Identification of a mammalian protein that binds specifically to DNA containing methylated CpGs

The effects of DNA methylation on transcription and chromatin structure require that nuclear factors be able to distinguish methylated and nonmethylated DNA. We describe a methyl-CpG binding protein (MeCP) that complexes with a variety of unrelated DNA sequences when they are methylated at CpG. Fifteen or more symmetrically methylated CpG moieties per molecule are required for strong binding under our conditions. Competition experiments show that vertebrate DNAs bind to MeCP, whereas naturally nonmethylated genomes or cloned vertebrate genomes do not bind. Cross-linking experiments detect a 120 kd protein that correlates stringently with MeCP activity. Species and tissue comparisons show that MeCP is widely distributed in mammals except in embryonal carcinoma cell lines, which have very low levels.

Occult carcinoma of the breast masquerading as primary adenocarcinoma of the small intestine. A case report

A fifty-year-old woman with abdominal pain, diarrhea, and weight loss ultimately required exploratory laparotomy. The entire small intestine was extensively infiltrated by poorly differentiated adenocarcinoma; mesenteric lymph nodes and surrounding omentum were involved, but no extragastrointestinal tumor was found. A presumptive diagnosis of unresectable primary carcinoma of the small bowel was made. Chemotherapy was initiated with 5-fluorouracil 300 mg/m2/day by continuous intravenous infusion. Nine months later a left breast mass with multiple ipsilateral axillary and supraclavicular lymph nodes developed; biopsy revealed a poorly differentiated adenocarcinoma morphologically identical to the tumor involving her small bowel. In spite of breast irradiation and systemic hormonal therapy, the patient deteriorated rapidly and died from progressive metastatic disease.

Bacterial colonisation of leg ulcers and its effect on the success rate of skin grafting

There is little information on the immediate and long-term results of skin grafting to chronic lower limb ulcers. Our experience in their management had led us to analyse, retrospectively, the results of split thickness skin grafts applied to lower limb ulcers in 88 consecutive patients. Graft take has been related to bacterial growth from ulcer swabs taken on admission, preoperatively and postoperatively. Follow-up was for a median of 18 months. Initial graft take varied from 20% to 100% (median 85%). Bacterial flora grown from the ulcer swabs varied with the duration of the ulcer and the treatment. Analysis by bacterial type has shown that Staphylococcus aurcus and Pseudomonas significantly reduced skin graft healing. Overall, 90% of these ulcers had healed with a median of 6 weeks' in-patient treatment. Examination of the swab results from the 8 ulcers that were slow to heal postoperatively and the 8 ulcers that recurred 6 days to 8 months after discharge from hospital revealed that 15 out of 16 (94%) grew S. aurcus; none had Pseudomonas isolated from them. After eighteen months 8% of these ulcers remain active. Aetiology appears important as this figure is 6% for limbs affected by venous disease only, 13.3% for limbs with arterial disease only and 13.6% for limbs with both venous and arterial disease.

Three somatic responses in grief

The special instance in which the manifestations of grief are expressed principally in the somatic realm is discussed. Three case histories are presented to illustrate varieties of physical response to bereavement and to illustrate the various mechanisms responsible for the transformation of grief into physical symptomatology and illness.

The management of the limb in acute venous thrombosis

This review addresses the management of the limb in patients with deep vein thrombosis. The concepts that underline such treatment are reviewed and the importance of objective diagnosis before the institution of long term therapy is stressed. Management is considered in relation to the extent of segmental venous involvement and to the use of Heparin, Streptokinase, Warfarin and surgical therapy. There is a lack of adequate and comprehensive follow up data on the limb in patients with deep vein thrombosis and in particular there are few objective studies relating to the short and long term sequelae as far as valvular function is concerned. There is uncertainty concerning the appropriateness of continuing compression therapy and the value of such therapy in reducing long term morbidity. The importance of recognising the potentially severe ischaemic consequences of massive venous thrombosis are described, together with an outline management plan. The importance of short and long term follow up studies of the limb is stressed particularly in relation to potential changes in methods of treatment.

