Abnormalities of the corpus callosum in non-psychotic high-risk offspring of schizophrenia patients

Alterations in the structure of the corpus callosum (CC) have been observed in schizophrenia. Offspring of schizophrenia parents have 10-15 times higher risk for developing schizophrenia. We examined CC volume in offspring at genetic high-risk (HR) subjects. Since the sub-regions of the CC are topographically mapped to cortical brain regions, we hypothesized that HR subjects may show a decrement in total volume and differential volume decreases in sub-regions of the CC. The offspring of schizophrenia parents (HR; n=70; 36 males) and healthy volunteers with no family or personal history of psychotic disorders (healthy controls (HC); n=73; 37 males) matched for age, gender and education were selected for the study. Magnetic resonance images were collected using a GE 1.5 T scanner and processed using FreeSurfer image analysis software. The CC was divided into five neuroanatomically based partitions. The volume of total CC and the five sub-regions were measured blind to clinical information. With covariation for intracranial volume, HR subjects had significantly reduced total CC, more prominently observed in the anterior splenium. An age-related increase in CC volume was found in the anterior and posterior splenium of healthy controls but not in HR subjects. The volume reduction was greater in male than female HR subjects. The volume reduction in the CC may reflect a reduction in axonal fibers crossing the hemispheres and/or myelination between the left and right temporo-parietal cortices. The absence of an age-related volume increase suggests an abnormal developmental trajectory that may underlie susceptibility to schizophrenia.

The value of customised centiles in assessing perinatal mortality risk associated with parity and maternal size

OBJECTIVE

We wanted to compare customised and population standards for defining smallness for gestational age (SGA) in the assessment of perinatal mortality risk associated with parity and maternal size.

DESIGN

Population-based cohort study.

SETTING

Sweden.

POPULATION

Swedish Birth Registry database 1992-1995 with 354 205 complete records.

METHOD

Coefficients were derived and applied to determine SGA by the fully customised method, or by adjustment for fetal sex only, and using the same fetal weight standard.

MAIN OUTCOME MEASURE

Perinatal deaths and rates of small for gestational age (SGA) babies within subgroups stratified by parity, body mass index (BMI) and maternal size within the BMI range of 20.0-24.9.

RESULTS

Perinatal mortality rates (PMR) had a U-shaped distribution in parity groups, increased proportionately with maternal BMI, and had no association with maternal size within the normal BMI range. For each of these subgroups, SGA rates determined by the customised method showed strong association with the PMR. In contrast, SGA based on uncustomised, population-based centiles had poor correlation with perinatal mortality. The increased perinatal mortality risk in pregnancies of obese mothers was associated with an increased risk of SGA using customised centiles, and a decreased risk of SGA using population-based centiles.

CONCLUSION

The use of customised centiles to determine SGA improves the identification of pregnancies which are at increased risk of perinatal death.

Effect of neoadjuvant chemotherapy on oestrogen, progesterone, and HER-2 receptor expression in breast cancer

e11588

Background: Neoadjuvant chemotherapy(NC) is used in treating locally advanced operable breast cancer. After surgery, further adjuvant treatment is offered based on the estrogen receptor (ER), progesterone receptor (PR) and HER2 status. Treatment post operatively can be based on the ER/PR/HER2 status of the core biopsy taken preoperatively. It is not a usual practice in the United Kingdom to repeat these markers on the surgical specimen. However a change in ER/PR or HER2 status following NC could have a profound effect on adjuvant treatment with the real possibility of appropriate therapy being unknowingly withheld. The aim of our study was to determine the percentage of patients whose ER/PR, HER2 receptor expression change with NC and if these changes lead to change in their adjuvant treatment. Methods: This is a retrospective study of 32 patients with locally advanced breast cancer who had NC followed by breast conservation surgery or mastectomy. Quick score (Q score) for ER/PR and the HER2 expression was measured both from the preoperative core biopsy and from the excision specimen following NC. Results: After NC, 5 patients had complete pathological response and 2 patients had residual ductal carcinoma in situ. 25(78%) patients had residual invasive malignancy. Quantitative change in Q scores for ER and PR was seen in 6 patients(24%) and 10 patients (40%) respectively. ER status changed from positive to negative in 1 patient(4%). PR status changed from positive to negative in 4 patients(16%) and from negative to positive in one patient (4%). One patient(4%) changed from HER2 negative to HER2 positive after NC. Conclusions: Change in 1 patient(4%) from HER2 negative to HER2 positive lead to change in adjuvant treatment who would have otherwise not received transzutumab.Q scores changed in 24% and 40% for ER and PR respectively, however, no change was observed with regards to hormonal adjuvant treatment. A study with a bigger cohort might address this issue. We suggest that ER/PR/HER2 status should routinely be checked in both core biopsy sample and also resection specimen.

No significant financial relationships to disclose.

Cerebral palsy and restricted growth status at birth: population-based case-control study

OBJECTIVE

To evaluate the association between growth status at birth and subsequent development of cerebral palsy in preterm and term infants.

DESIGN

Population-based case-controlled study.

