Prenatal microarray analysis as second-tier diagnostic test: single-center prospective study

OBJECTIVE

To evaluate the usefulness of chromosome microarrays as a second-tier test in prenatal genetic testing.

METHODS

We prospectively analyzed 75 high-risk pregnancies undergoing invasive prenatal genetic testing in which the karyotype either was normal or had findings other than a common non-mosaic autosomal aneuploidy.

RESULTS

Chromosomal microarray analysis (CMA) was performed successfully in all cases. Pathological copy-number variations (CNVs) explaining the phenotypes were found in 11 cases (14.7%). Four cases were detected with an unbalanced translocation. In three of these cases, subsequent genetic analysis demonstrated that a parent was an unknown carrier of a balanced translocation. Among the 67 cases with normal karyo-types, submicroscopic rearrangements with pathological significance were detected in five (7.5%) and CNVs of unclear significance were detected in one (1.5%). CMA was able to discriminate correctly between true mosaicism and confined or pseudomosaicism in all six mosaic cases.

CONCLUSION

CMA is a valuable second-tier test in high-risk pregnancies for which identification or further delineation of genetic aberrations is important. Its higher resolution results in a higher detection rate of aberrant cases, with a clear clinical benefit for estimation of risk of recurrence.

[Occurrence and control of the Clostridium perfringens type A associated diarrhea of the suckling pigs with special consideration of the immunoprophylaxis]

OBJECTIVE

Clostridium (C.) perfringens type A is often associated with diarrhoea in suckling piglets. The impact of the alpha (α) and beta (β)2 toxins on the pathogenesis of the disease has not been conclusively answered. Previously, autologous vaccines were used to control this disease. The aim of our investigation was the classification of C. perfringens strains and the quantitative determination of the α and β2 toxins during the production of autologous vaccines. The efficacy of a commercial vaccine against the C. perfringens type A associated diarrhoea was tested using an animal intoxication model.

MATERIAL AND METHODS

A total of 1,434 C. perfringens strains from piglets with diarrhoea were classified using a multiplex PCR in the first part of the examination. In parallel, the α and β2 toxin content was determined quantitatively using ELISA tests. In the second part of the study 18 gilts were vaccinated twice in the last third of gestation to evaluate the α and β2 toxoid containing C.perfringens type A vaccine (Clostriporc A, IDT Biologika GmbH).

RESULTS

Of the C. perfringens strains which were found, 87.9% were type A ( cpa , cpb2 ), 6.3% type A ( cpa ), and 5.8% type C ( cpa , cpb , cpb2 ). Low to middle a toxin-producing strains often strongly expressed the β2 toxin. The vaccination led to the production of antibodies against the α and β2 toxins, which were transferred to the offspring by colostrum. Piglets were significantly protected (p<0.05) by the antibodies after having been challenged with an α and β2-containing supernatant of a heterologous C. perfringens type A strain.

CONCLUSION AND CLINICAL RELEVANCE

These results underline the importance of α and β2 toxin producing C.perfringens type A strains in diarrhoea in suckling piglets. Using the intoxication model, this vaccine showed significant protective effects against the α and β2 toxins.

Changes in quality of life of patients with lymphedema after lymphatic vessel transplantation

There are multiple treatment options for patients with chronic lymphedema, and one successful approach is lymph vessel transplantation. As quality of life assessments are frequently not utilized in standard treatment regimes, we investigated the change in quality of life for patients with chronic lymphedema (total = 212) who had undergone lymphatic vessel transplantation and conservative therapy for at least 6 months prior to operation. Quality of life was assessed by a modified standard questionnaire examining the physiological and psychological status of the patients. Results document a significant improvement in quality of life and underscore success of autologous lymphatic vessel transplantation as a therapy for lymphedema.