Graduated compression and its relation to venous refilling time

Graduated compression is important in improving venous function, but the pressure profiles of different brands of stockings in situ and effects on a direct measure of venous function have not been investigated. The pressure profiles of 15 different types of below knee compression stockings were established with a medical stocking tester in 13 healthy volunteers. Analysis of variance was performed for each stocking separately, considering the factors of size of stocking, site of measurement, and their interaction. The criteria used to define satisfactory function were that the stockings should have a significant linear trend with site--that is, graduation--and no other significant effects. Only five types of stockings met these standards. Venous function was then assessed by photoplethysmography in 19 patients with defined venous abnormalities. For each patient the effect on venous refilling time of three satisfactory and three unsatisfactory stockings was assessed. The three satisfactory stockings gave refilling times that were not significantly different from normal in patients with both superficial and deep vein incompetence, while refilling times with the three unsatisfactory stockings remained significantly below normal in all patients with deep vein incompetence; one stocking had no significant effect on refilling times in either group. Functional testing of compression hosiery should form part of future British Standards specifications.

Unrecognised aneurysmal disease in male hypertensive patients

The risk of an aneurysm leaking is related to its size. The operative mortality of elective surgery should be less than 5% but is frequently more than 50% following rupture. Many patients previously undiagnosed present with rupture, yet are on long-term treatment for hypertension. Two-hundred hypertensive male patients over the age of 50 have been clinically examined, and subsequently undergone ultrasound examination of the abdominal aorta. Fourteen asymptomatic aneurysms were detected, 9 on clinical examination, confirmed by ultrasound and C.T., and a further 5 detected by ultrasound, and also confirmed by C.T. Twenty-four patients were found to have carotid bruits, in 12 of whom the bruits were bilateral. Sixty-seven patients were found to have peripheral vascular disease. Routine abdominal ultrasound examination should be included in the regular assessment of hypertensive patients.

Leg ulcers: epidemiology and aetiology

In a regional Health District with a population of 198,900, 357 patients with 424 ulcerated legs were documented, an overall prevalence of 0.18 per cent. The prevalence of ulceration in the 92,100 aged greater than 40 years was 0.38 per cent. Fifty per cent of the lesions had been present for more than one year, and 62 per cent of patients had never attended any hospital. The patients were stratified by history of peripheral arterial disease. A random sample (100 patients, 193 legs) was examined by ultrasound and photoplethysmography to assess the venous and arterial circulation; 38 per cent had evidence of deep vein involvement and 43 per cent had superficial vein incompetence. An ischaemic element was present either in isolation (9 per cent) or combined with venous disease (22 per cent) in a total of 31 per cent, with a mean pressure index of 0.62 (s.d. 0.14). Simple objective methods of assessment together with dedicated community staff with ready access to specialized facilities can enhance the service provided to patients with leg ulcers.

Facilitation of nasogastric and nasotracheal intubation with a nasopharyngeal airway

The two new uses for the nasopharyngeal airway include facilitation of nasogastric intubation and nasotracheal intubation. First this technique takes advantage of the nasopharyngeal airway's unique ability to traverse the nasopharynx atraumatically and serve as a conduit for the smaller nasogastric tube. This technique also utilizes the nasopharyngeal airway to dilate the nasopharyngeal passage atraumatically, thus facilitating the passage of an endotracheal tube during nasotracheal intubation.

Peripheral vascular disease: prospective study of intraarterial digital subtraction angiography using a 9-inch intensifier

A prospective randomized study was undertaken to evaluate the role of intraarterial digital subtraction angiography (IADSA) in the study of peripheral vascular disease. Patients underwent either conventional film-based angiography alone, digital subtraction angiography (DSA) alone, or a combined study. With a 9-inch image intensifier, DSA alone resulted in cost savings of film and contrast material but required a significantly longer examination period than the other groups and an increased iodine dose per examination. When the images were analyzed by a radiologist and a vascular surgeon, the DSA studies provided less detail in the aortoiliac region than the other techniques but had advantages in demonstrating the runoff vessels. IADSA examination should not replace conventional arteriography in patients with peripheral vascular disease but has a useful complementary role.

Mortality and rebleeding after hypertensive variceal disconnections

Forty-five patients had operative disconnections of portoazygos venous collaterals for variceal hemorrhage. Nineteen alcoholic patients had urgent partial azygos disconnection (PAD) to control bleeding; this involved intragastric variceal and coronary and distal gastric-vein ligation. A complete azygos disconnection (CAD), which also included splenectomy, was done urgently in 14 patients and electively in 12 patients; 15 were alcoholics. All patients were assessed for operative risk by a modified Child's classification. Hospital mortality after urgent PAD or CAD in alcoholics was 67%, largely due to intraperitoneal sepsis or hepatorenal failure with recurrent hemorrhage. Operative modified Child's classification of survivors was better (lower) than in nonsurvivors. Eleven nonalcoholic patients had CAD; two died of intraperitoneal sepsis. Nine survivors did not rebleed nor have encephalopathy develop during an average follow-up of 41 months. Complete azygos disconnection was a good alternative, particularly in the elective setting, for patients with nonalcoholic portal hypertension.