SETTING

Cerebral palsy register in Western Sweden. Subjects Cohort of 334 singletons born between 1983 and 1990, with cerebral palsy diagnosed from age 4, and 668 singletons matched for gestation, gender and delivery unit.

METHOD

Growth status at birth was determined using small for gestational age (SGA) categories, with customised birthweight percentiles (SGAcust) based on the Swedish population.

MAIN OUTCOME MEASURES

Proportion of babies that were SGAcust, comparing cases and controls in three gestational age categories: early preterm (24-33 weeks), late preterm (34-36 weeks) and term (37+ weeks).

RESULTS

Of the 334 children with cerebral palsy, 87 (26.6%) were born early preterm, 27 (8.1%) late preterm and 218 (66%) at term. Children who had been born at term were more likely to have been SGA <1st customised percentile (SGAcust1) than their matched controls (OR 6.6, 95% CI 2.3-18.6). In contrast, children with cerebral palsy born preterm were not more likely to have been SGAcust1 (OR 0.9, 95% CI 0.4-1.9), and this applied to early preterm as well as late preterm births. For less severely small babies (SGA between 1st and 5th customised percentiles), the association with cerebral palsy remained significant for term births (OR 5.2, 95% CI 2.7-10.1) but was again not significant for preterm births.

CONCLUSIONS

Term singletons with severely SGA birthweights had a five- to seven-fold risk of developing cerebral palsy compared with gestational age-matched infants with birthweights within normal limits. For children born preterm, SGA was not more likely to be present in cases than in controls. These findings support the concept of cerebral palsy as a multifactorial condition and highlight the importance of antenatal surveillance of fetal growth.

Customized birthweight standards for a Spanish population

OBJECTIVE

To analyse the biological factors affecting birthweight and to derive customized birthweight standards for a Spanish population.

METHODS

A retrospective cohort was created with all the singleton pregnancies delivered at term and free of pathology in our Institution. Birthweight was modeled by multiple linear regression from maternal (ethnic origin, maternal height, booking weight, smoking, and parity), and fetal (gender, gestational age) characteristics.

RESULTS

In addition to gestational age and sex, height, booking weight, ethnic origin, parity, and smoking all have significant and independent effects on birthweight. Women from East-Asia, Morocco and South-America had newborns on average 83 g, 74 g and 95 g heavier than White-European Spanish women. The effect of smoking was found to be dose-related.

CONCLUSION

We found the relative effect of the maternal and fetal characteristics to be very similar to that reported in previous studies. We report coefficients for ethnic groups that account for a sizeable proportion of the population composition of several European countries.

Association of smoking during pregnancy and fetal growth restriction: subgroups of higher susceptibility

OBJECTIVE

To analyze the association between maternal smoking and fetal growth restriction, defined as a failure to achieve the growth potential, and to define subgroups of higher susceptibility for this association.

STUDY DESIGN

A definition of growth restriction by customized birthweight standards applied to 13,661 non-malformed singleton deliveries. Customization was performed by maternal ethnic origin, height, booking weight, parity, gestational age at delivery and fetal gender. The adjusted risk of smoking for customized smallness-for-gestational age and the identification of subgroups with higher susceptibility were assessed by logistic regression.

RESULTS

Overall, the adjusted odds ratio of smoking (all levels of exposure grouped) for the occurrence of growth restriction was 1.9 (95% confidence interval: 1.69-2.13). Smoking was etiologically responsible for 13.9% (95% confidence interval: 11.2-16.5) of the cases of growth restriction occurring in the population. Smoking resulted in an increasingly greater risk of growth restriction with progressive levels of cigarette consumption. The risk of smoking for fetal growth restriction was significantly greater in older women and those with a previous history of spontaneous preterm delivery.

CONCLUSIONS

Smoking is associated with a higher risk for growth restriction. In addition, older pregnant women and those with a previous history of preterm delivery have an increased susceptibility.

Edwardsiella tarda septicemia with underlying multiple liver abscesses

Edwardsiella tarda has recently been described as a member of the family Enterobacteriaceae. The genus Edwardsiella contains three species; E. hoshinae, E. ictaluri and E. tarda. Edwardsiella tarda is the only species which has been recognised as pathogenic to humans, especially in those with an underlying disease. The most common presentation is watery diarrhoea. Extra intestinal infections have been reported infrequently. Humans seem to be infected or colonised with Edwardsiella through ingestion or inoculation of a wound. This report is of a patient with multiple liver abscesses due to E. tarda who later developed bacterial peritonitis and septicaemic shock.

The diagnosis of invasive lobular breast carcinoma. Does MRI have a role?

Invasive lobular breast carcinoma accounts for approximately 15% of all breast cancers and is difficult to detect using conventional breast imaging techniques. We report a comparison between clinical, ultrasound scan (USS), mammographic and magnetic resonance imaging (MRI) of 22 patients with invasive lobular breast carcinomas. Actual tumour size was ascertained by histopathology. MRI detected 21 of the 22 invasive lobular cancers whilst mammography and USS detected 16 and 20 respectively. 19 tumours were clinically palpable. MRI was more accurate at assessing tumour size than USS and clinical examination, both of which underestimated tumour size.