Isolation and characterization of circulating tumor cells from patients with localized and metastatic prostate cancer

Rare circulating tumor cells (CTCs) are present in the blood of patients with metastatic epithelial cancers but have been difficult to measure routinely. We report a quantitative automated imaging system for analysis of prostate CTCs, taking advantage of prostate-specific antigen (PSA), a unique prostate tumor-associated marker. The specificity of PSA staining enabled optimization of criteria for baseline image intensity, morphometric measurements, and integration of multiple signals in a three-dimensional microfluidic device. In a pilot analysis, we detected CTCs in prostate cancer patients with localized disease, before surgical tumor removal in 8 of 19 (42%) patients (range, 38 to 222 CTCs per milliliter). For 6 of the 8 patients with preoperative CTCs, a precipitous postoperative decline (<24 hours) suggests a short half-life for CTCs in the blood circulation. Other patients had persistent CTCs for up to 3 months after prostate removal, suggesting early but transient disseminated tumor deposits. In patients with metastatic prostate cancer, CTCs were detected in 23 of 36 (64%) cases (range, 14 to 5000 CTCs per milliliter). In previously untreated patients followed longitudinally, the numbers of CTCs declined after the initiation of effective therapy. The prostate cancer-specific TMPRSS2-ERG fusion was detectable in RNA extracted from CTCs from 9 of 20 (45%) patients with metastatic disease, and dual staining of captured CTCs for PSA and the cell division marker Ki67 indicated a broad range for the proportion of proliferating cells among CTCs. This method for analysis of CTCs will facilitate the application of noninvasive tumor sampling to direct targeted therapies in advanced prostate cancer and warrants the initiation of long-term clinical studies to test the importance of CTCs in invasive localized disease.

Structure of the Sec23p/24p and Sec13p/31p complexes of COPII

COPII-coated vesicles carry proteins from the endoplasmic reticulum to the Golgi complex. This vesicular transport can be reconstituted by using three cytosolic components containing five proteins: the small GTPase Sar1p, the Sec23p/24p complex, and the Sec13p/Sec31p complex. We have used a combination of biochemistry and electron microscopy to investigate the molecular organization and structure of Sec23p/24p and Sec13p/31p complexes. The three-dimensional reconstruction of Sec23p/24p reveals that it has a bone-shaped structure, (17 nm in length), composed of two similar globular domains, one corresponding to Sec23p and the other to Sec24p. Sec13p/31p is a heterotetramer composed of two copies of Sec13p and two copies of Sec31p. It has an elongated shape, is 28-30 nm in length, and contains five consecutive globular domains linked by relatively flexible joints. Putting together the architecture of these Sec complexes with the interactions between their subunits and the appearance of the coat in COPII-coated vesicles, we present a model for COPII coat organization.

Investigation of the efficacy of a genetically-stabile live Salmonella typhimurium vaccine for use in swine

Hybrid swine (Landrace x Pietrain) aged 3-4 weeks were immunized twice at an interval of 3 weeks solely by the oral route and by the oral/parenteral route to evaluate the efficacy of a live S. Typhimurium vaccine. In each experiment a control group was run without vaccination. The animals were challenged at the age of 8-10 weeks by oral test infection with a labelled S. Typhimurium DT 104 strain. An ELISA was used to establish the presence of antibodies to S. Typhimurium in serum samples, coupled with clinical investigation. The presence of the challenge strain in the ileal and caecal mucosa and in the ileocolic lymph nodes was investigated quantitatively using the Koch plating method to determine the degree of colonization of those organs at the time of slaughter. The clinical course of disease was used to assess the success of vaccination. However, it was not possible to trigger, in a reproducible manner, clinical signs of disease in unvaccinated animals through infection. The vaccinated animals had a significantly lower (p < 0.05) colonization of the ileal and caecal mucosa than the unvaccinated animals. This was also seen to a lesser degree for the ileocolic lymph nodes.

[Effects of prepartum infusion solutions on glucose and bilirubin metabolism of mother and child in the prepartum and postpartum period]

BACKGROUND

Administration of glucose 5% infusion is regularly used in obstetrics. The purpose of the study was to investigate the effects of glucose as compared to xylose and electrolyte solutions on parameters of maternal and fetal glucose and bilirubin metabolism during labour and after delivery.

