Lumbosacral nerve root stimulation comparing electrical with surface magnetic coil techniques. Stimulation of lumbosacral nerve roots using a monopolar needle electrode was compared with magnetic stimulation using a 7-cm diameter surface coil. Compound muscle action potentials were recorded from the tibialis anterior (TA) and flexor hallucis brevis (FHB) muscles. Although the mean latency of CMAPs did not differ using the two techniques, amplitudes were considerably larger using a needle. Mean amplitudes were 66% (TA) and 64% (FHB) of the direct M response obtained by distal, supramaximal stimulation compared with mean values using maximal magnetic coil stimulation of 36% (TA) and 25% (FHB). Minimum F-wave latencies from FHB were used to estimate the site of nerve root stimulation using both techniques. Although there was a large amount of variability in the data from individual subjects, the results suggested that, on the average, both forms of stimulation act proximal to the intervertebral foramen. We conclude that a needle electrode is a more suitable technique for stimulating lumbosacral nerve roots.


Severe acute axonal form of Guillain-Barré syndrome associated with IgG anti-GD1a antibodies. We report cases of 2 patients with pure motor Guillain-Barré syndrome of explosive onset who required mechanical ventilation for more than 2 months. Their electrophysiologic findings and poor clinical recoveries suggested severe axonal degeneration involving the motor nerves. Enzyme-linked immunosorbent assay and thin-layer chromatogram-immunostaining showed the sera of both patients had high IgG antibody titer against GD1a ganglioside. Their titers decreased with the clinical course of the illness. GD1a as well as GM1, appears to be the target pathogenic antigen in motor axon disorders. Elevated IgG anti-GD1a antibody titer may prove useful for predicting severe GBS.


The relative diagnostic sensitivity of different F-wave parameters in various polyneuropathies. We studied F-wave minimum latency, persistence, and chronodispersion in the median and ulnar nerves of 70 controls and 75 patients with various polyneuropathies. Prolonged minimum latency was the most frequent F-wave abnormality in all groups of patients with polyneuropathy. The finding of decreased persistence or absence of F-responses was comparable in sensitivity to prolonged minimum latency in Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP), whereas chronodispersion had a comparable sensitivity only in CIDP. Decreased persistence of obtained F-responses, and the absence of F-responses in nerves with low compound muscle action potential amplitudes, were nonspecific findings. F-wave studies often provide useful additional information in the evaluation of patients suspected of having a polyneuropathy. In patients with axonal polyneuropathies, we found that F-wave studies are significantly more sensitive than standard motor conduction studies in identifying physiological abnormalities of motor axons. Furthermore, in a patient with an acquired polyneuropathy, the finding of markedly prolonged minimum latency, or the absence of F-responses in nerves with normal CMAP amplitude, is highly specific for the presence of demyelination.


Satellite cells in innervated and denervated muscles treated with clenbuterol. The sympathomimetic agent, clenbuterol, induces a muscle-specific hypertrophy in both normal and catabolic muscle. Drug-induced hypertrophy is not generally associated with an increase in DNA content, thus the role of satellite cells in the response of soleus muscles from weanling rats is questioned. Following simultaneous sciatic section and administration of clenbuterol, responses are similar in innervated and denervated muscles after 4 days. Increased protein accretion in treated muscles is associated with evidence of satellite cell activation, but with little evidence of division. It is speculated that satellite cell production of growth factors may play an important role in the hypertrophic action of clenbuterol, and the clinical implications of the findings are discussed.


Autonomic surface potential analysis: assessment of reproducibility and sensitivity. There has been recent interest in measuring sympathetic sudomotor function by autonomic surface potential analysis. The purpose of the present study was to assess factors affecting the reproducibility of the test. We determined the within-day and between-day reproducibility in 24 healthy volunteers. We used an increasing rather than a constant electrical stimulus to minimize habituation. The amplitudes were still highly variable (an average within-day coefficient of variation in the soles of 35%). Habituation did not, however, affect the latencies of the responses, which were much more reproducible (an average within-day coefficient of variation in the soles of 8%). Studies of between-day reproducibility revealed that the mean amplitudes were lower on day 2 vs. day 1 (0.706 +/- 0.10 vs. 0.85 +/- 0.10 mV in the soles, P less than 0.01) but the mean latencies were similar on the different testing days (2.09 +/- .04 seconds for the soles on day 1 vs. 2.16 +/- .05 seconds on day 2). We also assessed the sensitivity of surface potential analysis and report the results of testing 35 patients with far advanced autonomic neuropathy.


Effects of phenytoin in two myotonic horses with hyperkalemic periodic paralysis. The effects of phenytoin treatment were evaluated in 2 myotonic horses with hyperkalemic periodic paralysis (HPP). Phenytoin treatment abolished the clinical signs of muscle fasciculations following oral potassium challenge and decreased or abolished repetitive firing and myotonic discharges found on electromyographic examination. In both horses, an abnormally low threshold for calcium-induced calcium release was measured in heavy sarcoplasmic reticulum fractions from skeletal muscle, and this threshold increased with phenytoin treatment. Results suggest phenytoin is useful in modifying disordered ion regulation in the sarcolemma and sarcoplasmic reticulum of skeletal muscle in equine hyperkalemic periodic paralysis.


Obstetrical lumbosacral plexus injury.

Obstetrical lumbosacral plexus injury. Injuries to the lumbosacral plexus during labor and delivery have been reported in the literature for years, but have lacked electrophysiologic testing to substantiate the location of the nerve injury. We report 2 cases with comprehensive electrophysiologic testing which localizes the site of this obstetrical paralysis to the lumbosacral trunk (L4-5) and S-1 root where they join and pass over the pelvic rim. The paralysis may be mild or severe. Small maternal size, a large fetus, midforceps rotation, and fetal malposition may place the mother at risk for this nerve injury.


Increasing the proliferative capacity of muscular dystrophy myoblasts. Temperature-sensitive immortalized neural cells may be utilized to produce genetically engineered neural transplants. We have used a similar approach with mdx myoblasts. Control and mdx myoblasts were immortalized with a recombinant retrovirus that effects the expression of a temperature-sensitive simian virus 40 large T antigen. The resultant cells divide indefinitely at 34 degrees C, but differentiate at 38 degrees C, both morphologically and immunocytochemically. Polymerase chain reaction analysis of RNA confirmed the presence of the dystrophin point mutation in the mdx cells and its absence in the control cells. A similar approach may be useful for the proliferation, modification, and reimplantation of autologous cells from patients with degenerative and dystrophic disorders such as Duchenne muscular dystrophy.


Far-field potentials in circular volumes: the effect of different volume sizes and intercompartmental openings. Preliminary investigations of circular volume conductors suggested that far-field potential magnitude declines progressively slower with increasing radial distance from a current source and follows a cosine function with angular displacement of the recording electrode from the electrical generator's axis. Using circular volumes of 6 differing radii, the mathematical relationship between angle, radii, and far-field potential amplitude is determined. Previous theoretical relationships of amplitude versus dipolar spacing, current, and distance from a dipole generator in a bounded volume conducting medium are verified for the near-field. Far-field potentials in circular volumes are found to become constant at radii greater than 75% of the bounded volume's radius. Additionally, an adjoining volume conductor acts simply as a passive fluid-filled electrode (wick electrode) to the circular volume containing the generator until the intercompartmental opening to the circular volume exceeds 20% of its circumference. This finding was clinically supported by recording similar P9 somatosensory-evoked far-field potentials generated caudal to the foramen magnum from various portions of the cranium, whose connections to the torso, foramen magnum, and neck, average 6.2% and 17.8%, respectively. Finally, 3 circular volume conductors were connected in series by channels less than 20% of the volume conductor's circumference. Both adjoining circular volumes were equipotential to the far-field potential present at the boundary of the first circular volume containing the dipole generator. This observation supports the clinical finding of far-field potential transmission through multiple human bodies in conductive contact.


Effects of the early administration of enalapril on mortality in patients with acute myocardial infarction. Results of the Cooperative New Scandinavian Enalapril Survival Study II (CONSENSUS II). Long-term administration of angiotensin-converting--enzyme (ACE) inhibitors has been shown to improve survival in patients with symptomatic left ventricular failure and to attenuate left ventricular dilatation in patients with myocardial infarction. We studied whether mortality could be reduced during the 6 months after an acute myocardial infarction with use of the ACE inhibitor enalapril. At 103 Scandinavian centers patients with acute myocardial infarctions and blood pressure above 100/60 mm Hg were randomly assigned to treatment with either enalapril or placebo, in addition to conventional therapy. Therapy was initiated with an intravenous infusion of enalapril (enalaprilat) within 24 hours after the onset of chest pain, followed by administration of oral enalapril. Of the 6090 patients enrolled, 3046 were assigned to placebo and 3044 to enalapril. The life-table mortality rates in the two groups at one and six months were not significantly different (6.3 and 10.2 percent in the placebo group vs. 7.2 and 11.0 percent in the enalapril group, P = 0.26). The relative risk of death in the enalapril group was 1.10 (95 percent confidence interval, 0.93 to 1.29). Death due to progressive heart failure occurred in 104 patients (3.4 percent) in the placebo group and 132 (4.3 percent) in the enalapril group (P = 0.06). Therapy had to be changed because of worsening heart failure in 30 percent of the placebo group and 27 percent of the enalapril group (P less than 0.006). Early hypotension (systolic pressure less than 90 mm Hg or diastolic pressure less than 50 mm Hg) occurred in 12 percent of the enalapril group and 3 percent of the placebo group (P less than 0.001). Enalapril therapy started within 24 hours of the onset of acute myocardial infarction does not improve survival during the 180 days after infarction.