Premenstrual symptomatology, locus of control, anxiety and depression in women with normal menstrual cycles

The present study was designed to investigate the relationships between premenstrual symptomatology, locus of control, anxiety, and depression in women with normal menstrual cycles. Sixty-nine female participants completed a survey, comprised of the Menstrual Distress Questionnaire (MDQ; Moos, 1968), Levenson's (1981) locus of control scales, the Depression Anxiety Stress Scale (DASS; Lovibond and Lovibond, 1995), and a questionnaire constructed by the researchers based on the DSM-IV criteria for Premenstrual Dysphoric Disorder (PMDD). Both overall and specific subtypes of premenstrual symptomatology were found to correlate with external locus of control, anxiety, and depression. In addition, locus of control was found to moderate the relationship between premenstrual symptomatology, anxiety and depression. Finally, women who were in the premenstrual phase when completing the questionnaire scored significantly lower on the internal scale than those in either the follicular or early luteal phases. It was concluded that an external locus of control may be associated with a susceptibility to depression or anxiety when certain premenstrual or postmenstrual changes are experienced.

Breast papilloma: mammogram, ultrasound and MRI appearances

Breast papilloma are difficult to diagnose by triple assessment. Their symptoms, clinical signs and radiological appearances are differing widely. In this paper, we report the symptoms and clinical signs of 35 patients with proven breast papilloma and consider the relative merits of mammography, ultrasound scans and magnetic resonance imaging in their assessment.

Emergence of catatonia during ECT

Emergence of catatonia during electroconvulsive therapy (ECT) is unexpected, as catatonia responds well to ECT. We report four cases with onset of catatonia during ECT. Four inpatients with affective disorders (three without prior catatonia) developed catatonia by Bush-Francis criteria during a course of ECT. All four patients had been taking benzodiazepines, which were stopped 5-15 days before ECT. Two became catatonic after ECT no. 4, one after ECT no. 1, and one after ECT no. 10. The episodes of catatonia resolved promptly with the resumption of benzodiazepines. Two patients completed a course of ECT, whereas two received neuroleptics and/or antidepressants without further ECT. All showed improvements in their affective and psychotic symptoms. The cases illustrate the appearance of catatonia during a course of ECT and suggest recent cessation of benzodiazepines as a risk factor. Benzodiazepines relieve the catatonia, and ECT may be continued.

Primary intraosseous carcinoma of the jaw: pooled analysis of world literature and report of two new cases

Primary intraosseous carcinoma (PIOC) is a rare malignant neoplasm of the jaw. These tumours are believed to arise from the odontogenic epithelium and hence are also referred to as odontogenic carcinoma. A detailed search was made for squamous cell PIOC of the jaw in English literature using Medline Cancer CD. The data obtained were transferred onto dBase software. Two detailed case reports of patients treated at Regional Cancer Centre, Trivandrum during 1996 and 1997 were also included. A pooled analysis was carried out. Survival analysis was carried out using Kaplan-Meier method and log-rank statistics were used for comparing survival. A total of 35 cases were analysed, of which 33 were from published literature. The mean age of the patients at the time of diagnosis was 52.3 years with male to female ratio being 2.5:1. Posterior mandible was the predominant site. The median follow-up time was 28 months. Overall survival at 5 years was 37.8% (95% CI; 14.8-61.0) while the corresponding disease free survival was 29.8% (95% CI; 9.2-54.1). Primary intraosseous carcinoma is a rare tumour of jawbones, characterized by progressive swelling of the jaw, pain and loosening of tooth. The tumour is locally aggressive and metastasizes to regional nodes. The overall and disease free survival is poor with almost 50% patients failing loco-regionally within the first 2 years of follow-up.

Perinatal outcome in SGA births defined by customised versus population-based birthweight standards

OBJECTIVE

To determine whether customised birthweight standard improves the definition of small for gestational age and its association with adverse pregnancy outcomes such as stillbirth, neonatal death, or low Apgar score.

DESIGN

Population based cohort study.

POPULATION

Births in Sweden between 1992-95 (n = 326,377).

METHODS

Risks of stillbirth, neonatal death, and Apgar score under four at five minutes were calculated for the lowest 10% birthweights according to population-based and customised standards, and were compared with the data from the group with birthweights over this limit. Population attributable risks for stillbirth using various birthweight centile cutoffs were calculated for the two standards.

OUTCOME MEASURES

Odds ratios and 95% confidence intervals for stillbirth, neonatal death and Apgar score under four at five minutes, and population attributable risks for stillbirth at different birthweight centiles.

RESULTS

Risks of stillbirth, neonatal death, and Apgar score under four at five minutes and population attributable risks of stillbirth were consistently higher if 'small for gestational age' was classified by a customised rather than by the population-based birthweight standard. Compared with infants who were not small for gestational age by both standards, the odds ratio for stillbirth was 6.1 (95% CI 5.0-7.5) for small for gestational age by customised standard only, whereas it was 1.2 (95 % CI 0.8-1.9) for small for gestational age by population standard only.

CONCLUSIONS

Compared with the population-based birthweight standard, a customised birthweight standard increases identification of fetuses at risk of stillbirth, neonatal death and Apgar score under 4 at 5 minutes, probably due to improved identification of fetal growth restriction.