PATIENTS AND METHODS

53 pregnant women (> or = 37 weeks of gestation, uncomplicated pregnancies) were randomised by entering the delivery ward. Under labour either glucose 5%, xylose 5% or electrolyte infusions were administered. Maternal serum glucose, serum osmolarity, insulin and glucagon were analysed before administration and 20 minutes after delivery. In the newborn blood osmolarity and serum glucose levels were analysed in the umbilical cord directly after birth and in capillary blood samplings 2 hours after birth.

RESULTS

Maternal blood glucose levels 20 min. post partum were significantly different (p < 0.05). Maternal insulin and glucagon concentrations 20 min. pp showed similar trends with glucose levels but were not significantly different. Glucose levels in the umbilical cord were significantly higher in the glucose than in the electrolyte group, but not higher than in the Xylit group. In contrast, the glucose-levels in the newborns after 2 h were significantly higher in the glucose group compared with both other groups. No significant differences were observed in bilirubin levels. Osmolarity in the umbilical cord between groups differed significantly.

CONCLUSIONS AND DISCUSSION

In conclusion, the administration of different solutions showed a distinct influence on the maternal and neonatal glucose metabolism. A significant impact on the bilirubin levels could not be shown in this study.

Psychosocial effects of enhanced external counterpulsation in the angina patient: a second study

Enhanced external counterpulsation (EECP) is a noninvasive technique that has shown promise in the treatment of ischemic coronary artery disease. Patients undergoing EECP were tested for alterations in psychosocial state associated with treatment. Overall perception of health and quality of life improved with EECP. There was also significant improvement in levels of depression, anxiety, and somatization but no change in levels of anger or hostility. On most measures, change was more significant for subjects who showed objective evidence of resolution of ischemia. Given the known predictive relationship between depression and mortality from cardiac disease, the improvement in depression scores through EECP indicates a finding of potential importance that may warrant further study in future research.

Alexander disease: diagnosis with MR imaging

BACKGROUND AND PURPOSE

To date, the demonstration of Rosenthal fibers on brain biopsy or autopsy specimens is considered a prerequisite for a definitive diagnosis of Alexander disease. We initiated a multiinstitutional survey of MR abnormalities in both presumed and confirmed cases of Alexander disease to assess the possibility of an MR-based diagnosis.

METHODS

MR imaging studies in three patients with an autopsy-based diagnosis of Alexander disease were analyzed to define MR criteria for the diagnosis. These criteria were then applied to 217 children with leukoencephalopathy of unknown origin.

RESULTS

Five MR imaging criteria were defined: extensive cerebral white matter changes with frontal predominance, a periventricular rim with high signal on T1-weighted images and low signal on T2-weighted images, abnormalities of basal ganglia and thalami, brain stem abnormalities, and contrast enhancement of particular gray and white matter structures. Four of the five criteria had to be met for an MR imaging-based diagnosis. In a retrospective analysis of the MR studies of the 217 patients, 19 were found who fulfilled these criteria. No other essentially new MR abnormalities were found in these patients. In four of the 19 patients, subsequent histologic confirmation was obtained. The clinical symptomatology was the same in the patients with and without histologic confirmation and correlated well with the MR abnormalities. MR abnormalities were in close agreement with the known histopathologic findings of Alexander disease.

CONCLUSION

The defined criteria are sufficient for an in vivo MR imaging diagnosis of Alexander disease; only in atypical cases is a brain biopsy still necessary for a definitive diagnosis.

[A new live Salmonella enteritidis vaccine for chickens--experimental evidence of its safety and efficacy]

Within the works for the registration of a new live Salmonella Enteritidis vaccine for layers, safety and efficacy of the vaccine strain were tested by experimental studies. After oral administration of the single and the tenfold dose, no incompatibility reactions were seen in day-old chicks. The laying performance and the egg weight were not affected by the vaccination of the chickens during the laying period. There was only a limited period in which the excretion of the vaccine strain and its persistency in organs were seen. Even after the threefold oral vaccination the vaccine strain could not be isolated from eggs and internal organs of slaughtered chickens. Moreover, a high safety for non-target animals (cattle, pigs) could be established. Studies with BALB/c mice proved that a cell-mediated immunity and the development of complement-fixing antibodies is induced by the vaccine. Efficacy studies in target animals were carried out by a proved dependable oral challenge system that reproduces a latent infection with marked S. Enteritidis strains and by means of the seeder-bird method. The test results demonstrate that the vaccination is capable to avert or to reduce an infection significantly.