Neurocysticercosis in an Orthodox Jewish community in New York City. From June 1990 through July 1991, intracerebral infection with the larval stage of the pork tapeworm Taenia solium was diagnosed in four unrelated persons in an Orthodox Jewish community in New York City. None of the patients had eaten pork, and only one had traveled to a country in which T. solium infection was endemic. We investigated this outbreak, screened serum samples from family members and household contacts for antibodies to cysticercosis, and examined stool specimens from household employees for eggs of taenia species. The four patients had recurrent seizures and brain lesions that were radiologically consistent with the presence of cysticerci. The diagnosis was confirmed in two patients by a brain biopsy, and in two by immunoblot assays for cysticercus antibodies. Of 17 immediate family members screened serologically, 7 from two families had cysticercus antibodies. Magnetic resonance imaging of the brain showed cystic lesions in two of the seropositive family members, one of whom had had a seizure. Examinations of six domestic employees from all four households revealed an active infection with taenia species in one and a positive serologic test in another. Since these women had recently emigrated from Latin American countries where T. solium infection is endemic, they were the most likely sources of infection in the members of these households. A diagnosis of neurocysticercosis should be considered in patients with seizures and radiologic evidence of cystic brain lesions, even in those who do not eat pork and who have not traveled to a country in which T. solium infection is endemic. Recent emigrants from countries in which T. solium infection is endemic should be screened for tapeworm infection in their stools before they are employed as housekeepers or food handlers.


The course of seizures after treatment for cerebral cysticercosis. Worldwide, cerebral cysticercosis is one of the most common causes of seizure disorders. Modern cysticidal drugs can usually eliminate the parasite from the brain, but there have been doubts as to whether such treatment improves the seizure disorder. We studied 240 patients with seizures and cysticercosis of the brain parenchyma. Of these patients, 118 received cysticidal therapy (albendazole, praziquantel, or both) for lesions without inflammation on imaging studies (group 1); 49 patients with similar lesions either were not offered or refused cysticidal medication (group 2). Another 58 patients with inflammation around cysts (making spontaneous resolution more likely) also did not receive cysticidal medication (group 3), whereas cysticerci were removed surgically in 15 patients (group 4). The 240 patients were followed for a mean (+/- SE) of 92 +/- 7 months. In the patients treated with cysticidal medications, there was an 82 percent reduction in the mean number of brain cysts (from 5.0 to 0.9) and a 95 percent reduction in the mean frequency of seizures (from 11.3 to 0.6 per year; P less than 0.001). After three years of follow-up, 64 patients in group 1 (54 percent) were seizure-free. By contrast, the untreated patients (group 2) averaged 10.9 seizures per year; none were seizure-free. Among those with inflamed cysts (group 3), there was a 74 percent reduction in the frequency of seizures (from 7.5 to 2.7 per year), and 18 patients (31 percent) became seizure-free. After surgical treatment (group 4), there was an 87 percent reduction in the frequency of seizures (from 12.8 to 1.7 per year), and six patients (40 percent) became seizure-free. After medical treatment of neurocysticercosis, there is usually remission or marked improvement in the associated seizure disorder.


Human general transcription factor IIH phosphorylates the C-terminal domain of RNA polymerase II. Phosphorylation of the carboxy-terminal domain of the largest subunit of RNA polymerase II is believed to control the transition from transcription initiation to elongation. The general transcription factor IIH (TFIIH) contains a kinase activity capable of phosphorylating this domain. Factors that promote the association of RNA polymerase II with the preinitiation complex stimulate this activity. The transcription factor IIE, which is required for the stable association of TFIIH with the preinitiation complex, affects the processivity of TFIIH kinase.


Optical imaging of epileptiform and functional activity in human cerebral cortex. Optical imaging of animal somatosensory, olfactory and visual cortices has revealed maps of functional activity. In non-human primates, high-resolution maps of the visual cortex have been obtained using only an intrinsic reflection signal. Although the time course of the signal is slower than membrane potential changes, the maximum optical changes correspond to the maximal neuronal activity. The intrinsic optical signal may represent the flow of ionic currents, oxygen delivery, changes in blood volume, potassium accumulation or glial swelling. Here we use similar techniques to obtain maps from human cortex during stimulation-evoked epileptiform afterdischarges and cognitively evoked functional activity. Optical changes increased in magnitude as the intensity and duration of the afterdischarges increased. In areas surrounding the afterdischarge activity, optical changes were in the opposite direction and possibly represent an inhibitory surround. Large optical changes were found in the sensory cortex during tongue movement and in Broca's and Wernicke's language areas during naming exercises. The adaptation of high-resolution optical imaging for use on human cortex provides a new technique for investigation of the organization of the sensory and motor cortices, language, and other cognitive processes.


Nitric oxide release from a single cell measured in situ by a porphyrinic-based microsensor. Nitric oxide is an important bioregulatory molecule, being responsible, for example, for activity of endothelium-derived relaxing factor (EDRF). Acute hypertension, diabetes, ischaemia and atherosclerosis are associated with abnormalities of EDRF. Nitric oxide is thought to be a retrograde messenger in the central nervous system. The technology is not yet available for rapid detection of NO released by a single cell in the presence of oxygen and/or nitrite, so the release, distribution and reactivity of endogenous NO in biological systems cannot be analysed. Here we describe a porphyrinic microsensor that we have developed and applied to monitoring NO release in a microsystem. We selectively measured in situ the NO released from a single cell with a response time of less than 10 ms. The microsensor consists of p-type semiconducting polymeric porphyrin and a cationic exchanger (Nafion) deposited on a thermally sharpened carbon fibre with a tip diameter of approximately 0.5 microns. The microsensor, which can be operated in either the amperometric or voltammetric mode, is characterized by a linear response up to 300 microM and a detection limit of 10 nM. Nitric oxide at the level of 10(-20) mols can be detected in a single cell.


[Variation in serum cholesterol level in the same person: what is the true value and when is it called a significant change?]. The blood cholesterol level is not constant over time. Changing values may be found when rechecking high values, especially in patients on a diet or receiving medication. Repeated measurements are necessary. It will then be possible to estimate the 'true mean value'. This is the theoretical average of a large number of measurements taken from one person. The study concentrated on the intra-individual variation of the serum cholesterol and the consequences for screening and follow-up. For this purpose, during a period of four weeks, cholesterol levels were measured 12 times in 33 men aged 25-40. The mean coefficient of variation was 5.7%, with wide differences between participants, ranging from 2.9% to 9.8%. The position of the 'true mean value' was estimated (with 90% confidence), after I resp. 3 determinations. These findings have consequences for the classification of subjects in the different risk categories as defined in the Dutch Cholesterol Consensus. It is also possible to determine if, after a period of intervention, there is a significant decline in the cholesterol level. Roughly, a decline of 10-12% indicates a significant difference.


[Effect of short-term use of omega-3-type polyunsaturated fatty acids in subjects with hypertriglyceridemia]. To study the effect of omega-3 polyunsaturated fatty acid supplementation on lipid profile in hypertriglyceridaemic patients. General practice. Prospective, double blind study of 12 weeks' duration. Eight patients received fish oil (1800 mg C20: 5 omega-3 eicosapentaenoic acid (EPA) and 1200 mg C22:6 omega-3 docosahexaenoic acid (DHA). Nine patients received corn oil (3000 mg C18: 2 omega-6 linoleic acid daily). Lipid profile analysis showed a decrease in triglyceride levels after fish oil supplementation. An unexpected and unexplained finding was the rise in total cholesterol and LDH cholesterol with corn oil supplementation. Fish oil causes a decrease in triglyceride levels in hypertriglyceridaemic patients.


[Functioning of an Exercise electrocardiographic service for family physicians; a report of 498 patients]. In Rotterdam GPs have the possibility of requesting an exertion ECG for their patients from the Foundation Thrombosis Service and Physicians' Laboratory. A follow-up study was carried out in order to gain insight into the functioning of this service. Over a period of three months, 266 GPs referred 498 patients to the service for an exertion ECG. The GPs received an enquiry form with questions on the referral and the functioning of the service. The patients were followed up for two weeks in connection with any (cardiovascular) events and with the management by the GP. An ECG was regarded as positive if the ST showed a depression greater than or equal to 1.5 mm. None of the patients died during the period of the investigation. Of the patients with positive and with negative ECGs, 41% and 37%, respectively, had no more complaints, 40% and 28% the same complaints, and 3% and 0.5% more complaints. Of the patients with a negative ECG (n = 439), 3.9% were referred to a cardiologist. If no ECG had been made, this proportion would have been 39%. The Foundation Thrombosis Service and Physicians' Laboratory Rotterdam provides an essential contribution to GPs' decision making concerning referral of patients with vague cardiac complaints to a cardiologist.


Diurnal and seasonal variations in the occurrence of stroke: a community-based study. Several hospital-based studies suggest a circadian rhythm for stroke, with a peak of onset in the morning. To verify whether these results could be confirmed in a community-based study, we used data from the SEPIVAC, a community-based stroke register in Umbria, Italy. Cerebral infarctions (48%), primary intracerebral hemorrhages (54%), subarachnoid hemorrhages (53%) and 'not known' strokes (51%) were all more common between 6 a.m. and noon, and this peak was still present when strokes recognized on awakening were evenly redistributed over the sleep period. Looking at the subgroups of cerebral infarction, lacunar syndromes were more common during sleep. Cerebral infarctions were more frequent during winter, and primary intracerebral hemorrhages during autumn.


Vascular dementia: a clinical and death certificate study. We compared the extent of documentation of the diagnoses, vascular dementia and stroke, on inpatient (hospital) medical records and death certificates among 23 multi-infarct dementia index cases and 14 multi-infarct controls without cognitive dysfunction who were enrolled in a hospital-based case-control study and were followed longitudinally. Both the inpatient medical records and the death certificates markedly under-diagnosed vascular dementia when compared to the case-control study diagnosis. Furthermore, the diagnosis of stroke was grossly underdiagnosed on the death certificates. In lieu of the lack of medical record and death certificate documentation of vascular dementia, studies that utilize such information may be in considerable error. Clarification of the criteria for the diagnosis of vascular dementia and greater physician and public awareness of vascular dementia are needed.


Mortality rates for Parkinson's disease and parkinsonism in Italy (1969-1987). The mortality rates (MRs) for Parkinson's disease (PD) and parkinsonism were analyzed for the period 1969-1987 in Italy, considering the population aged greater than or equal to 25. MRs were then age-adjusted taking the 1981 Italian population as standard. We found an increase in MRs for PD during the period studied. The Italian average annual age-adjusted MR was 5.73, ranging from 4.76 (1969) to 6.81 (1985). Moreover we noticed some interesting differences in the geographic distribution of MRs between the five big areas Italy was divided into. We also found that, while the MR for the ages 65-79 years was quite constant in the period studied, there was a marked increase in the MR for ages greater than 79 years from 1980 onwards. The geographic differences we found in MRs deserve to be analyzed in further epidemiological studies.