Mice with a homozygous gene trap vector insertion in mgcRacGAP die during pre-implantation development

In a phenotypic screen in mice using a gene trap approach in embryonic stem cells, we have identified a recessive loss-of-function mutation in the mgcRacGAP gene. Maternal protein is present in the oocyte, and mgcRacGAP gene transcription starts at the four-cell stage and persists throughout mouse pre-implantation development. Total mgcRacGAP deficiency results in pre-implantation lethality. Such E3.5 embryos display a dramatic reduction in cell number, but undergo compaction and form a blastocoel. At E3.0-3.5, binucleated blastomeres in which the nuclei are partially interconnected are frequently observed, suggesting that mgcRacGAP is required for normal mitosis and cytokinesis in the pre-implantation embryo. All homozygous mutant blastocysts fail to grow out on fibronectin-coated substrates, but a fraction of them can still induce decidual swelling in vivo. The mgcRacGAP mRNA expression pattern in post-implantation embryos and adult mouse brain suggests a role in neuronal cells. Our results indicate that mgcRacGAP is essential for the earliest stages of mouse embryogenesis, and add evidence that CYK-4-like proteins also play a role in microtubule-dependent steps in the cytokinesis of vertebrate cells. In addition, the severe phenotype of null embryos indicates that mgcRacGAP is functionally non-redundant and cannot be substituted by other GAPs during early cleavage of the mammalian embryo.

Anterior cruciate ligament rupture: reconstruction surgery and rehabilitation. A nation-wide survey of current practice

A database of the current practice of anterior cruciate ligament (ACL) reconstruction surgery in Great Britain was collated from a postal survey. This survey revealed that clear trends are emerging in the United Kingdom (UK) with regard to ACL reconstruction surgery (such as the type of graft used and timing of surgery) and rehabilitation. Certain issues, however, remain controversial, including bracing and knee range of movement. Clinical outcome measures are consistently used to judge operative success, but few specialists use defined objective measurements such as the IKDC scoring system.

ECT for prolonged catatonia

OBJECTIVE AND BACKGROUND

Electroconvulsive therapy (ECT) is highly effective for acute catatonia but its use in prolonged catatonia is not well established. We report three cases of prolonged catatonia with medical complications or comorbidities treated by ECT.

METHOD

Case reports.

RESULTS

A 24 year-old woman developed fever and autonomic instability after parenteral neuroleptics. Catatonia and autonomic signs persisted for 14 weeks. After minimal improvement from lorazepam, 15 bilateral ECTs led to resolution. A 26-year-old woman with a history of lupus erythematosus, complicated by lupus cerebritis with lesions in the cortex and basal ganglia and a communicating hydrocephalus, was catatonic for 9 weeks. Lorazepam produced marginal improvement. A series of 14 bilateral ECTs led to improved mobility, speech, and interaction, but the response was less robust than Case 1. A 40-year-old man with mental retardation and intermittent psychosis developed severe neuroleptic malignant syndrome and remained catatonic for 4 months. After lorazepam produced minimal improvement, his catatonia resolved with 20 bilateral ECTs.

CONCLUSIONS

ECT may improve prolonged catatonia with complex medical comorbidities, but may require many treatment sessions. Gross cerebral pathology may predict a less robust response. As for acute catatonia, ECT may resolve prolonged catatonia after benzodiazepines have failed.

Can delirium relieve psychosis?

A delirium presages a poor prognosis in hospitalized patients, but an incidental delirium is a feature of some psychiatric treatments. We report five cases in which delirium preceded the relief of affective and psychotic symptoms of a major mental illness. The experience stimulated a review of the literature on delirium in psychiatric treatments. Five inpatients (aged 53 to 69 years) with an exacerbation of chronic mental illness developed deliria from medications (n = 4) and electrolyte disturbance (n = 1). The deliria were managed with medication washout or correction of electrolyte imbalance. The progress of the patients was noted clinically and summarized. The clinical signs of delirium such as confusion, disorganized speech, sleep-wake cycle changes, and hallucinations persisted for 24 to 72 hours. As the delirium cleared, psychotic and affective symptoms improved or resolved. The improvements persisted for 1 to 5 months, with low doses of medications in two of the cases. A delirium may precede clinical improvement in affective and psychotic symptoms. Historically, some treatments for mental illness induce an incidental delirium (e.g., electroconvulsive therapy [ECT] and insulin coma). Why a delirium should presage a beneficial effect on psychosis is unclear, but the emergence of delirium may herald a beneficial pathophysiology.

Intraoperative axillary lymph node assessment in breast cancer

Bedside assessment of axillary lymph node metastases in breast cancer is notoriously inaccurate. The aim of this study was to assess the accuracy of the clinical assessment of the presence of axillary node metastases in patients with breast cancer, both at the bedside and intraoperatively. Intraoperative assessment was significantly more accurate than bedside assessment, having an accuracy of 86%, compared with 66% of bedside clinical assessment. As axillary lymph node involvement is an important prognostic factor in breast cancer, this technique which has a high specificity and far higher sensitivity than bedside clinical assessment and may have a valuable role to play in planning management.