The p24 proteins are not essential for vesicular transport in Saccharomyces cerevisiae

To investigate the factors involved in the sorting of cargo proteins into COPII endoplasmic reticulum (ER) to Golgi apparatus transport vesicles, we have created a strain of S. cerevisiae (p24Delta8) that lacks all eight members of the p24 family of transmembrane proteins (Emp24p, Erv25p, and Erp1p to Erp6p). The p24 proteins have been implicated in COPI and COPII vesicle formation, cargo protein sorting, and regulation of vesicular transport in eukaryotic cells. We find that p24Delta8 cells grow identically to wild type and show delays of invertase and Gas1p ER-to-Golgi transport identical to those seen in a single Deltaemp24 deletion strain. Thus, p24 proteins do not have an essential function in the secretory pathway. Instead, they may serve as quality control factors to restrict the entry of proteins into COPII vesicles.

Alexander disease--classification revisited and isolation of a neonatal form

Alexander disease is usually classified according to the age of onset, e.g. an infantile form with onset during the first two years of life, a juvenile form with onset in childhood, mainly school age. It has been recognized, however, that the clinical course can be very variable within these groups. Thus, this clinical classification is not a useful predictor of severity and progression of the disease. This is demonstrated here on the basis of the history of seven own patients and a literature review. Only an onset in very early infancy, during the neonatal period, seemed to be associated with a rather uniform pattern of disease course, often leading to early death. This neonatal form showed very stereotyped symptoms, in part different from later onset: Early, often intractable, generalized seizures; hydrocephalus with raised intracranial pressure due to aqueductal stenosis because of pathological astroglia proliferation; lack of developmental progression but without prominent spasticity or ataxia; elevated CSF protein content. This was associated with the well-established neuroradiological findings, e.g. severe white matter affection with fronto-temporal predominance, involvement of basal ganglia and periventricular enhancement as an obligatory symptom. The identification of this early onset form is especially important as seizures and signs of raised intracranial pressure may mislead the diagnosis.

[Heart rate variability--physiology, methods of registration and application in pediatric sleep laboratory]

Heart rate variability (HRV) has become the focus of interest of a multitude of investigations being a parameter that can easily be recorded. Accepted clinical indications in adults include evaluation of diabetic neuropathy and prediction of prognosis after myocardial infarction in adults. In children, HRV is regularly being registered in the pediatric sleep laboratory in sleep related breathing disorders, after apparent life threatening events, or in infants with assumed increased risk for sudden infant death syndrome. However, uniform interpretation criteria have not been established in these situations, at least partially due to insufficient understanding of physiology and pathophysiology of HRV in this age group. In this overview, current knowledge on HRV in infants and children is summarized and its clinical relevance discussed. In addition, technical requirements and methods of analysis which have a major impact on calculated parameters are being presented.

Acute appendicitis in children: comparison of clinical diagnosis with ultrasound and CT imaging

BACKGROUND

There is strong evidence that imaging with ultrasound and CT can be of substantial diagnostic value in the diagnosis of acute appendicitis in children, but there is limited information of the impact of imaging on the management of these patients and its possible effect on surgical findings.

OBJECTIVE

We studied the impact of imaging in the management of acute appendicitis, in particular its effect on the rate of negative appendectomies and perforations.

PATIENTS AND METHODS

We reviewed retrospectively the clinical records and imaging findings of 633 consecutive children and adolescents seen on an emergency basis with clinical suspicion of acute appendicitis. Two hundred seventy patients were operated upon on clinical evidence alone, while 360 were referred for US or CT, and occasionally both, because of doubtful clinical findings.