A large-scale study of epilepsy in Ecuador: methodological aspects. The methodology is presented of a large-scale study of epilepsy carried out in a highland area in northern Ecuador, South America, covering a population of 72,121 people; The study was carried out in two phases, the first, a cross-sectional phase, consisted of a house-to-house survey of all persons in this population, screening for epileptic seizures using a specially designed questionnaire. Possible cases identified in screening were assessed in a cascade diagnostic procedure applied by general doctors and neurologists. Its objectives were: to establish a comprehensive epidemiological profile of epileptic seizures; to describe the clinical phenomenology of this condition in the community; to validate methods for diagnosis and classification of epileptic seizures by a non-specialised team; and to ascertain the community's knowledge, attitudes and practices regarding epilepsy. A sample was selected in this phase in order to study the social aspects of epilepsy in this community. The second phase, which was longitudinal, assessed the ability of non-specialist care in the treatment of epilepsy. It consisted of a prospective clinical trial of antiepileptic therapy in untreated patients using two standard anti-epileptic drugs. Patients were followed for 12 months by a multidisciplinary team consisting of a primary health worker, rural doctor, neurologist, anthropologist, and psychologist. Standardised, reproducible instruments and methods were used. This study was carried out through co-operation between the medical profession, political agencies and the pharmaceutical industry, at an international level. We consider this a model for further large-scale studies of this type.


HLA determinants in familial multiple sclerosis. HLA-A, -B, -C, -DR, -DQ antigens were studied in 11 multiplex MS families, 11 single-case MS families and 100 healthy subjects. The HLA DR4 was the most frequent antigen in all MS patients (p = 0.015). When the antigenic frequency in index familial cases was compared with that in single cases, the DR4 antigen was found to be more frequent (p = 0.01) in familial cases only. Furthermore, when the DR4 antigen was excluded from the analysis, we observed an increase in DR2 (p = 0.11) only in the familial MS cases. These results can be compatible with a multifactorial hypothesis according to which the HLA genes have an important role in MS susceptibility in familial cases.


Multiple sclerosis in the Faroe Islands and the lack of protection by exposure in infancy. Using data from 32 patients with symptom onset between 1943 and 1973, we described the occurrence of clinical neurologic multiple sclerosis (CNMS) in the Faroe Islands as then constituting three epidemics. We concluded that CNMS is the rare late result of infection with the primary MS affection (PMSA), a state requiring some 2 years of exposure for acquisition by Faroese. Our theses are that PMSA was first transmitted during World War II by affected by asymptomatic British troops to Faroese aged 11-45; that this (F1) cohort of affected asymptomatic Faroese under age 27 in 1945 transmitted PMSA to the next (F2) cohort of Faroese comprising those attaining age 11 each year from 1945 until F1 input ceased; that the F2 cohort similarly transmitted PMSA to the third (F3) cohort of Faroese. Cases of CNMS defining epidemics I-III were members of the respective F1-F3 cohorts. Within the F4 cohort of Faroese there is now a fourth epidemic of CNMS, with 7 patients with symptom onset between 1984 and 1989. Intermittency of the year of birth for CNMS cases is thus a reflection of membership in these separate population cohorts, and does not indicate 'protection' in infancy or childhood. There is no evidence for an extra-Faroese source of MS after the first epidemic. No model of acute infection with short transmissibility fits the data.


[Transanal endoscopic microsurgery: technique and clinical results]. A new system has been developed for transanal endoscopic microsurgery (TEM), which allows all the conventional surgical techniques within the rectal cavity. The main indication is the removal of sessile adenomas. "Early rectal carcinomas" are also suitable for local excision. We perform local excision of advanced cancer only in cases where a contraindication exists to perform radical surgery or when the patients is unwilling to undergo demolitive surgery. The system has been employed at our Surgical Department on 206 patients in 223 cases. In 192 cases (87.7%) only one local excision was carried out due to sufficient excision as confirmed by histology (including patients with early "low risk" cancer). the postoperative course of 208 cases (93.3%) was free from any complications. The recurrence rate of adenomas amounted to 5.2%. This technique is particularly applicable for elderly, high risk patients and those with broad based adenomas so that anterior resection, abdominoperineal resection or other invasive operations can be avoided.


[Abdominal visceral lesions in patients with multiple trauma]. The paper describes a series of 385 cases of multiple injuries which were treated between 1987 and 1991 at the Emergency Unit of the Fatebenefratelli Hospital in Milan. Special attention was paid to abdominal trauma and visceral injuries in terms of both diagnosis and treatment.


[Subdiaphragmatic aortic clamping in abdominal hemorrhagic emergencies]. The paper describes a technique of subdiaphragmatic aortic clamping as a provisional method to stop blood flow in abdominal hemorrhage emergencies. The numerous indications for the method and satisfactory results obtained by its use are described.


[Thymostimulin immunoprophylaxis in elective abdominal surgery]. The Authors report their experience of 121 patients who had undergone an elective abdominal operation and who had been previously considered under an immunological point of view and classified as anergic. The Authors have found a notable reduction of postoperative infection incidence in the 61 anergic operated patients who have been treated with Thymostimulin; they conclude by underlining the importance of careful consideration and eventual correction of immunological alterations of the patients of the patients who must undergo an operation.


[Antibiotic prophylaxis in surgery. Results of a 4-year personal case series]. A prospective study of surgical infections in our Department of Surgery in the years 1986-1989 is reported. 2719 patients entered the study: they represent the total number of patients operated in the above said period (628 urgent and 2091 elective operations). As suggested in 1964 by Altmeier, surgical procedures were classified in four groups according to the potential risk of intraoperative contamination. For every septic complication observed pertinent cultures were performed and responsible pathogens identified. We present our protocol of antibacterial prophylaxis which distinguishes antibiotics given as "ultra short term", "short term", "antibiotic prophylaxis". The results obtained and particularly the total number of infections (3.9%), and the percentage of infections in group 3 (4.6%) and in group 4 (23.1%) procedures validate the usefulness of antibiotic prophylaxis in these patients. In group 1 and group 2 patients the usefulness of antibiotic prophylaxis seems very doubtful.


[Mirizzi's syndrome type II: a diagnostic and therapeutic problem]. The paper reports a case of cholestatic icterus caused by a large calculus in the infundibulum of the gallbladder with a cholecysto-choledochal fistula and hepato-choledochal block (Mirizzi's type II syndrome). The diagnostic iter complicated the evolution, raising questions regarding the therapeutic strategy.


[Porcelain gallbladder. Case reports].

[Porcelain gallbladder. Case reports]. The Authors report some observations on gallbladder calcification with the presentation of two clinical cases. The pathologic anatomy and the clinical aspects of this infrequent affection are described. The Authors underline the importance of surgical treatment, considering the frequency of carcinoma in porcelain gallbladder.


[Leiomyoma of the small intestine. Case report]. The paper reports the case of a 53-year-old man admitted to hospital with melena. The initial diagnosis was bleeding duodenal ulcer; after 8 weeks of therapy the duodenal ulcer was completely healed, but renewed intestinal bleeding occurred three months later. Angiography of the upper mesenteric artery revealed a clear tumour form. A tumour of the small intestine the size of a fist was found during surgery. An ileal resection was performed. Histopathological tests confirmed the diagnosis of leiomyoma of the small intestine.


[A rare case of breast ectopy associated with partial agenesis of osteo-muscular structures of the thoracic wall. Proposal of an original reparative technique]. The Authors report a case of chest wall malformation characterized by costal defect (6th and 7th ribs), hypoplasia of the serratus and pectoralis major muscles, left mammary ectopy and mucoviscidosis. The case is reported because of the very singular malformative association and the originality of the reparative procedure. Appearance has been improved and a good shape and breast projection achieved.


[Mayer-Rokitansky syndrome. Case report]. Uterine anomalies associated with congenital renal agenesis and skeletal abnormalities represent an uncommon pathology that often presents important diagnostic problems. A case of Mayer-Rokitansky syndrome is reported. The embryologic, clinical, pathologic and therapeutic implications of this disease are briefly discussed.


[Verneuil's suppurative hidradenitis. A case report]. The Authors reports a case of Verneuil's disease in a perineal location. They focus on etiopathogenetic aspects and problems of differential diagnosis, before reviewing the various therapeutic options. Surgery is the only effective therapy and takes the form of an extensive excision of the cutaneous zone affected with 2nd intention recovery, or a dermoepidermal auto-graft. A long follow-up is important to monitor the possible recurrence of lesions generally due to the incomplete removal of the area affected by the process.


[Peripheral neoplastic embolism. A rare pathology]. The paper reports case of tumour embolus which was brought to the Authors' attention. Proposals for treating for this rare pathology are outlined following a review of the literature.


[Role of loco-regional anesthesia in the surgical treatment of atheromatous lesions of the carotid bifurcation]. The Authors report a case of carotid bifurcation endarterectomy under loco-regional anesthesia. Despite a stump pressure of 44 mmHg, considered by the most of the Authors, the borderline value for carotid endarterectomy without shunt, the patient had a cerebral ischemic attack after 30 seconds of carotid clamping. So, the local anesthesia represents a valid alternative in order to detect an intolerance to clamping and underlines the importance of cerebral protection in this kind of surgical approach.


A practical, step-by-step approach to stress management for women. Stress is a significant threat to the physical and emotional health of contemporary American women. Primary health care providers are an excellent resource for women in need of education about the seriousness of stress. Clinicians can work with women to prevent unnecessary exposure to stressors and to help them learn adaptive coping skills. This article offers a practical, step-by-step approach to stress management for women. Assessment processes, planning concepts and relevant intervention strategies are discussed.


Recognizing and managing mycobacterial diseases in clients with AIDS. Mycobacterial diseases are common in people infected with human immunodeficiency virus. Mycobacterium tuberculosis (MTB) and Mycobacterium avium intracellulare (MAI), the specific pathogens most frequently involved, cause pulmonary tuberculosis and disseminated MAI infections. Pulmonary tuberculosis incidence was on the decline from 1950 to 1985, but since 1985 has been on the rise worldwide. Prior to the onset of AIDS, MAI infections were rare in humans. However, disseminated MAI seems to be associated with the terminal stage of AIDS. The symptomatology of MTB and MAI infections is similar, yet diagnosis and treatment vary. Pulmonary TB can be treated effectively with chemotherapy and isolation to prevent transmission. Because MAI infection is not a communicable disease, isolation is not necessary. Effective treatment for disseminated MAI remains under investigation; currently, a regimen of four to five drugs is recommended. There are however, significant side effects associated with this therapy. Because the number of AIDS patients is increasing, it is imperative for clinicians to understand the mycobacterial diseases and how best to manage them.