Residual catatonic state following neuroleptic malignant syndrome

Neuroleptic malignant syndrome (NMS) is usually a self-limited disorder, with most cases resolving within 2 weeks after antipsychotic drug discontinuation. However, the course of NMS may not always be short-lived. In this report, the authors describe five patients who developed a residual catatonic state that persisted after acute hyperthermic symptoms of NMS had subsided and compare them with 27 similar cases in the literature. Two of our patients recovered gradually with supportive treatment. Three patients were treated with electroconvulsive therapy (ECT). Of these, two showed a positive response, although one died later of intercurrent pneumonia. A third patient did not respond to ECT, but recovered gradually thereafter. Although dopamine agonists or benzodiazepines have been advocated for the treatment of residual symptoms in previous case reports, ECT was the treatment most often associated with a rapid response and no mortality, even in patients refractory to pharmacotherapy. In conclusion, catatonic and parkinsonian symptoms of NMS may persist as a residual state lasting for weeks to months after more fulminant acute symptoms abate. These residual symptoms may be more likely to develop in patients with pre-existing structural brain disorders. Although patients may improve gradually with supportive care or pharmacotherapy, ECT can often be highly effective in treating the residual catatonic state that follows NMS.

Early pregnancy predictors of preterm birth: the role of a prolonged menstruation-conception interval

OBJECTIVE

To study early pregnancy characteristics as possible risk factors associated with preterm birth.

DESIGN

Retrospective analysis of prospectively collected maternity data.

POPULATION

21,069 singleton deliveries with record of a specified last menstrual period and a midtrimester dating scan.

SETTING

Catchment area of tertiary centre serving a general maternity population.

METHODS

Univariate and multivariate analysis. Variables included: maternal age; height; weight at first visit; parity; ethnic group; cigarette smoking and alcohol consumption recorded in early pregnancy; history of abortion; history of preterm birth; and discrepancy between menstrual dates and ultrasound dates.

MAIN OUTCOME MEASURES

Adjusted odds ratios for factors associated with preterm birth, stratified according to parity (nulliparae vs multiparae) and gestational age (early preterm, 24-33 weeks; late preterm, 34-36 weeks; all preterm, < 37 weeks). Population attributable risk (aetiologic fraction) of the significant variables for preterm birth.

RESULTS

The overall preterm (< 37 weeks) delivery rate according to scan dates was 7 x 0%. Preterm birth was associated with young (< 20 years), short (< or = 155 cm) and underweight (< or = 52 kg) mothers, non-Europeans, cigarette smokers, previous abortion or previous preterm delivery, and a prolonged menstruation-conception interval. Preterm births which followed the spontaneous onset of labour (72%) had results which were similar to the overall group, while there were too few iatrogenic preterm deliveries for separate analysis. Logistic regression showed that associations varied in different parity and gestational age groups. For nulliparae, smoking was not associated with preterm birth, but it was strongly associated with multiparous women (adjusted OR 1 x 8, 95% CI 1 x 6-2 x 1). A past history of premature delivery had the highest risk for birth before 34 weeks in the index pregnancy (adjusted OR 5 x 1, 95% CI 3 x 4-7 x 6). A discrepancy between menstrual and scan dates of greater than +7 days, suggestive of a prolonged interval between last menstruation and conception, was present in 23 x 3% of all pregnancies, and was associated with an increased risk of preterm delivery in all gestational age categories for nulliparae (adjusted OR 1 x 5, 95% CI 1 x 3-1 x 8) and multiparae (adjusted OR 1 x 9, 95% CI 1 x 6-2 x 2). Because of its high prevalence, this variable constituted a relatively high population-attributable risk for premature birth for both nulliparae (10 x 7%) and multiparae (16 x 6%).

CONCLUSIONS

A discrepancy of more than +7 days between menstrual and scan dates, indicating a prolonged interval between last menstruation and conception, is a significant predictor of preterm birth. This effect is independent of other factors such as maternal age, height, weight and smoking which are also associated with prematurity. In a maternity population with ultrasound scan dates and recorded last menstrual period, this variable can be easily calculated and used as a marker for increased surveillance.

Customized fetal weight limits for antenatal detection of fetal growth restriction

OBJECTIVE

To define cut-off limits for individually adjustable fetal weight standards for the detection of intrauterine growth restriction.

DESIGN

Retrospective study, with the outcome measures small-for-gestational age (SGA) birth weight, operative delivery for fetal distress, umbilical artery pH < 7.15, and admission to the neonatal intensive care unit.

SUBJECTS AND METHODS

Two hundred and fifteen women considered to be at increased risk of uteroplacental insufficiency were recruited to a study of serial ultrasound scans. Fetal weights were derived using standard formulae and, retrospectively, weight percentiles were calculated after individual adjustment for maternal height, weight in early pregnancy, ethnic group, parity and fetal sex.

INTRODUCTION

One or more antenatal scans indicative of fetal weight below the 10th customized percentile were predictive for a SGA neonate at birth (P < 0.001), operative delivery for fetal distress (P < 0.01) and admission to neonatal intensive care (P < 0.01) but not for a low umbilical artery pH (P = 0.6). Receiver-operator curves showed the optimal customized fetal weight percentile limit for predicting an SGA neonate to be the 18th percentile (sensitivity 83%, specificity 79%, positive predictive value 63% and negative predictive value 92%). For the prediction of operative delivery for fetal distress and admission to neonatal intensive care, the optional customized cut-off value was the 8th percentile.