RESULTS

Acute appendicitis was found in 237 of those on clinical grounds alone, 68 of whom had perforation and related complications. Thus the rate of negative exploration and the rate of perforation were13 % and 29 %, respectively. One hundred eighty-two patients had preoperative US (sensitivity 74 %, specificity 94 %), 119 had CT (sensitivity 84 %, specificity 99 %), and 59 had both US and CT (sensitivity 75 %, specificity 100 %, but often with interpretation at variance with each other). The rate of negative appendectomy and perforation was 8 % and 23 %, respectively, for US, 5 % and 54 % for CT, and 9 % and 71 % when both examinations were performed. There is no statistical significance between the rates of diagnostic performance of US, CT, or their combination, nor between the negative appendectomy rates of each group, but the rate of perforation was significantly higher when CT was performed, alone or after US.

CONCLUSION

The retrospective nature of the study prevents precise definition of the clinical characteristics and selection criteria for diagnostic examinations that may contribute to the management of children with suspected acute appendicitis. It was designed, however, to reflect the diagnostic approach and management of these patients, under the care of many decision makers and interpreters of imaging examinations, prevalent today in most hospital-based clinical practices. It is suggested that imaging increases diagnostic accuracy in difficult cases, but it might be one of the factors increasing the rate of perforations.

The control of necrotic enteritis in sucking piglets by means of a Clostridium perfringens toxoid vaccine

Necrotic enteritis in sucking piglets constitutes a serious problem in piglet rearing units because of the high morbidity and mortality associated with the disease. The primary causal agent is Clostridium perfringens type C. The beta-toxin plays a decisive role in the pathogenesis of this disease. A toxoid vaccine for use in sows has been developed and studied in field trials. The European Pharmacopoeia Monograph on vaccines for use in animals lays down a method of the efficacy testing based on the immunization of rabbits, the collection of pooled sera and the subsequent assay of anti-toxin antibodies in mice using an appropriate test toxin. The vaccine is regarded as effective if it induces a minimum of 10 IU of beta-anti-toxin per ml of rabbit serum. We have established a range of 17.14-98.23 IU beta-anti-toxin per ml rabbit serum induced by a sample of C. perfringens toxoid vaccine. The vaccine has been used under field conditions in different rearing units at the same time, mostly in the form of emergency vaccinations following the outbreak of disease. The outcome of vaccination was evaluated by recording the total numbers of piglets born alive and the piglet losses. Use of the vaccine, coupled with other measures, resulted in an approximately 30% reduction in the number of losses.

Crystal structures of two H-2Db/glycopeptide complexes suggest a molecular basis for CTL cross-reactivity

Two synthetic O-GlcNAc-bearing peptides that elicit H-2Db-restricted glycopeptide-specific cytotoxic T cells (CTL) have been shown to display nonreciprocal patterns of cross-reactivity. Here, we present the crystal structures of the H-2Db glycopeptide complexes to 2.85 A resolution or better. In both cases, the glycan is solvent exposed and available for direct recognition by the T cell receptor (TCR). We have modeled the complex formed between the MHC-glycopeptide complexes and their respective TCRs, showing that a single saccharide residue can be accommodated in the standard TCR-MHC geometry. The models also reveal a possible molecular basis for the observed cross-reactivity patterns of the CTL clones, which appear to be influenced by the length of the CDR3 loop and the nature of the immunizing ligand.

Motilin in human milk: identification and stability during digestion

The presence of motilin in human milk and the influence of human milk on the degradation of [125I][Nle13] porcine motilin by gastric and duodenal fluids were investigated. Milk and plasma samples were collected from 14 mothers, and motilin was measured by radioimmunoassay. Plasma levels were 416 +/- 37 pg/mL. In 8 defatted samples the motilin level was 105 +/- 14 pg/mL, in the six others levels were above 1000 pg/mL but dilution curves were non-linear. After solid-phase extraction milk levels were 108 +/- 21 pg/mL in 13 samples, in 1 sample the dilution curve was still non-linear. The stability of motilin after ingestion was studied in vitro by incubating [121I][Nle13] porcine motilin with gastric and intestinal juices obtained from newborns (10 times diluted). Incubations were performed at 37 degrees C at pH 1.8, 3.2 and 5.8 for the gastric fluid and at pH 7.4 for the duodenal fluid. After different times of intervals (5, 10, 20 and 30 minutes) intact motilin was precipitated with trichloroacetic acid and the radioactivity of the supernatant was determined. Motilin was rapidly degraded by gastric juice. The breakdown was greatest at pH 3.2 (74% after 30 minutes) and lowest at pH 5.8 (29%), the pH after milk feeding in neonates. Degradation by intestinal juice at pH 7.4 was also very rapid (77% after 30 minutes). Human milk and BSA inhibited partially the gastric digestion at pH 3.2 (17 and 29%, respectively). Digestion by intestinal juice was not affected by human milk and BSA. These results suggest that digestion of motilin in the stomach may be sufficiently retarded by human milk in the newborn to exert a biological role.