Fractures of the mandible: role of the general dentist. Mandibular fractures are the second most common facial fracture, the majority being the result of interpersonal violence, road traffic accidents, or sports injuries. Although most of these patients attend a hospital, it is not uncommon for patients with these injuries to present first to the general dentist, perhaps complaining of a loose tooth or abnormal bite. A careful history should be taken from the patient in order to identify the possibility of other injuries. Mandibular fractures are rarely life-threatening, although airway difficulties can arise. A systematic approach to diagnosis is essential if fractures are not to be missed, including radiological assessment in two planes at right angles. The initial treatment consists of airway management, control of fracture segments, and pharmacologic management. Most fractures have been traditionally managed by the use of intermaxillary fixation; however, increasing use is being made of open reduction and internal fixation techniques. Occasionally, general dentists are involved in the post-operative care of the patient following definitive management.


Dentures, prosthetic treatment needs, and mucosal health in an institutionalised elderly population. A survey of 359 elderly residents of rest homes and geriatric hospitals in the Manawatu and Horowhenua regions showed that 80.5 percent were fully edentulous. Full upper and lower dentures were worn by 64 percent of the total sample, and 31 percent of the dentate group wore one or more partial dentures. Prosthetic treatment needs were dominated by full dentures: 18 percent of upper dentures and 26 percent of lower dentures were considered to need replacement. A further 24 percent of full lower dentures required relining. Only 7 percent of the dentures were named. One third of the subjects had mucosal lesions, the most common lesions being angular cheilitis (present in 18 percent of subjects), traumatic ulcers (14 percent), atrophic glossitis (12 percent), and leukoplakia (present in 8 percent of subjects). No malignant lesions were found.


The copy denture technique.

The copy denture technique. The copy denture technique facilitates the replication of the good feature of existing dentures. Assessment of the existing dentures provides essential information for diagnosis and treatment planning. Copy templates are made which exhibit those features of the existing dentures which are satisfactory and are to be reproduced in the new dentures, while facilitating controlled and predictable modification of undesirable features. All impressions and occlusal registrations are obtained with the aid of the templates which then provide stable trial bases. The patient may adapt to the new dentures quicker because of the reproduction of familiar features.


Zygomatic bone fractures complicated by retrobulbar haemorrhage. The two patients described in this report demonstrate retrobulbar haemorrhage as a complication of zygomatic bone fracture. Successful treatment of this rare but very serious complication involves urgent consultation with an ophthalmology service, and immediate medical and surgical management. It is extremely important to check the vision of patients with zygomatic bone fracture, before and after surgery, and consideration should be given to obtaining an ophthalmology opinion for all fractures involving the orbit. A simple examination, which every dentist should be able to perform, should include inspection of the eye, a test of visual acuity, testing eye movements, testing visual fields, reaction of the pupils, and an examination for proptosis.


Selenium status of Christchurch infants and the effect of diet. New Zealanders, because of a soil deficiency, have a low intake of selenium. To determine the impact of this on the infant population in Christchurch. we have measured red cell and plasma selenium and the selenoenzyme, glutathione peroxidase, in 70 infants less than 12 months old and related these to age and diet. the infant population as a whole had mean plasma levels of selenium and glutathione peroxidase of 33 micrograms/L and 97 U/L compared with adult values of 74 micrograms/L and 150 U/L. Infant red cell levels of 0.30 mu g selenium and 9.0 U glutathione peroxidase per g haemoglobin were similar to those in adults. The selenium status of most breast fed infants after birth remained similar to that of cord blood. Mean plasma selenium and glutathione peroxidase levels in formula fed infants were about half those of breast fed infants, and their red cell selenium was also significantly lower. These did not increase until solids were introduced into the diet. The status of the infants reflected their diet, with the concentration of selenium in formulae being 3.9-5.2 micrograms/mL compared with a mean of 13.4 micrograms/mL in breast milk. since infants in more replete selenium areas show a gradual rise in blood selenium parameters after birth, this study suggests that formula fed and some breast fed infants in Christchurch receive an inadequate selenium intake. Consideration should be given to supplementing infant formulae and perhaps also the diet of pregnant and/or breast feeding mothers.


Audit of prioritisation for coronary revascularisation procedures: implications for rationing. to audit prioritisation of patients awaiting coronary revascularisation. the case records of 92 Christchurch patients referred for coronary artery bypass surgery (CABG) or percutaneous transluminal angioplasty (PTCA) from January to April 1990 were reviewed. The actual waiting time was compared with a nominally optimal waiting time, determined from an urgency rating score based primarily on severity of angina and coronary anatomy. of 56 patients referred for CABG, 47 had left main or multivessel disease including proximal stenosis of the left anterior descending artery. Fifty had Canadian class III or IV angina and 18 had impaired left ventricular function. At the time of review (January 1991), 16 had not yet had an operation. The mean waiting time was at least 163 (SD 116) days. Only nine (16%) had CABG within the maximum optimal time. Thirty-six patients had PTCA within eight months, mean waiting time 80 (53) days. These patients had less severe disease, but similar severity of angina. Nineteen (53%) had their procedure within the optimal period. waiting times for coronary revascularisation are excessive, even for high risk patients. Prospective monitoring of the waiting list using a standardised urgency rating score is likely to provide useful information on the dynamics of the waiting list for coronary revascularisation. Furthermore, the effects of further rationing of services can be analysed.


Outpatient clinic nonarrivals and cancellations. outpatient clinics account for much of the work and expenditure in public hospitals. Many hospitals are trying to improve clinic efficiency. This research was conducted to assess the extent and characteristics of outpatient nonarrivals and cancellations at Dunedin Hospital, and to make suggestions for improvements. data on 37,271 appointments scheduled during six months of 1990 were obtained. Nonarrivals and cancellations were examined in relation to characteristics of the patient, clinic and appointment. a large proportion (21.2%) of the appointments were not completed, comprising 8.3% nonarrivals, 7.5% patient cancellations, and 5.4% clinic cancellations or reschedulings. Nonarrivals were related to characteristics of the patient; including age, sex, ethnic group, and marital status. The proportions of nonarrivals and cancellations varied among different clinics. For new appointments, longer waiting times from referral were related to nonarrivals and patient cancellations. outpatient nonarrivals and cancellations pose a large problem at Dunedin Hospital. They could be reduced if some clinics provided more information for patients, arranged better cover for consultant absences, minimised clerical errors, decreased waiting times for new referrals, and used patient reminders.


Motor vehicle road crashes during the fourteenth and fifteenth years of life. From a sample of 848 teenagers, 50 individuals reported a total of 52 motor vehicle road crash events: 42 involved a car, six a motorcycle, and four a bus, over a two year period. Males and females were equally represented in each type of crash. Twenty-one of the car crashes, four of the motorcycle crashes and three of the bus crashes involved injury. The injuries sustained in the motorcycle crashes were predominantly to the extremities and in the other crashes they were mainly to the head or face. On average drivers less than 25 years of age had more passengers in their cars and were involved in more nighttime crashes. A seat belt was worn in only 18 (44%) of the car crashes. A motorcycle helmet was worn in four of the six motorcycle crashes. Six (15%) crashes were reported to have involved alcohol. The main areas of risk associated with motor vehicle road crashes involving teenagers and young adults have been addressed by legislation or the graduated drivers' licensing system. An evaluation of these measures is required to establish whether they are effective.


How well are we protecting our children? An immunisation coverage survey in Hawke's Bay. In July 1991, an immunisation coverage survey was conducted to assess the proportion of two year old children who have been vaccinated in the Hawke's Bay. Parents from a representative sample of 100 households with children between the ages of two and four years of age were interviewed regarding household characteristics and parental attitudes towards immunisation. Immunisation histories were abstracted from each child's Health and Development Record Book or, if this was not available or was incomplete, from records retained by the general practitioner(s) responsible for administering immunisations to the child. Coverage levels among two year olds exceeded 85% for all postneonatal vaccinations scheduled for the first year of life; however, levels among two year olds were lower than 85% for all vaccinations scheduled to be received after the first birthday. Overall, only 61% (95% confidence interval (CI) = 50.7, 70.6) of the children were fully vaccinated by the age of two years. Children living in a household where the principal source of income was from benefits were almost 60% less likely to have been fully immunised at two years of age (odds ratio (OR) = 0.42, 95% CI = 0.18, 0.97), as were Maori children (OR = 0.43, 95% CI = 0.18, 1.06). These results emphasise the need for enhanced education about the importance of completing the full series of recommended vaccinations and of on-time vaccination, as well as for checking childrens' vaccination histories at every contact with the healthcare system and, where necessary, administering past-due immunisations.


The 1991 measles epidemic: how effective is the vaccine? To estimate measles vaccine efficacy in the field in New Zealand, during the 1991 measles epidemic. Notifications in the Wellington Area Health Board region from the first 21 weeks of the 1991 measles epidemic (1444 cases) were analysed to estimate vaccine efficacy. Estimates of 70% and 80% immunisation coverage were used in this analysis for the age groups of 1-4 years, 5-9 years, 10-14 years, and 15-19 years. A trend was demonstrated, suggesting a reduction in vaccine efficacy (VE) for the two older age groups at 70% coverage (1-4 years 69% VE, 5-9y 68%, 10-14y 46%, 15-19y 47%) and 80% coverage (1-4y 82%, 5-9y 81%, 10-14y 69%, 15-19y 69%). Potential sources of bias are highlighted and their impact on the vaccine efficacy estimates discussed. There are multiple sources of bias that exist. If New Zealand is to improve and monitor the quality of its vaccination programmes, good quality information is required, which may include the need for immunisation registers, or ongoing case control studies in certain circumstances.