CONCLUSIONS

The assessment of fetal weight using ultrasound and an individually-adjusted standard is predictive of growth restriction and perinatal events associated with hypoxia or diminished reserve. The optimal cut-off value for predicting operative delivery for fetal distress or admission to the neonatal intensive care unit suggests that the 10th customized percentile is a good limit for clinical use.

Catatonic signs in neuroleptic malignant syndrome

The study assessed catatonic signs in neuroleptic malignant syndrome (NMS). Records of inpatients meeting both stringent research criteria and DSM-IV criteria (n = 11) or only DSM-IV criteria (n = 5) for NMS were identified. The records were systematically rated on a 23-item rating scale for the presence of catatonic signs. Scores for NMS severity were related to the number of catatonic signs. Fifteen patients met both research criteria for catatonia and DSM-IV motor criteria for organic catatonia. The severity scores of NMS correlated with the number of catatonic signs (Spearman rho = +.71, P < .005). We conclude that multiple catatonic signs are present in NMS and the severity of NMS predicts the number of catatonic signs.

Respiratory diphtheria in three paediatric patients

From August till November 1998, the Paediatric and Anaesthetic Units of Hospital Kuala Terengganu managed three patients from Kuala Terengganu District who were ventilated for respiratory diphtheria. Their ages were 5, 4 and 7 years old and their immunisation for diphtheria were not complete. All three patients presented with respiratory distress and were ventilated for upper airway obstruction. Their treatment included intravenous penicillin and diphtheria antitoxin. One patient died of cardiogenic shock with secondary pneumonia. Pharyngeal and tonsillar swabs of all three patients grew toxigenic Corynebacterium diphtheriae biotype mitis. There were 765 throat cultures taken from contacts. The confirmed positive cultures grew 2 toxigenic and 3 non-toxigenic Corynebacterium diphtheriae biotype mitis and surprisingly, 10 non-toxigenic biotype gravis. A prevalence study is needed to document the endemicity of diphtheria in Kuala Terengganu and to determine the carrier rate of both biotypes. Steps have been taken to increase the immunisation coverage in children. The giving of regular booster doses of diphtheria toxoid to the adult population should be considered.

Over a decade of experience with a yeast recombinant hepatitis B vaccine

Experience with the yeast recombinant hepatitis B vaccine Engerix-B now exceeds 10 years. We reviewed published studies on this vaccine. These show the vaccine to be safe, causing mostly only minor local symptoms and to be highly immunogenic both in monitored clinical trials and under field conditions. Engerix-B consistently elicits high geometric mean antibody titres and a high protective efficacy has been established in three groups at high-risk of hepatitis B infection, homosexual men, institutionalised mentally handicapped subjects and neonates of chronic carrier mothers. The profile of the recombinant hepatitis B vaccine in certain high-risk groups and immuno compromised people is discussed. Finally we present updated post marketing surveillance data based on 496 million distributed doses of vaccine.

Neuregulins and ErbB receptors in cultured neonatal astrocytes

Neuregulins (NRGs) are a family of growth factors involved in signaling between neurons and glial cells of the peripheral and central nervous system. NRGs are synthesized and secreted by a number of cell types including Schwann cells, neurons, and oligodendrocytes. NRG transduction signals are mediated by the erbB family of receptor tyrosine kinases. These NRGs may be important for paracrine or autocrine signaling during development, injury, and the normal functioning of the central nervous system. In this study, we characterize the NRGs and erbB receptors expressed by cultured neonatal rat astrocytes. Using immunoblotting protocols with pan-specific antibodies, we identified eleven NRG molecular weight isoforms from approximately 16 kDa to 105 kDa in cultured neonatal rat astrocytes. Immunocyotchemistry with isoform-specific antibodies revealed the expression of both major isoform families (NRGalpha, NRGbeta). Additionally, astrocyte-conditioned media contained two molecular weight isoforms of NRGs. We detected mRNA expression of NRGalpha and NRGbeta in astrocytes by amplifying mRNA transcripts with reverse transcription polymerase chain reaction. Furthermore, we confirm that cultured astrocytes express all four erbB receptors as detected by immunocytochemical and immunoblotting techniques. These data indicate that astrocytes contain and secrete NRGs.