Nucleation of COPII vesicular coat complex by endoplasmic reticulum to Golgi vesicle SNAREs

Protein trafficking from the endoplasmic reticulum (ER) to the Golgi apparatus involves specific uptake into coat protein complex II (COPII)-coated vesicles of secretory and of vesicle targeting (v-SNARE) proteins. Here, two ER to Golgi v-SNAREs, Bet1p and Bos1p, were shown to interact specifically with Sar1p, Sec23p, and Sec24p, components of the COPII coat, in a guanine nucleotide-dependent fashion. Other v-SNAREs, Sec22p and Ykt6p, might interact more weakly with the COPII coat or interact indirectly by binding to Bet1p or Bos1p. The data suggest that transmembrane proteins can be taken up into COPII vesicles by direct interactions with the coat proteins and may play a structural role in the assembly of the COPII coat complex.

Fast association rates suggest a conformational change in the MHC class I molecule H-2Db upon peptide binding

Major histocompatibility complex (MHC) class I molecules bind peptides in the endoplasmic reticulum (ER). For this binding reaction, when performed in vitro, widely differing association rates have been reported. We have expressed empty soluble H-2Db class I molecules in Chinese hamster ovary (CHO) cells and generated complete sets of association, dissociation, and equilibrium constants of unmodified peptides using tritium-labeled peptides and stopped-flow fluorescence spectroscopy. We find that (i) the transition midpoint of temperature denaturation (Tm) of the protein is shifted from 30.5 to 56 degrees C upon the binding of a high-affinity peptide. (ii) With the peptide SV-324-332 (sequence FAPGNYPAL) at 4 degrees C, the dissociation rate constant of 1.02 x 10(-5) s-1 and an equilibrium constant of 8.5 x 10(7) M-1 predict an association rate constant of 870 M-1 s-1 for a simple one-step model of binding. (iii) In contrast, binding of this peptide proceeds much faster, with 1.4 x 10(6) M-1 s-1. These "mismatch kinetics" suggest that peptide binding occurs in several steps, most likely via a conformational rearrangement of the peptide binding groove. The structure of the peptide-class I complex at the time-point of peptide recognition may therefore be different from the equilibrium crystal structures. (iv) Association of modified peptides, in the presence of detergent, or above the Tm of the empty molecule is considerably slower. This might explain why fast on-rates have not been observed in previous studies.

[Vaccination of pigeons against Salmonella infections]

The efficiency of the live vaccine Zoosal T with a double marker mutant of Salmonella Typhimurium was tested on conditioned pigeons. For challenge infection we used a pigeon specific variation copenhagen strain in a defined state of virulence. The reduction of mortality and the persistence of Salmonella in organs were evaluated. An oral booster enhances the protection due to vaccination.

[From infant nurse to "baby-friendly hospital"--promotion of breast feeding in the University Women's Hospital in Leipzig]

The attitude of medical professionals towards natural infant feeding is decisive in the support of mothers who want to breastfeed. The atmosphere in a "Baby-Friendly Hospital" is determined by the creation of conditions for breastfeeding on demand and for early, undisturbed mother-child contact. At the University Women's Hospital in Leipzig the development of good breastfeeding management was supported by the employment of a "breastfeeding nurse" and enhanced by continuing education for physicians, nurses and midwives in lactation and breastfeeding. In this way comprehensive, uniform information as well as practical guidance important for breastfeeding success were ensured for pregnant and young mothers.