Beneficial effect of simvastatin in patients with drug resistant familial hypercholesterolaemia. To investigate the effects of simvastatin in patients with heterozygous familial hypercholesterolaemia refractory or intolerant to routine drug therapy. Eighteen patients were given increasing doses of 10, 20 and 40 mg simvastatin for eight week periods, followed by a control period on their former drug therapy in a prospective, crossover clinical study. Mean total and low density lipoprotein cholesterol (SEM) were significantly lower on 40 mg simvastatin alone than at the end of the control period (7.3 (0.3) mmol/L vs 10.7 (0.4) and 5.1 (0.3) vs 7.8 (0.5) respectively; p less than 0.01). Apo-B was also significantly lower on 40 mg simvastatin (p less than 0.01). Simvastatin offers effective cholesterol lowering for patients with drug resistant familial hypercholesterolaemia.


Benzodiazepine use in general practice--is it a problem? The aim of this study was to describe benzodiazepine use in a general practice. A prevalence study in an Auckland general practice was undertaken to describe the benzodiazepines prescribed, patterns of use and compliance. An associated case control study compared benzodiazepine users and nonusers. The age standardised prevalence rate of benzodiazepine use in this Auckland general practice was 3.4% for patients over 20 years of age. The benzodiazepine users described were predominantly elderly (70% over 60 years of age) and female (62.5%). They had significantly more medical and psychiatric complaints than matched controls. Triazolam and diazepam accounted for 60.9% of the benzodiazepines prescribed. Over one-third of the patients using benzodiazepines were concurrently prescribed other psychotropic medications, primarily tricyclic antidepressants. This rate suggests an overall decline in benzodiazepine use since previous studies. Benzodiazepines continue to be prescribed predominantly in the elderly, a group at considerable risk from side effects. Doctors should continue to inform their patients about the side effects of benzodiazepines, the risks of dependence and difficulties of withdrawal.


Foodhandling practices of Dunedin caterers: a cause for concern. Foodhandling practices in the Dunedin catering industry were assessed to determine if they were correct, preventing the transmission of foodborne disease to the public. A random sample of 300 foodservice outlets was selected. Information was collected during personal interviews with managers using a prepared questionnaire. Potentially dangerous practices were further analysed and summed to identify "at risk" operations. Response rate was 71%. Thirty-six percent of restaurants, 27% of takeaway bars and 25% of deli-bars and butchers could have been considered at risk operations. Few managers had any formal training in preparing and serving food, and less than 20% of managers and personnel had any food hygiene training. Current legislation and its enforcement is unable to adequately address incorrect food handling practices. It is recommended that revisions of the law emphasise the importance of correct practices and their enforcement. Food hygiene training should become compulsory for all who work in the catering industry.


The stability of 99Tcm directly labelled to an Fab' antibody via stannous ion and mercaptoethanol reduction. The anti-CEA FO23C5 F(ab')2 antibody was directly radiolabelled with 99mTcm by two methods (stannous ion and mercaptoethanol reduction) and compared in vitro and in vivo for label stability. By both methods, reduction of the F(ab')2 fragment produced primarily Fab' fragments. By both methods, the label was stable to 99Tcm-pertechnetate formation in vitro. Analysis by high performance liquid chromatography (HPLC) of serum, urine, kidney and liver homogenates from mice injected with 99Tcm-antibodies by both methods consistently showed a prominent radiolabelled peak with an estimated molecular weight of about 300 daltons. An identical peak was observed in the analysis of patient samples in a related investigation from this laboratory. Cysteine was radiolabelled with reduced 99Tcm and analysed by HPLC and thin layer chromatography (TLC); one of the 99Tcm-cysteine species so produced showed the same chromatographic behaviour as that of the 300 dalton species. In conclusion, the FO23C5 and other antibodies are stably labelled with 99Tcm via either stannous ion or mercaptoethanol reduction. In mice and in patients, the labelled proteins are either catabolized or, more likely, the 99Tcm label is transchelated such that the label is present on several low molecular weight species, the most prominent of which is postulated to be 99Tcm-cysteine.


A pharmacological guide to medicines which interfere with the biodistribution of radiolabelled meta-iodobenzylguanidine (MIBG). Radiolabelled meta-iodobenzylguanidine (MIBG) is widely used in the diagnosis, follow-up and treatment of patients with tumours of neural crest origin. Some commonly prescribed and readily available over-the-counter medicines interfere with the uptake and biodistribution of this radiopharmaceutical. This may lead to poor concentration of radiolabelled MIBG within the target organs and tissues. The clinical implications are a potentially inaccurate assessment of tumour burden during diagnostic studies and a suboptimal radiation dose when MIBG is employed for targetted radiotherapy. In order to avoid false negative results a comprehensive list of prescribed and over-the-counter medicines that have the potential to inhibit uptake of MIBG has been compiled. It is hoped that this will help nuclear medicine physicians to avoid this pitfall.


Single photon emission computed tomography using 99Tcm-HMPAO in Alzheimer's disease. Brain single photon emission computed tomography (SPET) using 99mTcm-hexamethylpropyleneamine oxime (HMPAO) was performed in 37 patients satisfying the standard clinical criteria of Alzheimer's disease (AD), correlating results with patient's age of onset, duration of illness, severity of dementia, neuropsychological impairment, computed tomography (CT) and EEG findings. All patients had abnormal SPET: 23 were bilaterally symmetric, 10 were bilaterally asymmetric and four showed unilateral low regional cerebral perfusion. Low perfusion in bilateral parietal regions was the most consistent finding and was present alone or with other abnormal regions in 31 patients (84%). The only significant clinical correlation was found between asymmetric SPET changes and onset of disease before the age of 65 years. Fifty per cent of patients with presenile onset, but only 19% with senile onset had asymmetric low regional cerebral perfusion. Fifteen of the 36 patients had normal brain CT scans, and 9 of 31 patients receiving EEG examination had normal results. Although clinical evaluation is the most valuable diagnostic tool, brain SPET is a sensitive test for physiological investigation in AD.


Assessment of tissue viability in frostbite by 99Tcm-HDP scintigraphy: an experimental study in New Zealand white rabbits. Since the appearance of superficial tissue is often an unreliable indicator of deep tissue viability in cases of frostbite, radionuclide scintigraphy with 99Tcm-disodium oxidronate (HDP) was used to assess changes in tissue viability after experimental freezing and thawing of the rabbit ear. One shaved ear, left or right, of each of eight New Zealand white rabbits was frozen with a glass bottle (diameter of bottom 2 cm) filled with liquid nitrogen (-180 degrees C) for 5 min under Ketalar-Rompun anesthesia, the other ear serving as a control. Radionuclide scintigraphy was performed by giving a bolus intravenous injection of 130-170 MBq (3.5-4.5 mCi) 99Tcm-HDP. Radionuclide imaging was used to follow the development of the demarcation line. Scintigraphy was performed 2 h after frostbite and then after 24 h, 48 h, 1 week and 3 weeks. The frostbitten area seemed macroscopically to be warm and swollen immediately after the induction of frostbite. Scintigraphy showed the frostbitten area to be much warmer than the surrounding tissue for the first week and it was not until after that the first cold spots appeared in the middle of the frostbitten area. The necrotic and vital tissue could easily be distinguished after 3 weeks.


The effect of intracavernosal haemodilution on the radionuclide quantification of penile vascular changes during pharmacologically induced penile erections. Radionuclide phallography was performed using 99Tcm-labelled red blood cells in conjunction with pharmacologically induced penile erections. The radioactivity content of aliquots of systemic venous blood taken from the antecubital vein was compared with aliquots of blood withdrawn from the penile cavernosa 20 min after an intracavernosal injection of 10 micrograms prostaglandin E1. The cavernosal samples showed significantly lower counts per unit of blood compared to the systemic venous blood indicating a comparatively lower concentration of tagged red blood cells. On haematological analysis, a significant difference in the haematocrit of the two samples was also established. The fall in the cavernosal haematocrit was found to result from dilution of the cavernosal blood pool by the injected volume of the drug since larger volumes of injection produced a greater fall in the haematocrit. Restriction of the cavernosal venous outflow in response to the injection of the vasoactive drug causes sequestration of the diluted blood in the cavernosal compartment. This factor might affect the quantification of penile blood volume using radiotracer methods.


Difference in inhaled aerosol deposition patterns in the lungs due to three different sized aerosols. Deposition patterns of inhaled aerosol in the lungs were studied in five normal subjects and 20 patients with lung disease by inhaling radioaerosols with three different particle size distributions. These aerosols were generated from BARC, UltraVent, and Mistogen-EN-142. Particle size distributions generated by these three nebulizers were 0.84, 1.04 and 1.93 microns in activity median aerodynamic diameter (AMAD) with its geometric standard deviation (sigma g) of 1.73, 1.71 and 1.52, respectively. Deposition patterns of inhaled aerosols were compared qualitatively and quantitatively by studying six different parameters: alveolar deposition ratio (ALDR), Xmax, Xmean, standard deviation (S.D.), skewness and kurtosis of the radioactive distribution in the lungs following inhalation. It has been found that aerosol deposition patterns varied with particle size. The unevenness of aerosol deposition, Xmax, Xmean and the number of 'hot spots' became more prominent with the increase in particle size, whereas values of ALDR and S.D. decreased as particle size increased. Knowing these deposition characteristics would facilitate a judicious application of aerosol inhalation to medical use.


Assessment of an attenuation correction for SPET by means of PET images. The attenuation correction for single photon emission computed tomography (SPET) data developed by Luig et al. was tested with positron emission tomography (PET) data. Since the PET attenuation correction is very precise, it may be used as a reliable measure of the functionality of the SPET correction. It was found that, in the case of homogeneous attenuation and activity distribution, the results of Luig's correction are equivalent to those obtained with the PET correction. Inhomogeneous distributions of activity are corrected satisfactorily as long as the absorption of the medium is sufficiently homogeneous. Inhomogeneous absorption, however, leads to inadequate correction. In the case of sections through the lung, Luig's method might 'correct' the data in the wrong direction.


A randomized comparison of secondary closure and secondary intention in patients with superficial wound dehiscence. To determine whether secondary closure or secondary intention results differ with respect to time for complete healing and number of postoperative visits in patients with superficial wound dehiscence. A randomized trial involved 33 obstetric and gynecologic patients at the University of Mississippi Medical Center who experienced superficial wound dehiscence. Subjects were assigned to secondary-closure or secondary-intention groups. The two groups were similar in age, absolute body weight, percent ideal body weight, length of the primary surgical procedure, estimated blood loss at the primary surgical procedure, portion of the would that opened, preoperative hemoglobin concentration, and preoperative hematocrit. Patients randomized to secondary closure required a mean (+/- standard deviation) of 17.6 +/- 7.2 days from dehiscence to complete healing, whereas those assigned to secondary intention required 61.2 +/- 35.8 days (P less than .001). The secondary-closure group required a mean of 2.0 +/- 0.7 postoperative visits, compared with 8.4 +/- 6.2 visits in the secondary-intention group (P less than .001). Secondary closure of superficial wound dehiscence is superior to healing by secondary intention.