Studies on the haemopoietic toxicity of nitrous oxide in man

Nitrous oxide inactivates vitamin B12 and in man can produce a megaloblastic anaemia. Haematological and biochemical changes were studied in nine surgical patients ventilated with 70% N2O for up to 24 h and in three control patients. There was a rise in the numbers of hypersegmented neutrophils in peripheral blood following N2O. Serial bone marrow aspirates showed gross megaloblastic change after 24 h of N2O which had reverted to normoblastic but dyserythropoietic haemopoiesis by 1 week. Giant forms of early myeloid precursors were also seen after 24 h ventilation with N2O but by 1 week abnormalities were evident in more mature cells, metamyelocytes and segmented neutrophils. Megaloblastosis was associated with abnormal dU suppression which showed a correction pattern similar to that seen in vitamin B12 deficiency. Administration of N2O was also associated with a progressive rise in serum folate and fall in serum methionine levels. No similar patterns were seen in the three control patients.

Technology, Enterprise, and American Economic Growth

The weakening of technology-based economic growth in the United States may be due to inflation and to fundamental characteristics of American society and not, as is often suggested, to low expenditures on research and development, too much regulation, or risk-averse corporate management. Accordingly, renewed economic growth will require constraining inflation, as well as private initiatives and public policies that reflect the nature of technological progress and of the American people.

Long-term toluene abuse

The authors briefly review the literature on the use of toluene as an intoxicating agent. They describe two cases in which the habit of sniffing toluene vapors extended over many years, discuss the rarity of this condition, and speculate about the conditions that might account for both the rarity and the occurrence of long-term toluene abuse.

Preliminary experience with prostaglandins E1 and I2 in peripheral vascular disease

Severe extremity ischemia frequently cannot be relieved by surgical means and failure of current drug therapy may then result in prolonged disability or amputation. Prostaglandins E1 (PGE1) and I2 (prostacyclin, PGI2) are potent vasodilators and inhibitors of platelet aggregation which have been reported to be of value in the treatment of peripheral ischemia. Nineteen patents with severe extremity ischemia and one with vasculitic leg ulceration were treated on 25 occasions by intravascular infusion of PGE1 or PGI2 for 72 to 96 hours. Causes of ischemia were arteriosclerosis, Raynaud's phenomenon (secondary), Buerger's disease, and "trash" foot. Prolonged pain relief and promotion of tissue healing occurred mainly in patents with patent proximal axial arteries. Patency of the superficial femoral artery was associated with a good clinical response in eight of nine cases of foot ischemia, and mean hallux temperature rose 4.6 +/- 2.5 degrees C. In contrast, occlusion of the artery was associated with failure in eight of nine cases, and hallux temperature rose 0.6 degrees +/- 1.3 degrees C. PGE1 or PGI2 administered intravenously may be the treatment of choice for severe ischemia in distal arteriopathy, although the exact mechanisms by which these prostaglandins act are far from clear.

Carcinoembryonic antigen and L-fucose in malignant and benign mammary disease

A prospective study of 123 patients was undertaken to determine whether carcinoembryonic antigen (CEA) or L-fucose could be used as "tumor markers" to distinguish patients who had mammary cancer (41) from patients who had benign mammary disease (41) and patients who did not have mammary cancer (41). The predictive value of positive test results for both L-fucose and CEA was lower for patients who smoked than for those who did not. The sensitivities of CEA and L-fucose indicators are both below 55%. There were frequent false-positive and false-negative results. A substantial overlap in the levels of CEA and L-fucose was found for the patients who had mammary cancer and those who had benign mammary disease. CEA and L-fucose performed similarly in distinguishing cancer from benign disease. For patients who smoked, however, the predictive value of L-fucose was only 44%. The effect of smoking on L-fucose levels may account for discrepancies in L-fucose data reported in previous studies of mammary cancer. Neither CEA nor L-fucose were found to be of value in screening for mammary cancer.