Promoting use of a preferred histamine H2-receptor antagonist in managed care organizations

A program to promote generic cimetidine as the preferred histamine H2-receptor antagonist (HRA) in the managed care organizations (MCOs) served by a pharmacy benefit management company is described. A pharmacy benefit management company conducted a literature review to substantiate the therapeutic equivalence of the HRAs and to set conservative criteria for identifying candidates for conversion to oral cimetidine therapy. During the third quarter of 1994, the prescriber for each patient identified was sent a document listing the patient's current HRA therapy, the date of his or her last prescription refill, and the name and telephone number of the dispensing pharmacy. A letter summarized the literature; outlined the criteria used to identify candidate patients; gave the current indications, dosages, and average wholesale prices of the HRAs; and asked the prescriber to switch the patient to generic cimetidine. HRA use in an MCO that participated in the program was compared with HRA use in a nonparticipating MCO for the second quarter of 1994 (the baseline period), the fourth quarter of 1994, and the first quarter of 1995. The nonparticipating MCO showed no change between baseline and 1995 in the proportion of HRA prescriptions accounted for by brand-name and generic cimetidine combined (14% for each period). The average acquisition cost per HRA prescription remained about $75 for each study quarter. In the participating MCO, the proportion of HRA prescriptions accounted for by brand-name plus generic cimetidine increased from 18% at baseline to 39% in the first quarter of 1995. The average acquisition cost per HRA prescription fell from $71 at baseline to $65 in the first quarter of 1995. A program to shift the use of brand-name HRAs to generic cimetidine in MCOs successfully altered prescribing patterns and reduced expenditures for these agents.

[Periodic breathing with periodic oxygen variation in infancy]

Oxycardiorespirographies, recording arterial oxygen saturation (SaO2), breathing movements, heart rate and ECG with a mean recording time of 22.3 hours, were performed on 85 preterm (mean postconceptional age: 38 weeks) and 81 term infants (mean postconceptional age 42.4 weeks). 83% of the preterm infants showed periodic breathing (PB), in 97% of them this was accompanied by periodic variations of arterial oxygen saturation (PVO). Periodic breathing occurred in 61% of the term infants, 84% of them showed PVO during periodic breathing. The mean variation of oxygen saturation was between 92.8 and 96.8% (+/- 1.7) for preterm and between 92.9 and 96.0% (+/- 2.2) for term infants. In some infants the peak to peak amplitude of the SaO2 cycles was up to 22%, sometimes a further fall of SaO2 occurred. There was a strong correlation of the PVO both at the beginning and end of the episode as well as with the PB-cycle periodicity itself. The fall of the oxygen saturation occurred 3.1 to 7.8 s after the beginning of the first apnea of an episode of periodic breathing, the minimum SaO2 was reached approximately 4.2 to 8.6 s later. This periodic rapid fall of SaO2 from a high oxygenation level cannot be explained by the apneas of a rather short duration during periodic breathing. It is discussed that PVO during periodic breathing may be caused by an ideopathic right to left shunting across fetal circulation pathways which occurs intermittently and periodically. This mechanism could-via patterns of reaction exhibited during the fetal and neonatal time period-lead to acute hypoxemia, as found in apparently life threatening events (ALTE) and as postulated in sudden infant death (SID).

Gender differences in cerebral perfusion in cocaine abuse: technetium-99m-HMPAO SPECT study of drug-abusing women

Cocaine abuse continues to be a major public health concern, with a variety of medical and neurologic sequelae. Previous studies have demonstrated abnormalities in cerebral perfusion in chronic cocaine abusers and after acute administration of cocaine. Although women are becoming increasingly represented among drug abusers, few studies have included women. To the authors' knowledge, none has compared cerebral perfusion in asymptomatic women with that in men.

METHODS

The cerebral perfusion of 13 cocaine-dependent women, 4 of whom were also heroin dependent, was studied with 99mTc hexamethylpropyleneamine oxime (HMPAO) SPECT. These women were compared with 13 cocaine-dependent men and 26 healthy control subjects. Structural brain lesions and neurologic abnormalities were excluded by MRI and neurologic evaluation. Perfusion studies were interpreted in a standardized fashion by reviewers blinded to clinical information.