Hysteroscopic endometrial ablation using the rollerball electrode. To assess the efficacy of hysteroscopic endometrial ablation with the rollerball resectoscope. From April 1989 to March 1991, 64 women underwent hysteroscopic endometrial ablation using electrosurgery. Telephone follow-up was obtained for 61 patients at least 6 months after the procedure. The majority of patients requested endometrial ablation because of irregular heavy menses, and two patients presented with postmenopausal bleeding. All patients had preoperative endometrial sampling that demonstrated benign endometrial histology. Five women had previous endometrial ablation with the Nd:YAG laser, with persistent bleeding. Eight patients had endometrial polyps and six had submucous fibroids that were resected at the time of hysteroscopic ablation. The average operative time was 31.6 minutes, and an average of 304 mL of distending medium was absorbed during the procedure. Complications included one uterine perforation in a patient who had a previous Nd:YAG ablation, and one epidural anesthetic complication. At follow-up, 18 women (29.5%) reported amenorrhea, 16 (26.2%) reported spotting, 21 (34.4%) reported decreased menstrual flow, four (6.6%) had no change, and two (3.3%) noted increased flow. Subjectively, 49 patients (80.3%) reported a satisfactory outcome. Of the 12 who were not satisfied, seven underwent a repeat ablation with satisfactory results, four chose hysterectomy, and one elected not to have further therapy. Endometrial ablation with the rollerball electrode is a safe, excellent method of management in women with excessive menstrual flow and provides a cost-effective, minimally invasive alternative to hysterectomy.


Quantitative and qualitative effects of douche preparations on vaginal microflora. To determine the effect of douching on the quantitative and qualitative makeup of the vaginal microflora. We first evaluated the effect of douching with a solution of physiologic saline to determine the effect of washing the vaginal surface. Two douche preparations, one containing 0.04% acetic acid and one containing 0.30% povidone-iodine, were evaluated subsequently to determine whether any effects occurred in addition to those noted with saline. Duplicate vaginal swab samples were obtained at predetermined intervals from ten healthy volunteers for three sampling cycles before and after use of the douche preparations for various periods of time. Samples were analyzed for total facultative and obligately anaerobic bacterial populations. The use of a douche preparation containing acetic acid caused a transient reduction of the total bacterial counts, with most of the change attributable to the effect of washing the surface of the vaginal vault as noted with physiologic saline. In contrast, the povidone-iodine preparation caused a significant reduction in total counts compared with those obtained after use of a physiologic saline solution by the same subjects (P = .02). Little change in the qualitative makeup of the vaginal microflora occurred. The use of povidone-iodine douches decreases the numbers of the dominant bacterial species beyond those expected with other douches. In some individuals, such changes may allow rapid proliferation of potential pathogens during this altered state, increasing the risk of associated infections.


Treatment of premenstrual syndrome with fluoxetine: a double-blind, placebo-controlled, crossover study. Although its etiology is unknown, it has been hypothesized that premenstrual syndrome (PMS) is linked to a deficiency of central serotoninergic activity. In the present study, we evaluated the effect of fluoxetine, a specific serotonin uptake inhibitor, on PMS symptoms. Following extensive screening, including several psychological inventories, eight women with severe persistent PMS participated in a 6-month double-blind, placebo-controlled, crossover study which included three months each of daily fluoxetine 20 mg or placebo, administered in a randomized order. Symptoms were evaluated using the Calendar of Premenstrual Experiences and other psychometric measures. Compared with placebo, treatment with fluoxetine was associated with an improvement in PMS symptoms as judged by highly significant decreases in behavioral (P less than .005), physical (P less than .05), and total (P less than .005) Calendar of Premenstrual Experiences scores; Beck Depression Inventory scores (P less than .005); Profile of Mood States subscales scores including depression (P less than .005), tension (P less than .005), and anger (P less than .01); and State-Trait Anxiety Inventory scores. The use of fluoxetine was associated with a greater mean reduction in behavioral (75%) than in physical scores (40%), with a mean decrease in total Calendar of Premenstrual Experiences scores of 62%, which rendered these scores similar to follicular phase values. Thus, the luteal phase symptomatology of PMS was effectively abolished. At this dose, no significant side effects or complications were noted during treatment. Fluoxetine appears to be a highly effective, well-tolerated treatment for the psychological and physical symptoms accompanying severe PMS.


Chorionic villus sampling: transabdominal versus transcervical approach in more than 4000 cases. To address the evolving trends in the choice of transabdominal or transcervical chorionic villus sampling (CVS) at a teaching hospital and to evaluate the influence of gestational age on the approach chosen. We analyzed our CVS data base, which contained information from 1986-1991. The proportions of transabdominal and transcervical CVS were tabulated for each year. In addition, the distribution of the CVS approaches over the various gestational ages was examined. During the study period, 4290 CVS procedures were performed. The rate of the transabdominal technique was stable at about 15% per year except for the first 2 years, when essentially all procedures were transcervical. Use of transabdominal CVS increased with advancing gestational age, from 3.6% at less than 10 weeks' gestation to 97.6% at greater than 14 weeks (chi 2 = 120, P less than .001; r = 0.791). The choice between the transabdominal and transcervical approach to CVS largely reflects the route emphasized during the physician's training. When choice is based strictly on technical limitations due to placental position, the overall transabdominal CVS rate is approximately 15%. A shift from transcervical to transabdominal CVS occurs with increasing gestational age as the placenta gains bulk and moves away from the cervix. After 14 weeks' gestation, most procedures are performed transabdominally.


Accelerated cardiac growth and abnormal cardiac flow in fetuses of type I diabetic mothers. To determine the growth patterns of the fetal heart and the development of cardiac function during gestation in fetuses of diabetic mothers, and to compare these findings with those of normal fetuses. Serial M-mode and Doppler echocardiographic recordings were made at 4-week intervals in 14 fetuses of well-controlled type I insulin-dependent diabetic mothers and in ten control fetuses at 20-36 weeks' gestation. The following variables were measured: interventricular septal thickness, left ventricular wall thickness, right ventricular wall thickness, ratio between the peak velocities during early passive ventricular filling and active atrial filling at the level of the atrioventricular valves, peak velocities, and time to peak velocity at the level of the ascending aorta and pulmonary artery. In both groups of fetuses, all of the indices increased linearly with gestation. However, fetuses of diabetic mothers showed significant differences in the slope and intercept values for the function describing the growth of the interventricular septum (P less than or equal to .001) and the right and left ventricular wall thicknesses (P less than or equal to .01), resulting in accelerated cardiac growth. The function describing the development of the ratios between early and active ventricular filling showed differences in slope and intercept values at the level of both the mitral (P less than or equal to .001) and tricuspid valves (P less than or equal to .001), resulting in a lower rate of increase during diabetic pregnancy when compared with control fetuses. Significantly higher intercept values were found in the functions describing the increase of peak velocities in the aorta and pulmonary artery in fetuses of diabetic mothers (P less than or equal to .01), whereas the slopes were similar to those of control fetuses. No differences were found in the time to peak values between the groups of fetuses. No relationships were found between the echocardiographic results and the metabolic control of pregnancy or fetal characteristics. This study suggests that strict maternal diabetes control does not exclude accelerated fetal cardiac growth and abnormal development of cardiac function.


Umbilical artery velocimetry in predicting perinatal outcome with intrapartum fetal distress. The aim of this study was to see whether umbilical artery Doppler velocimetry predicts intrapartum fetal distress evidenced by poor perinatal outcome. Umbilical velocimetry was performed on 102 parturients with a presumptive diagnosis of fetal distress based on fetal heart rate (FHR) patterns. A mean systolic-diastolic ratio (S/D) of 3 or more after 30 weeks' gestation was considered abnormal. Poor perinatal outcome was defined by any of the following: small for gestational age, low Apgar score, acidosis, meconium below the vocal cords, prolonged neonatal hospital stay, neonatal intensive care unit admission, and neonatal morbidity. Eighty-two patients had normal S/Ds and 20 had abnormal ratios. Eighteen neonates (90%) in the abnormal-SD group had at least one adverse outcome, compared with only 13 (15.8%) of those with a normal S/D, a statistically significant difference (P less than .001). Umbilical artery S/D used as a screening tool to detect poor perinatal outcome had a sensitivity of 65-100%, specificity of 83-92%, positive predictive value of 20-81%, negative predictive value of 91-100%, and a kappa index of 0.24-0.63. These findings suggest that umbilical artery Doppler velocimetry may be useful as an adjunct in the assessment of intrapartum FHR patterns suggesting fetal distress.


Natural history of the minimally abnormal Papanicolaou smear. We sought to determine the natural history of the cytologic and colposcopic changes in patients with minimal abnormalities on their Papanicolaou smears (atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion [SIL]). Between November 1988 and November 1990, 632 women with abnormal Papanicolaou smears as listed above were evaluated at Los Angeles County-Olive View Medical Center. Each had review of cytology, repeat Papanicolaou smear, and colposcopy of the lower genital tract. We excluded those who were pregnant or had findings demonstrative of moderate dysplasia or worse, or had a cervical biopsy for any other indication. Women with symptomatic vaginal discharge were treated and remained in the study. Subjects were followed every 3 months with repeat Papanicolaou smear and colposcopy for a minimum of 9 months. If at any time the Papanicolaou smear or colposcopy was consistent with moderate dysplasia or worse, directed biopsies and endocervical curettage were performed, and treatment was given accordingly. Two hundred ninety-four patients fulfilled all inclusion criteria and had adequate follow-up data. Nine months after enrollment, 42 of 91 women (46.2%) with atypical squamous cells had persistent changes, none had progression, and 49 (53.8%) had regression to normal. In those with low-grade SIL, 37 of 203 cases (18.2%) persisted, seven (3.4%) progressed, and 159 (78.3%) regressed by 9 months. Patients in the first group were more likely to have persistence of the cytologic abnormalities than were those in the second (P less than .01). Only the latter group progressed to high-grade dysplasia during the 9-month study interval. The majority of women with confirmed minimal cytologic changes on Papanicolaou smear will have complete colposcopic and cytologic regression over a short interval.