Amino acid substitutions reveal distinct functions of serine 186 of the ZEBRA protein in activation of early lytic cycle genes and synergy with the Epstein-Barr virus R transactivator

The ZEBRA protein mediates the switch between the latent and lytic life cycles of Epstein-Barr virus. Z(S186A), a point mutant in ZEBRA's basic domain in which serine 186 is changed to alanine, is unable to induce expression of lytic cycle mRNAs or proteins from the latent EBV genome even though it retains the ability to activate transcription from reporters bearing known ZEBRA-responsive promoters (A. L. Francis et al., J. Virol. 71:3054-3061, 1997). We now describe three distinct phenotypes of ZEBRA mutants bearing different amino acid substitutions at S186. These phenotypes are based on the capacity of the mutants to activate expression of the BRLF1 and BMRF1 genes, which are targets of ZEBRA's action, and to synergize with the BRLF1 gene product Rta (R transactivator) in activating expression of downstream genes. One mutant class, represented by Z(S186T), was similar to the wild type, although reduced in the capacity to activate BRLF1 and BMRF1 early lytic cycle genes from the latent virus. A second class, represented by Z(S186C) and Z(S186G), was impaired in transcriptional activation, unable to activate early lytic cycle products from the latent virus, and not rescued by overexpression of Rta. A third class, Z(S186A), although unable by itself to activate BRLF1 or other lytic cycle genes, synergized with Rta. Rta rescued the capacity of Z(S186A) to activate the BMRF1 early lytic cycle gene from the latent virus. All mutant classes bound to DNA in vitro, although their capacity to bind to different ZEBRA response elements varied. Serine 186 of ZEBRA is a critical residue that is required for the distinct activities of induction of BRLF1 expression and for synergy with Rta. Since only Z(S186T) among the mutants behaved similarly to the wild type, activation of BRLF1 likely requires phosphorylation of S186. However, since Z(S186A) could synergize with Rta, synergy with Rta does not appear to be dependent on phosphorylation of S186. S186 likely mediates DNA recognition on the BRLF1 promoter in the context of the latent virus, protein-protein interactions, or both. The Z(S186) mutants define the amino acid side chains required for these functions.

Controlled trial of fundal height measurement plotted on customised antenatal growth charts

OBJECTIVE

The purpose of this study was to evaluate the effect of a policy of standard antenatal care which included plotting fundal height measurements on customised antenatal charts in the community.

DESIGN

Prospective, non-randomised, controlled, population-based study.

POPULATION

Two defined and separate referral areas from community to teaching hospital, with similar delivery rates and socioeconomic characteristics. A total of 1272 consecutively booked women with singleton pregnancies and dating ultrasound scans before 22 weeks of gestation.

INTERVENTION

In the study area customised fundal height charts were issued to each mother at the routine hospital booking scan, on which regular fundal height measurements were to be plotted by community midwives. The charts adjusted limits according to maternal characteristics including height, weight, parity and ethnic group. Usual management in the control area included fundal height assessment by abdominal palpation and recording on a standard co-operation card.

OUTCOME MEASURES

Antenatal detection of small and large for gestational age babies; number of antenatal investigations for fetal growth in each group.

RESULTS

The study group had a significantly higher antenatal detection rate of small for gestational age babies (48% vs 29%, odds ratio 2.2, 95% confidence interval 1.1-4.5) and large for gestational age babies (46% vs 24%, OR 2.6, CI 1.3-5.5). There was no increase in the study group in the overall number of scans per pregnancy done in the ultrasound department (1.2 vs 1.3, P = 0.14), but a slight decrease in repeat (two or more) third trimester scans (OR 0.8, CI 0.6-1.0, P = 0.08). Women in the study group had significantly fewer referrals for investigation in a pregnancy assessment centre (OR 0.7, CI 0.5-0.9; P = 0.01) and fewer admissions to the antenatal ward (OR 0.6, CI 0.4-0.7, P < 0.001). There were no differences in perinatal outcome.

CONCLUSIONS

Serial measurement of fundal height plotted on customised charts leads to increased antenatal detection of small and large babies. This is accompanied by fewer investigations, which is likely to represent increased confidence in the community to recognise normal fetal growth. With adjustments for physiological variables, fundal height measurements appear to be a cost effective screening method which can result in substantial improvements in the antenatal assessment of fetal growth.

Fetal growth rate and adverse perinatal events

OBJECTIVE

To study fetal weight gain and its association with adverse perinatal events in a serially scanned high-risk population.

SUBJECTS AND METHODS

A total of 200 pregnant women considered at increased risk of uteroplacental insufficiency had a total of 1140 scans in the third trimester, with a median of six scans in each pregnancy. The average fetal growth rate was retrospectively calculated for the last 6 weeks to birth, and expressed as daily weight gain in grams per day. Adverse pregnancy outcome was defined as operative delivery for fetal distress, acidotic umbilical artery pH (< 7.15), or admission to the neonatal intensive care unit (NICU).

RESULTS

Fetuses with normal outcome in this high-risk pregnancy population had an average antenatal growth rate of 24.2 g/day. Compared to pregnancies with normal outcome, the growth rate was slower in those that required operative delivery for fetal distress (20.9 g/day, p < 0.05) and those that required admission to the NICU (20.3 g/day, p < 0.05). The growth rate in pregnancies resulting in acidotic umbilical artery pH also seemed lower, but this did not reach statistical significance.

CONCLUSIONS

Impaired fetal weight gain prior to birth is associated with adverse perinatal events suggestive of growth failure.