RESULTS

It was found that cocaine-dependent women were much less likely to have abnormal study findings than cocaine-dependent men (p = 0.003) and were indistinguishable from normal women (p = 1.0). However, the results in both women and men who concurrently used heroin plus cocaine were all abnormal. Perfusion abnormalities tended to be located in anterior brain structures, such as the frontal and temporal cortex and the basal ganglia.

CONCLUSION

These data suggest that cocaine-dependent women have fewer abnormalities in cerebral perfusion than cocaine-dependent men, but that concurrent abuse of heroin and cocaine is associated with more perfusion abnormalities in both sexes.

Disordered communication and grieving in deaf member families

When a deaf child is born to hearing parents, a grieving process is initiated in the parents. Unresolved grieving over their child's deafness often makes it difficult for hearing parents to accept the importance of signing, thus increasing the child's problems--a further source of grief for these parents. Clinical illustrations are provided of (1) the reciprocal relationship between disruption of the mourning process and disturbance of communication between family members, and (2) the transmission of the dysfunctional relationship between hearing parents and deaf children to the subsequent relationship between the deaf children, when they reach adulthood, and their hearing children.

Arthroscopic treatment of synovial impingement of the ankle

Twenty-nine cases of operative arthroscopy of the ankle were done between 1985 and 1989 for synovial impingement of the ankle. The average age of the patients was 37 years. All patients (17 men, 12 women) reported an earlier history of injury, with 24 of the patients (83%) noting chronic ankle pain after an inversion injury and 5 of the patients (17%) reporting a previous ankle fracture. Physical examination elicited anterolateral tenderness at the ankle in all cases with associated anteromedial pain in 4 patients. A demonstrable "click" was evident in 6 of the patients (21%) on forced dorsiflexion of the ankle. All patients failed conservative treatment including physical therapy and nonsteroidal antiinflammatory drugs. Surgery was performed at an average of 36 months postinjury. Ankle arthroscopy revealed extensive hypertrophic synovial thickening and scar tissue anterolaterally, indicating synovial impingement in all patients. Associated chondromalacia of the distal tibia was seen in 21% of the patients. Operative arthroscopy included partial synovectomy and debridement of the hypertrophic tissue and partial shaving chondroplasty of the tibia when indicated. Postoperatively, patients were weightbearing as tolerated. Results were assessed subjectively and objectively. At 25-month followup 26 patients had excellent or good results and 3 had fair results; there were no poor results. There were no major complications, including infection or neurovascular compromise. The 3 patients with associated ankle instability comprised the "fair" result group and eventually required lateral ankle reconstruction. Thus, chronic ankle pain due to synovial impingement can be safely, predictably, and effectively treated by operative ankle arthroscopy.

[Consequences of the composition of human milk for the nutrition of low-birth-weight neonates. III. Sodium and potassium]

The concentrations of sodium and potassium were studied in the 24 hour pooled human milk of 37 mothers delivered preterm (PTM) and of 19 mothers delivered at term (TM) from the second to the eighth postnatal day and in addition in the PTM during the third week of lactation. During the 4th week of life the sodium balance was estimated in 31 very low birth weight infants fed a human milk formula enriched with NaCl (n = 11) or NaH2PO4 (n = 11) and in 9 infants fed the same formula without supplementary sodium. The concentrations of sodium decrease significantly during the first week of lactation. The values are significantly higher in PTM than in TM during the first 3 days but decrease in both milks to values between 1 and 2 mmol/100 ml. The concentrations of potassium increase up to the 4th day of lactation and fall to approximately 1.5 mmol/100 ml at the end of the first week of lactation. There are no differences between PTM and TM. In all three balance groups the sodium balance are positive. But only in the infants fed a sodium-supplemented human milk formula the weight gain was adequate according to the protein and caloric intakes. No signs of a pathological sodium retention could be observed during the balance period. The data suggest that a sodium intake of more than 2.5 mmol/kg/day is necessary for optimal growth. Thus, the phosphorus supplementation should be done generally as 1 mmol NaH2PO4/100 ml human milk in very low birth weight infants.