Strategies for improving the specificity of screening for ovarian cancer with tumor-associated antigens CA 125, CA 15-3, and TAG 72.3. To assess different strategies for improving the specificity of screening for ovarian cancer with tumor-associated antigens, including concomitant measurement of multiple tumor markers and serial measurement of CA 125. A combination of CA 125, CA 15-3, and TAG 72.3 was evaluated in serum samples from 217 of 1010 apparently healthy postmenopausal women who had participated in a study of screening for ovarian cancer and who had a serum CA 125 level of 20 U/mL or greater. In addition, serial serum CA 125 levels were determined in 30 women with an initially elevated CA 125 level (30 U/mL or more) and 30 women with a CA 125 level less than 30 U/mL. The specificity of CA 125 at upper limits of 30 and 50 U/mL was increased from 97.0 and 99.5%, respectively, to 98.9 and 99.9% when a positive test was defined as an elevated serum CA 125 level in combination with either a CA 15-3 greater than 30 U/mL or a TAG 72.3 greater than 10 U/mL. Definition of a positive result as a serum CA 125 level greater than 50 U/mL at the initial test and greater than 30 U/mL at 3-month follow-up achieved a specificity of 99.6%. Levels of specificity suitable for screening asymptomatic postmenopausal women can be achieved using tumor-associated antigens measured serially or in combination. Further studies are required to determine the sensitivity of these strategies for preclinical ovarian cancer.


The relationship between breast cancer survival and prior postmenopausal estrogen use. The growth of breast cancer may be mediated by endogenous or exogenous sex steroid hormones, particularly estrogen. However, neither contraceptive nor noncontraceptive estrogen use has been associated definitively with an increased risk of developing breast cancer. In this study, we addressed a corollary question: If a postmenopausal woman develops carcinoma of the breast, is her survival affected by previous use of replacement estrogen? Two hundred fifty-six postmenopausal women with breast cancer entered our Tumor Registry between 1972-1981, inclusive. Of these, 174 took no replacement estrogen before the diagnosis (never-users), 21 had used estrogen previously (past users), and 61 were taking estrogen at the time of diagnosis (current users). Survival analysis revealed a median survival of less than 84 months after diagnosis for never- and past users and greater than 143 months for current users, but these differences were not significant when controlled for stage of disease at diagnosis. We conclude that prior postmenopausal estrogen replacement therapy does not compromise survival in women who subsequently develop carcinoma of the breast.


Interleukin-1 inhibits growth of normal human endometrial stromal cells. To understand growth regulation of the endometrium by studying the effect of interleukin-1 beta (IL-1) on human endometrial stromal cell proliferation in vitro. Endometrial stromal cells from human endometrium were separated and purified and placed in culture. Fresh and first- and sixth-passage cells were incubated with IL-1 (0.025, 0.25, and 2.5 ng/mL) for 24, 48, and 72 hours, respectively. Proliferation as a function of DNA synthesis was assessed by measuring 3H-thymidine incorporation. Experiments were then repeated in the presence of indomethacin to determine whether IL-1 effects were dependent upon prostaglandin synthesis. We evaluated overall growth by adding IL-1 to cell cultures of sixth-passage stromal cells every 3 days and by performing cell count studies. Interleukin-1 beta significantly inhibited 3H-thymidine uptake in freshly explanted endometrial stromal cells at all doses in a dose-dependent manner; a 44% inhibition was seen at 2.5 ng/mL IL-1 after 72 hours of incubation. In first- and sixth-passage cells, 3H-thymidine uptake was inhibited only at intermediate and high doses of IL-1. Cell count studies showed that sixth-passage cells were significantly inhibited by IL-1 after 23 days of growth (22%; P less than .01). Adding indomethacin did not affect inhibition of growth. Interleukin-1 beta inhibits growth of normal human endometrial stromal cells in vitro and does not appear to be mediated by arachidonic acid metabolites. This inhibition of growth may be important for maintenance of a normal endometrial phenotype.


Immunohistochemical localization of inhibin/activin subunits in human placenta. To examine the cellular localization of each inhibin subunit in human placenta throughout pregnancy. Placental tissues were collected and fixed in Bouin's solution, and studied with the immunohistochemical technique avidin-biotin-peroxidase complex. There was immunohistochemical staining with antisera against each inhibin subunit in the syncytiotrophoblast, but not in the cytotrophoblast. In the first-trimester placenta, positive immunostaining for alpha- and beta A-subunits was clearly observed in the syncytial layer of villi, whereas staining for beta B-subunit was faint. In the second-trimester placenta, the relative intensities of staining for alpha- and beta A-subunits were similar to those in the first-trimester placenta, and enhanced positive immunostaining with beta B-subunit antiserum was observed. The relative amount of immunostainable alpha-subunit declined within the syncytiotrophoblast of the third-trimester placenta, whereas levels of immunostainable beta-subunits were unchanged. Inhibin subunits may be produced in the syncytiotrophoblast throughout pregnancy, and activin as well as inhibin may be synthesized in the syncytiotrophoblast of the term placenta.


Quadruplet pregnancy: contemporary management and outcome. Quadruplets are occurring more frequently as assisted-reproduction techniques improve fertility in couples previously unable to conceive. Ten quadruplet pregnancies cared for in one perinatal practice over 5 years had excellent outcome. The mean gestational age at delivery was 32.5 weeks, compared with approximately 30 weeks in the literature. There were no perinatal deaths and no long-term morbidity. Our patients were compared with a series of 57 consecutive patients with quadruplet pregnancies monitored by a home monitoring system. Parity of 1 or more appeared to improve outcome. Pregnancy-induced hypertension occurred in nine of our pregnancies and necessitated delivery in seven instances. Fetal distress was responsible for two deliveries and uncontrollable preterm labor for only one. Key points in our management protocol include prophylactic use of low-dose aspirin, home contraction monitoring, use of terbutaline pump tocolysis, and bed rest at home starting at 16 weeks.


Risks associated with pregnancy in spinal cord-injured women. We reviewed the experience with pregnancy in spinal cord-injured women at the University of Washington over the past 10 years. During that time, 11 women with spinal cord injury had 13 pregnancies. Infant outcome was uniformly good. No major obstetric complication occurred. The mothers experienced medical problems including urinary tract infection in ten and pyelonephritis in three. Autonomic hyperreflexia occurred in three of five subjects with lesions at or above the sixth thoracic vertebra. Pregnancy in the spinal cord-injured patient involves medical risk for the mother, but with careful management, an excellent outcome for both mother and infant may be anticipated.


Pregnancy outcome following exposure to angiotensin-converting enzyme inhibitors. Case reports of suspected adverse pregnancy outcomes associated with prenatal exposure to angiotensin-converting enzyme inhibitors, particularly oligohydramnios, prolonged neonatal anuria, and defects of ossification of the skull dome, prompted us to examine pregnancy outcome in a large cohort of pregnant women for whom complete drug exposure information was known. We studied the prescribed drug exposure histories and pregnancy outcomes of all women aged 15-44 years enrolled in Tennessee Medicaid who delivered a live-born or stillborn infant between January 1, 1983 and December 31, 1988. Of the 106,813 women enrolled in Tennessee Medicaid who delivered either a live-born or stillborn infant during the study period, 19 were exposed to an angiotensin-converting enzyme inhibitor during pregnancy. All 19 women delivered live infants. Among the 19 newborns, one preterm infant had prolonged anuria necessitating dialysis and a second preterm infant had microcephaly and a large occipital encephalocele. These outcomes represent a systematic follow-up of all angiotensin-converting enzyme inhibitor-exposed pregnancies. Despite the small number of exposures, there were two outcomes previously linked to prenatal use of these drugs, suggesting that the absolute risk may be high. In light of these findings and the case reports of others, it is prudent to avoid the use of angiotensin-converting enzyme inhibitors in pregnancy.


Antenatal treatment of fetal alloimmune thrombocytopenia. To review our experience with, and to evaluate the efficacy of, antenatal pharmacologic treatment of pregnancies complicated by alloimmune thrombocytopenia. We reviewed the records of six pregnancies complicated by alloimmune thrombocytopenia recently cared for at the University of Iowa Fetal Diagnosis and Treatment Unit. All patients had a history consistent with alloimmune thrombocytopenia in a previous gestation. All fetuses had thrombocytopenia on funipuncture at 20-32 weeks' gestation, and all patients and fetuses demonstrated a platelet antigen incompatibility. Three women initially received weekly gamma globulin infusions, two received gamma globulin and dexamethasone, and one had no initial treatment but was given gamma globulin and dexamethasone at 32 weeks' gestation. Repeat funipuncture was performed at 3.5- to 7-week intervals, and therapeutic modifications were made as necessary. In five cases, the last funipuncture before delivery documented platelet counts adequate for vaginal delivery. One woman, who received gamma globulin alone with good initial response, was delivered by cesarean for a platelet count of 25,000/microL at 39 weeks. Following delivery, all infants were thoroughly evaluated, and none had evidence of intracranial hemorrhage or other alloimmune thrombocytopenia-associated morbidity. All had normal platelet counts at discharge from the hospital. Our experience confirms the efficacy of gamma globulin treatment, but indicates that not all fetuses will respond to it alone. Serial funipunctures are essential to evaluate patient response and allow appropriate therapeutic modifications. Randomized studies are needed to determine the optimal antenatal pharmacologic therapy for this disease.


