorders, and young adults between the ages of 8-26 years. Isotopically determined TBW and fat free mass (FFM) were highly correlated with Ht2/R (r = 0.94, p = < 0.001, and r = 0.94, p = < 0.001, respectively). In a multiple regression analysis, 96% of the variability in FFM in normal subjects could be predicted by the following equation: FFM = 0.524 Ht2/R + 0.415 Wt-0.32, while in the group of patients by FFM = 0.659 Ht2/R + 0.254 Wt + 2.851. These data suggest that bioelectrical impedance measurements give valid and reliable estimates of FFM in children and adolescents. This easy technique could be incorporated in the auxologic follow up of children on hormone therapy.

Altered diastolic function in infants of mothers with gestational diabetes: no relation to macrosomia

In a previous study, asymptomatic infants of mothers with gestational diabetes (IGDMs) were observed to have altered left ventricular (LV) filling. In the present study, we reanalyzed the data to examine whether the observed abnormalities were related to maternal diabetes or due to the greater preponderance of macrosomic infants (32%) in the gestational diabetes group. No echocardiographic (systolic or diastolic) differences were observed when the data were compared in 16 large-for-gestational-age (LGA) and 24 appropriate-for-gestational-age (AGA) infants among IGDM. Comparison of 16 LGA IGDM and 17 LGA infants of control mothers revealed lower LV size during diastole and systole in the IGDM. The present analysis suggests that the cardiac alterations in the IGDMs are not due to the preponderance of macrosomia but, rather, the consequence of altered in utero metabolic environment.

Glucose metabolism during fasting through human pregnancy: comparison of tracer method with respiratory calorimetry

Glucose turnover and glucose oxidation were quantified in six normal pregnant women serially throughout pregnancy, using [U-13C]glucose tracer in combination with open-circuit indirect respiratory calorimetry. Five normal nonpregnant women were studied for comparison. With advancing gestation and increase in maternal body weight, there was a proportionate increase in the rate of appearance (Ra) of glucose so that Ra expressed per kilogram body weight did not change from the first to third trimester. The tracer measured rate of glucose oxidation expressed per kilogram body weight also did not change significantly throughout pregnancy. Oxygen consumption (VO2) in pregnant subjects did not differ from that in nonpregnant subjects. However, the respiratory exchange ratio (RER) increased significantly during pregnancy (0.88 +/- 0.53 3rd trimester and 0.76 +/- 0.50 nonpregnant, P < 0.01). The estimated contribution of carbohydrate to VO2 measured by respiratory calorimetry was greater than that measured by the tracer method. This discrepancy became wider as the respiratory quotient increased in late pregnancy. These data suggest that maternal glucose metabolism adjusts throughout pregnancy to meet the increased demands of the conceptus. The discrepancy between tracer method and respiratory calorimetry was probably due to the contribution of (fetal) lipogenesis and (maternal) gluconeogenesis to RER.

Glucose kinetics following administration of an intravenous fat emulsion to low-birth-weight neonates

To evaluate the mechanism(s) of the observed increase in plasma glucose concentration following the administration of an intravenous fat emulsion to the neonate, we measured glucose kinetics in eight low-birth-weight neonates by the prime constant rate infusion technique with D-[6,6-2H2]glucose at a rate of 0.22 +/- 0.01 mumol.kg-1 x min-1 (39.4 +/- 1.3 micrograms.kg-1 x min-1) while the neonates received 32 +/- 5 mumol.kg-1 x min-1 glucose (6.3 +/- 1.1 mg.kg-1 x min-1) plus an amino acid mixture (parenteral alimentation) alone and in combination with an intravenous fat emulsion (Intralipid). Following the latter combination, there were significant increases in plasma glucose concentration [4.07 +/- 0.11 (73 +/- 2 mg/dl) to 5.00 +/- 0.22 mmol/l (90 +/- 4 mg/dl); P < 0.01] and in plasma insulin concentration [72 +/- 14 (10 +/- 2 microU/ml) to 172 +/- 36 pmol/l (24 +/- 5 microU/ml); P < 0.05]. The parenteral alimentation and intravenous fat effusion combination did not affect the glucose production rate: 0.15 +/- 0.05 mumol.kg-1 x min-1 (0.03 +/- 0.01 mg.kg-1 x min-1) during the parenteral alimentation alone and 0.16 +/- 0.05 mumol.kg-1 x min-1 (0.03 +/- 0.01 mg.kg-1 x min-1) when parenteral alimentation was combined with an intravenous fat emulsion. We conclude that the increased plasma glucose concentration seen in association with administration of parenteral alimentation combined with an intravenous fat emulsion to the premature neonate is not due to enhanced glucose production but could be the result of alterations in glucose utilization.