Maternal serum alpha-fetoprotein levels as an index of fetal risk

In a prospective study on an obstetric population (1,059 cases) an association was found between elevated levels of maternal serum AFP at weeks 16 to 22 and the occurrence of premature labor or the need for emergency cesarean section in the third trimester. There was no association with other late fetal complications including perinatal death, perinatal asphyxia, and intrauterine growth retardation. The sensitivity of the test in respect of premature labor was 14 per cent but the high incidence of false-positive results reduces the practical value of the test.

Is measurement of placental function and maternal weight worth while?

A prospective survey of 1029 women delivered during 1976 at St. Bartholomew's Hospital was undertaken to assess the predictive value of a variety of clinical, ultrasonic, and biochemical variables in the detection of high-risk pregnancies. The best antenatal predictors of fetal risk were severe pre-eclampsia, depressed maternal serum levels of human placental lactogen, low maternal weight at 32 weeks' gestation, and heavy smoking by the mother. 62% of the high-fetal risk group had one or more of these features, but so did 33% of the controls.

Danazol therapy in hormone-sensitive mammary carcinoma

The effect of Danazol, a synthetic gonadotropin inhibitor, on two groups of Sprague-Dawley rats with dimethylbenze (a) anthracine (DMBA) induced mammary carcinoma was studied. Twenty-four (83%) of 29 control animals developed mammary tumors. Forty-four rats in one treatment group received Danazol after tumor reached 0.5 cm in diameter. Twenty-nine (66%) demonstrated tumor regression (p less than 0.005) and in 16 (36%) tumor disappeared (p less than 0.005). In a second treatment group (given Danazol daily after administration of DMBA), only seven of 50 rats (14%) developed palpable mammary carcinoma (p less than 0.0005). Danazol therapy resulted in regression of established mammary carcinoma in rats, and produced a striking inhibition of carcinogenesis in those animals treated from the time DMBA was administered. Danazol is clinically safe; studies using it in the treatment of breast cancer in women who are candidates for hormonal ablative therapy seem warranted.

Dose dependence of immunopotentiation and tumor regression induced by levamisole

Breast cancer was induced in female Sprague-Dawley rats by 7,12-dimethylbenz(a)anthracene. Once tumors had become established, they were treated with varying doses of the immunopotentiating drug, levamisole. Tumor growth was measured in the various dosage groups, and at 6 months after tumor induction the animals were sacrificed. Their immunological competence at this time was measured by the mitogen responses of splenic lymphocytes. Untreated animals with breast cancer were found to be immunosuppressed compared to normal animals. The drug levamisole resulted in immunopotentiation, but at high doses it was immunosuppressive. Tumor regression was observed at doses that resulted in immunopotentiation, but not at high doses. There was a significant correlation between immune competence and tumor regression. It is concluded that levamisole can cause regression of breast cancer in the rat but that this effect is critically dependent on the dose of the drug; these observations confirm previous studies carried out on human cells in vitro. It is recommended that high doses of the drug be avoided in human clinical trials and that the patients who receive this drug should have their immune responses carefully monitored.

Circulating levels of pregnancy-specific beta1-glycoprotein and human placental lactogen in the third trimester of pregnancy: their relationship to parity, birth weight, and placental weight

Circulating levels of pregnancy-specific beta1-glycoprotein (SP1) and human placental lactogen (HPL) were measured in 153 normal subjects during the third trimester of pregnancy. The levels of SP1 and HPL showed a skewed distribution and rose progressively to reach a plateau by the 36th week. The normal range was calculated by ranking the data and division into centiles as well as by logarithmic transformation of the values. A low but significant correlation was observed between SP1 and HPL levels, SP1 and birth weight. There was also a correlation between HPL levels and placental weight.

Pregnancy in cirrhotic and noncirrhotic portal hypertension

The course of pregnancy in 1 patient with chronic active hepatitis (CAH) and cirrhosis, and another with extrahepatic portal vein obstruction (EHPVO) is described. The management of pregnancy in these diseases associated with portal hypertension is discussed and risks of pregnancy are compared. The patient with CAH presented with anovulatory cycles, and ovulation occurred following immunosuppressive therapy. Both women experienced massive upper gastrointestinal bleeding from esophageal varices. Bleeding was difficult to control and required variceal ligation in 1. Both patients manifested features suggesting cerebral edema indicating the need for caution with fluid and electrolyte therapy. Recovery of the woman with CAH after termination of pregnancy was slow. Review of literature demonstrated that variceal bleeding occurred in 43% of women with EHPVO compared to 23% of those with CAH and cirrhosis. Additional complications including hepatocellular failure (24%) occurred in patients with CAH but not in EHPVO. The management of pregnancy in portal hypertension and advice for contraception or sterilization are discussed.