Hereditary breast cancer

Popliteal vein reflux reduces the healing of chronic venous ulcer

S. G. Darke, Vascular Surgery Department, Royal Bournemouth Hospital, Castle Lane East, Bournemouth BH7 7DW, UK

Predicting changes in the distribution of sweating following thoracoscopic sympathectomy

J. Collin, Nuffield Department of Surgery, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK

Author's reply J. A. Rennie, Academic Department of Surgery, King's College Hospital, Denmark Hill, London SE5 9RS, UK

Hereditary breast cancer

G. J. Hicken, A. Francis, S. A. Harries, Department of Surgery, Warwick Hospital, Lakin Road, Warwick CV34 5BW, UK

Laparoscopy for the impalpable testis

P. F. Jones, G. G. Youngson, Department of Surgery, Royal Aberdeen Children's Hospital, Cornhill Road, Aberdeen AB9 2ZG, UK

Helicobacter pylori and peptic ulcer surgery

I. L. P. Beales, Department of Gastroenterology, West Norwich Hospital, Bowthorpe Road, Norwich NR2 3TU, UK

Early effect of carotid endarterectomy on arterial blood pressure measured with an ambulatory monitor

S. L. Drinkwater, G. Stansby, H. H. G. Eastcott, Department of Surgery, St Mary's Hospital, Praed Street, London W2 1NY, UK

Author's reply S. R. Dodds, A. D. B. Chant, Department of Surgery, E Level, West Wing, Southampton General Hospital, Tremona Road, Southampton SO16 9YD, UK

Neuregulins in glial cells

The role of growth factors in controlling the development of glial cells in both the peripheral and central nervous systems has been investigated for a number of years. The recent discovery of a new family of growth factors termed the neuregulins (NRGs) has led to an explosion of information concerning the putative role of these growth factors in the development of Schwann cells (SC), oligodendrocytes (OLG), and astrocytes. Many of these previous studies have focused on the effects of exogenous NRGs on glial cell development and differentiation. We now review the evidence that these glial cells themselves produce NRGs and discuss the major implications of these findings with respect to glial cell development and diseases which affect glial cell function. We also discuss the potential role of endogenous NRGs following neural injury.

Tissues of MSH2-deficient mice demonstrate hypermutability on exposure to a DNA methylating agent

The mutational response of mismatch repair-deficient animals to the alkylating agent N-methyl-N-nitrosourea was evaluated by using a transgenic lacI reporter system. Although the mutations detected in MSH2 heterozygotes were similar to those of controls, MSH2-/- animals demonstrated striking increases in mutation frequency in response to this agent. G:C to A:T transitions at GpG sites, as opposed to CpG sites, dominated the mutational spectrum of both MSH2+/+ and MSH2-/- N-methyl-N-nitrosourea -treated animals. Extrapolating to humans with hereditary non-polyposis colorectal cancer, the results suggest that MSH2 heterozygotes are unlikely to be at increased risk of mutation, even when exposed to potent DNA methylating agents. In contrast, mismatch repair-deficient cells spontaneously arising within individuals with hereditary non-polyposis colorectal cancer would likely exhibit hypermutability in response to such mutagens, an outcome predicted to accelerate the pace of tumorigenesis.

Fetal weight gain in a serially scanned high-risk population

Physiological as well as pathological variables influence fetal growth. This study was undertaken to assess the influence of physiological variables on fetal weight gain in a high-risk population with normal outcome. A total of 121 pregnancies had 3-13 (median 8) ultrasound scans in the third trimester. Estimated fetal weight was calculated according to standard formulae. The estimated fetal weight at 30, 34 and 38 weeks and growth per day in the last 2 weeks prior to delivery were calculated and compared between subgroups defined on physiological characteristics, such as maternal height, maternal weight, parity and fetal sex. There were differences in growth curves for each of the physiological parameters studied. Maternal height and weight were significantly related to the estimated fetal weight throughout the third trimester but there were no significant differences in growth per day in the last 2 weeks before birth. In contrast, subgroups defined by parity and fetal sex did not show significant fetal weight differences in the third trimester, but the daily growth rate prior to birth was significantly higher for multiparae and male fetuses. Physiological factors affect fetal weight gain and need to be taken into account when fetal growth is monitored in high-risk pregnancies.

Catatonia and other motor syndromes in a chronically hospitalized psychiatric population

BACKGROUND

To determine the motor characteristics of chronic catatonia, catatonia and other motor disorders were systematically rated in a long-term hospitalized sample.

METHOD

Chronically hospitalized psychiatric inpatients (N = 42) with a clinical diagnosis of catatonic schizophrenia (295.2X) were rated for catatonia with a novel 23-item catatonia rating scale, and for parkinsonism, dyskinesia and akathisia using standard rating scales with scale-based criteria for case definition.

RESULTS

Catatonia was the sole motor syndrome in nine cases (21%), co-existed with parkinsonism in five (12%), tardive dyskinesia in four (10%), and both parkinsonism and tardive dyskinesia in 10 (24%). There was no correlation between total scores across the four rating scales. 'Rigidity' was the sole catatonic sign which overlapped with other scales. The symptom profile of catatonia in this chronic sample was similar to previous reports based on acutely ill patients.

CONCLUSION

Catatonia is distinguishable from other motor disorders in chronic psychiatric patients using the 23-item catatonia rating scale. The features of chronic catatonia are described, and the distribution of catatonic signs is similar for chronic and acute catatonia.