Effects of growth hormone releasing hormone on insulin action and insulin secretion in a hypopituitary patient evaluated by the clamp technique

The effect of growth hormone releasing hormone (GHRH-44) therapy on insulin action and secretion was evaluated in a hypopituitary patient after one month and one year of treatment. Hepatic and peripheral insulin action was studied with the hyperinsulinemic-euglycemic clamp in combination with [6,6-2H2]glucose tracer infusion. First and second phase insulin secretion was assessed with the hyperglycemic clamp. Prior to GHRH-44 therapy the hypopituitary patient had higher insulin mediated glucose disposal rate and lower basal and stimulated insulin concentrations by more than two standard deviations from the mean of a control group. Following therapy there was no change in basal hepatic glucose production; however, there was evidence of diminished peripheral insulin action. This was manifested by decreased insulin mediated glucose disposal during the hyperinsulinemic-euglycemic clamp, and increased insulin secretion during the hyperglycemic clamp. We conclude that GHRH-44 therapy in this patient was associated with decreased peripheral insulin action which was compensated for by increased insulin secretion.

Glycerol metabolism and triglyceride-fatty acid cycling in the human newborn: effect of maternal diabetes and intrauterine growth retardation

Kinetics of glycerol metabolism and triglyceride/fatty acid cycling were quantified in 12 healthy, normal, appropriate-for-gestational-age (AGA) infants, eight small-for-gestational-age (SGA) infants, and five infants of insulin-dependent diabetic mothers (IDM) at less than 48 h of age. Stable isotope-labeled [2-13C]glycerol and [6,6-2H2]glucose in combination with indirect respiratory calorimetry were used. The tracers were used as constant rate infusion and steady state isotopic enrichment of glucose, glycerol, and bicarbonate was measured by mass spectrometric methods. After a 7- to 9-h fast, the plasma glucose, glycerol, and FFA concentrations were similar in the AGA and IDM groups. In the SGA group, the plasma glucose concentration was significantly lower than that in the AGA group throughout the study, but plasma FFA and glycerol concentrations were not different from those in the AGA infants. Plasma betahydroxybutyrate concentration was significantly elevated in the AGA group compared with IDM and SGA infants (AGA 0.59 +/- 0.39, SGA 0.35 +/- 0.09, IDM 0.33 +/- 0.21 mmol/L; mean +/- SD). The rate of appearance of glycerol was significantly elevated (p less than 0.05) in SGA infants (AGA 9.47 +/- 2.11, IDM 9.55 +/- 2.14, SGA 12.15 +/- 3.87 mumol/kg.min). Between 80 and 90% of glycerol turnover was converted to glucose, accounting for 20% of glucose turnover with no significant difference in the three groups. Approximately 35% of glycerol carbon was recovered in the bicarbonate (CO2) pool. Less than 5% of CO2 carbon was derived from glycerol. Estimation of triglyceride-fatty acid cycle revealed that the triglyceride energy mobilized was increased in SGA infants.(ABSTRACT TRUNCATED AT 250 WORDS)

Altered diastolic function in asymptomatic infants of mothers with gestational diabetes