Deep venous thrombosis in patients having aorto-iliac reconstruction

The 125I-labelled fibrinogen test has been used to assess the incidence of deep venous thrombosis in 88 patients who had undergone elective aorto-iliac reconstruction. Deep venous thrombosis was detected in 18 (20.5 per cent). The results suggest that these patients merit prophylaxis.

Computerized evaluation of electroencephalographic changes accompanying exchange transfusion in Reye's syndrome

The EEGs of 7 children with Reye's syndrome (fatty liver and encephalopathy) were continuously recorded on magnetic tape for times ranging from 12 to 80 h. During these times the major therapy consisted of exchange blood transfusions. The tapes were automatically processed on a LINC-8 computer using a peak-detection algorithm. The main parameters investigated were the delta and theta indices, the mean EEG frequency, the mean peak-to-peak amplitude, and the frequency versus amplitude characteristics of the delta waves. In 5 patients who responded to therapy, a marked decrease in the delta activity and an increase in mean frequency were noted subsequent to exchange transfusions. In all 5 cases the delta waves exhibited a similar pattern of decreasing amplitude and increasing frequency following therapy. However, in 2 patients with a fatal outcome, no favorable EEG response was observed during treatment, and a simultaneous decline in both delta frequency and delta amplitude was noted as the clinical condition worsened. The results of this study indicate that continuous EEG monitoring in Reye's syndrome may be an important clinical adjunct in evaluating the effectiveness of exchange transfusion therapy and in signaling the need for further treatment.

The effect of footwear on venous pressure at the ankle

The response to exercise of venous pressure at the ankle was measured in two groups of normal subjects when barefoot, wearing normal shoes and in exercise sandals. The results demonstrate a significantly greater fall in venous pressure in exercise sandals than in shoes approximating to that of barefoot walking. In patients with superficial varices, the fall in venous pressure during exercise when wearing exercise sandals was again highly significant when compared to walking in shoes, approximating to normal values, and the possible therapeutic application of this finding is discussed.

Antithrombin III deficiency causing postsplenectomy mesenteric venous thrombosis coincident with thrombocytopenia

The most commonly recognized cause of mesenteric venous thrombosis following splenectomy is hypercoagulation secondary to reactive thrombocytosis. A case is reviewed in which hypercoagulation followed splenectomy for idiopathic thrombocytopenic purpura (ITP) in spite of persistent thrombocytopenia. Episodic mesenteric venous occlusion occurred due to antithrombin III deficiency. This hypercoagulable state may be the cause of primary acute mesenteric venous occlusive disease. Symptoms and signs suggesting thrombosis in the portal circulation demand immediate coagulation studies since even in the thrombocytopenic patient thrombotic proglems can occur. Surgical intervention is the treatment of choice for segmental small bowel ischemia; warfarin therapy is indicated when there is evidence of antithrombin III deficiency.

Fibrinolytic activator in the endothelium of the veins of the lower limb

The local fibrinolytic acitivity of the femoral, popliteal and soleal veins has been studied using a histochemical technique. The results suggest that the fibrinolytic activity in the soleal veins may be low when compared with that in the femoral and popliteal veins. This may be an aetiological factor responsible for the high incidence of thrombi occurring in the soleal veins.

Which breast to biopsy: an expanding dilemma

To provide insight into the significance of findings reported from screening asymptomatic women for breast cancer, we reviewed 19,928 mammographic studies with the accompanying physical examination and correlated these findings with 554 breast biopsies. Of 83 breast biopsies with suspicious findings on both physical examination and mammography, 72 demonstrated breast cancer (87%). Of 155 biopsies for suspicious changes on mammography alone, 50 (32%) demonstrated breast cancer. The accuracy of suspicious mammography was independent of findings limited to physical examination, 34 (17%) had breast cancer; 31 were in 152 biopsies of patients with mammography interpreted as normal (20%) and three were in biopsies of 52 patients (6%) in whom a visualized mass was interpreted as benign. One hundred and twelve breast biopsies were performed for changes interpreted as normal or benign. Six malignancies were discovered (5%). No cancer was found in 31 biopsies for nonpalpable benign mammographic abnormalities. Our results emphasize the importance of discriminating between nonvisualization of a mass and mammographic recognition of either a benign or malignant tumor. The reliability of interpretation is considerably greater for a visualized lesion than a nonvisualized one.