A comparison of pre-discharge survival and morbidity in singleton and twin very low birth weight infants. The perinatal mortality rate of twins is four to 11 times higher than that of singletons, and twins are widely reported to have more morbidity than singletons, mainly because of a higher preterm birth rate. However, it is not clear that live-born preterm birth rate. However, it is not clear that live-born preterm twins suffer greater morbidity than comparable singletons. In fact, twins have been reported to develop pulmonary maturity earlier than singletons, which might result in decreased morbidity relative to comparable preterm singletons. We conducted this retrospective review of 496 consecutive singleton and 104 twin infants weighing 500-1499 g and born alive at 24-31 weeks' gestation to determine whether pre-discharge survival and morbidity in very low birth weight (VLBW) twin infants were greater than those of comparable singletons. The mean (+/- standard deviation) gestational age of the singletons was 27.5 +/- 2.0 weeks and of the twins 27.6 +/- 2.0 weeks. There were no differences in mean gestational age, gestational age distribution, mean birth weight, birth weight distribution, gender, or maternal race between the two groups. The pre-discharge survival rate for twins (77%) was not significantly different than that of singletons (82%). There were no differences between twins and singletons in the incidences of neonatal respiratory distress syndrome (63 versus 71%), pulmonary interstitial emphysema (14 versus 16%), patent ductus arteriosus (28 versus 29%), necrotizing enterocolitis (3 versus 5%), intraventricular hemorrhage (11 versus 16%), and retinopathy of prematurity (11 versus 18%). The incidence of bronchopulmonary dysplasia was significantly less in twins (27 versus 46%; P = .001).(ABSTRACT TRUNCATED AT 250 WORDS)


Prostaglandin D2 production by term human decidua: cellular origins defined using flow cytometry. To measure prostaglandin (PG) D2 output by human decidua at term and to identify the cell population(s) responsible for its production. Decidual cell suspensions were prepared enzymatically and the cells were labeled with either of two monoclonal antibodies: F10/89/4, which recognizes the leukocyte common antigen (CD45), or L243, which labels HLA-DR and is specific for macrophages in this tissue. Cells were sorted on a Coulter EPICS 541 flow cytometer. Prostaglandin levels were measured by radioimmunoassay. Human decidua is an important intrauterine source of PGD2 at term. Twenty-nine percent (median) of decidual cells were CD45-positive and 12% were HLA-DR-positive; sorted cell populations were 95% pure. Prostaglandin D2 output (fmol/10(6) cells per 3 hours) by bone marrow-derived (CD45-positive) cells was significantly higher than that by non-bone marrow-derived cells: median 63 (range 35-67) versus 20 (13-21), respectively; HLA-DR-positive cells (macrophages) had the highest PGD2 production rate (186, range 97-288 fmol/10(6) cells per 3 hours). Under basal conditions, PGD2 production by unsorted term decidual cells was not influenced by labor. Bone marrow-derived cells (macrophages) are the major source of decidual PGD2 at term. Further studies are required to investigate the possible role of PG production by human decidual macrophages in the mechanism of term and/or preterm labor.


Unscheduled hospital admission following ambulatory gynecologic surgery. To identify causes of unscheduled admission following ambulatory gynecologic surgery. We compared each patient admitted on an unscheduled basis with two patients who did not require admission. Thirty demographic and clinical factors were evaluated by univariate analysis. Significant factors (P less than .05) were then analyzed using multivariate stepwise logistic regression. During a 4-year period, 90 patients required unscheduled admission. This represented 3.64% of 2470 patients who underwent ambulatory gynecologic surgery. Factors associated with admission by multivariate analysis included: 1) previous abdominal surgery, 2) significant medical illnesses, 3) preoperative hemoglobin concentration, 4) general anesthesia, 5) procedure length, and 6) blood loss. Sensitivity was 60.0%, specificity was 90.6%, and the overall correct rate of prediction was 80.4%. Postoperative emesis, the most common reason for unscheduled admissions, occurred in 23.4% of patients. Previous abdominal surgery and significant medical illnesses are factors that cannot be altered preoperatively. The need for general anesthesia, procedure length, and blood loss are functions of the procedure and cannot be easily modified. Postoperative emesis may warrant further investigation. Successful antiemetic therapy may reduce unscheduled admissions.


Fetal fibronectin: a method for detecting the presence of amniotic fluid. To determine whether fetal fibronectin is a sensitive test for the detection of amniotic fluid (AF) in women with rupture of the membranes. In a multicenter clinical trial, pooling, ferning, and nitrazine tests were compared with fetal fibronectin in 339 women at term (study group) with a clinical history of rupture of the membranes and in 67 women at term receiving routine prenatal care (controls). Ruptured membranes was diagnosed if any two of the standard tests were positive. Fetal fibronectin in the cervicovaginal secretions was determined using a qualitative enzyme-linked immunosorbent assay test. Fetal fibronectin was considered positive at 50 ng/mL. The sensitivity of fetal fibronectin in the women with ruptured membranes was 98.2%. No controls had ruptured membranes based on standard test results, but 13 women had fetal fibronectin present. The mean (+/- standard error) interval between sampling and delivery was significantly less in the women positive for fetal fibronectin (169.3 +/- 45.8 hours) than in those with no detectable fetal fibronectin (333.4 +/- 29.0 hours). Fetal fibronectin is a sensitive test for detection of AF in the vagina and compares favorably to standard tests. Its low specificity suggests that the assay may detect an alteration in membrane integrity. In addition, in patients without rupture of the membranes, the interval between sampling and delivery is significantly shorter if fetal fibronectin is present. We speculate that the presence of fetal fibronectin in cervicovaginal secretions may be a marker for impending labor in gravidas without gross rupture of the membranes.


The association of menstrual cycle, pregnancy, and menopause with recurrent oral aphthous stomatitis: a review and critique. To examine critically the postulated associations between recurrent aphthous stomatitis and the menstrual cycle, pregnancy, and menopause, and to determine why such associations had been accepted previously in the absence of convincing evidence. We used MEDLINE data base searches in 1988 and 1991 to identify all articles since 1966 referring to estrogen, progesterone, menstruation, menstrual cycle, menopause, or pregnancy, and to aphthous stomatitis. Similar searches were carried out in the Index to Dental Literature for the period 1942-1991, and in MEDLINE on CD-ROM in 1991. Articles uncovered were examined for further appropriate references in the 50-year period 1942-1991. We excluded letters, abstracts, and articles in journals that are not peer-reviewed. We discovered one retrospective study on aphthous ulceration and ovarian hormones, eight prospective studies, three uncontrolled trials on the use of hormones in aphthous stomatitis, one controlled trial, and four review papers. Each paper was carefully read, in translation where necessary, and opinions and findings were critically examined for source, authenticity, and statistical analysis. Each paper was also examined critically in terms of its review and acceptance of previous papers. The papers were too diverse in nature to permit a structured criticism. No associations have been established between aphthous stomatitis and the premenstrual period, pregnancy, or menopause. No properly designed study has shown a therapeutic effect of ovarian hormones on aphthous stomatitis. Reasons for this lack and the need for large-scale studies are identified.


Perinatal transmission of human immunodeficiency virus-1 infection and maternal immunization strategies for prevention. To review the current understanding of the epidemiologic and pathogenetic features of human immunodeficiency virus-1 (HIV-1) infection in pregnancy and perinatal HIV infection, and to explore immunization strategies for preventing maternal-infant transmission of HIV. MEDLINE data base and reference lists of articles were used to identify relevant papers. Reports from conferences were noted if the data had not yet been published. We reviewed all English-language papers pertaining to maternal or fetal infection with HIV, immunology of HIV infection, immunization of pregnant women, or immunization against HIV. Human immunodeficiency virus infection of women is increasing, and vertical transmission of HIV to children is a growing problem. There is evidence for intrauterine, intrapartum, and immediate postpartum transmission, but it is thought that the majority of transmissions occur peripartum by a minor subset of the maternal HIV-1 strains. Diagnostic advances include measurement of HIV-specific immunoglobulin A (IgA) and improved systems for polymerase chain reaction and virus isolation from potentially infected infants. Clinical and immunologic correlates of transmission remain uncertain. The epidemiology of transmission must be determined in more diverse populations. The timing and pathogenesis of HIV transmission from infected mother to fetus require better description, and improved diagnostic tools are needed. Immunologic and mechanical determinants that prevent transmission in the majority of cases need to be identified more precisely. Clinical trials to evaluate active immunization of HIV-infected pregnant women with candidate AIDS vaccines will potentially help answer many of these questions.


Adenosine in the treatment of maternal paroxysmal supraventricular tachycardia. Paroxysmal supraventricular tachycardia is the most common sustained cardiac arrhythmia in pregnant women. Because nearly 50% of these supraventricular tachyarrhythmias fail to respond to vagal maneuvers, other therapies are used, including electrocardioversion and pharmacologic agents. Propranolol, verapamil, and adenosine have Food and Drug Administration-approved labeling for acute termination of supraventricular tachycardia. Verapamil has been the most commonly used agent in the general population but it has several shortcomings, such as its potential to cause or exacerbate systemic hypotension, congestive heart failure, bradyarrhythmias, and ventricular fibrillation. In addition, verapamil readily crosses the placenta and has been shown to cause fetal bradycardia, heart block, depression of contractility, and hypotension. Adenosine has several advantages over verapamil, including rapid onset, brevity of side effects, theoretical safety, and probable lack of placental transfer. Adenosine ultimately may prove to be the preferred agent for termination of paroxysmal supraventricular tachycardia in the gravid woman.


Termination of supraventricular tachycardia with intravenous adenosine in a pregnant woman with Wolff-Parkinson-White syndrome. Pregnancy is associated with an increased frequency of arrhythmias in women with Wolff-Parkinson-White syndrome. We describe the use of intravenous (IV) adenosine for the acute termination of a narrow complex tachycardia in a pregnant patient with this syndrome. A 26-year-old woman with known Wolff-Parkinson-White syndrome presented with dizziness, palpitations, and a narrow complex supraventricular tachycardia. We used IV adenosine to convert the arrhythmia to a normal sinus rhythm. During labor, the patient again developed a narrow complex supraventricular tachycardia, and fetal monitoring revealed recurrent deep variable decelerations. Intravenous adenosine resulted in conversion to sinus rhythm and restoration of the fetal heart rate to normal. Cesarean delivery produced a healthy male infant. Adenosine is effective in rapidly terminating maternal narrow complex tachyarrhythmias before and during delivery in women with Wolff-Parkinson-White syndrome. It can also treat fetal bradycardia resulting from the maternal arrhythmia.


Hypoplastic pulmonary artery: an unusual entity mimicking pulmonary embolism during pregnancy. Hypoplastic pulmonary artery is an unusual congenital malformation. We describe a case of hypoplastic pulmonary artery diagnosed during the third trimester of pregnancy. The clinical and radiologic features mimicked pulmonary embolism, including hemoptysis, chest pain, pleural effusion, mild hypoxemia, and a suggestive ventilation-perfusion scan. Accurate differentiation of this entity from pulmonary embolism is necessary to obviate the need for prolonged anticoagulation.