Left and right ventricular filling was studied prospectively in 50 full-term (39.4 +/- 1.3 wk) asymptomatic newborns of mothers with gestational diabetes mellitus (GDM). Their data were compared with those of 80 asymptomatic full-term (39.8 +/- 1.2 wk) infants who served as control subjects. Infants were examined in the immediate newborn period (less than 48 h) and then again at 2-4 and 6-9 wk. Although mean weight, length, and gestational age did not differ, the mean +/- SD left ventricular dimensions during diastole (1.73 +/- 0.15 vs. 1.81 +/- 0.18 cm, P = 0.007) and systole (1.22 +/- 0.15 vs. 1.31 +/- 0.17 cm, P = 0.004) were significantly lower in infants of mothers with GDM compared with control infants. Diastolic measurements suggested a shift from the early diastolic filling of the ventricle to the later period of atrial systole in infants of mothers with GDM. A lower initial one-third area fraction and a higher peak flow velocity and velocity time integral during atrial systole were noted at the mitral valve in infants of mothers with GDM. These changes had resolved by 2-4 wk of age. The altered diastolic filling patterns in infants of mothers with GDM indicate poor myocardial relaxation and/or decreased passive compliance of the ventricular myocardium. These alterations were observed in asymptomatic infants in the absence of left ventricular or septal hypertrophy. If exposed to significant stress such as asphyxia or sepsis, the observed myocardial dysfunction could lead to higher morbidity in these infants.

Indium 111 oxine-labeled leukocytes for early diagnosis of ischemic enterocolitis

The feasibility of the use of indium 111 oxine-labeled autologous leukocytes for the diagnosis of ischemic enterocolitis in vivo was examined in an experimental model of ischemia in dogs. A 30-cm segment of small intestine was devascularized by ligating the arteries and veins from the last arcade in 7 dogs. A sham operation was performed in 3 control dogs. 111In oxine-labeled autologous white blood cells were infused 3.5 hours after operation. Anterior and lateral nuclear scanning was performed at 6 and 24 hours postinfusion with a gamma camera equipped with a low-energy magnifying multihole collimator. The animals were killed after 24 hours. The gross and microscopic appearance of the bowel was evaluated. The radioactivity in the serial specimens of the bowel was measured. In vivo scans were positive (ie, increased uptake in the bowel loop) in all dogs with intestinal ischemia at 6 and 24 hours. No significant uptake was noted in control dogs. Rectilinear scan of the bowel removed at autopsy showed a correlation between the area of infarction and tracer accumulation. In addition, there was a progressive decrease in uptake of 111In oxine from the center of the ischemic lesions to the periphery. Forty percent of the total radioactivity was measured at the center of the lesion, whereas only 6.5% was present at 22.5 cm from the center. Thus the ratio between the ischemic and normal tissue was 10:1 (range, 6.5 to 16). These studies demonstrate that 111In oxine-labeled autologous white blood cells can be used for the diagnosis of ischemic enterocolitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Decreased fetal movements with sustained maternal hyperglycemia using the glucose clamp technique

The purpose of this study was to evaluate the effect of sustained maternal hyperglycemia (120 mg/dl) on fetal activity. The glucose infusion study group was comprised of nine healthy gravidas between 36 and 40 weeks' gestation, and six patients served as controls. The protocol design included an overnight fast for all patients. Fetal movements were evaluated by external fetal monitoring. A 2-hour preinfusion evaluation of fetal activity served as the baseline control for each patient studied. Study patients then received a glucose infusion by a glucose clamp technique to maintain a sustained hyperglycemia of 120 mg/dl for 3 hours. After the glucose infusion, fetal movements were observed for 1 hour. Control patients received a saline infusion for 2 hours after a 2-hour baseline evaluation. Maternal hyperglycemia was associated with a significant decrease of fetal movements greater than 1 second duration during the first hour of glucose infusion. Fetal movements returned to baseline during the second and third hours of glucose infusion. Saline infusion was not associated with a decrease in fetal activity. We conclude that sustained maternal hyperglycemia is associated with a transient decrease in fetal movement during the first hour of glucose infusion followed by a return to the control (preinfusion) level of fetal activity. These data may have implications in the study of fetal behavior in diabetes mellitus.