The Misgav Ladach method for cesarean section: method description

SUBJECT

A method description is given for the Misgav Ladach method for cesarean section. This is based on the Joel-Cohen incision originally introduced for hysterectomy.

METHOD

The incision is a straight transverse incision somewhat higher than the Pfannenstiel incision. The subcutaneous tissue is left undisturbed apart from the midline. The rectus sheath is separated along its fibres. The rectus muscles are separated by pulling. The peritoneum is opened by stretching with index fingers. The uterus is opened with an index finger and the hole enlarged between the index finger of one hand and the thumb on the other. The uterus is closed with a one-layer continuous locking stitch. The visceral and parietal peritoneal layers are left open. The rectus muscle is not stitched. The rectus sheath is stitched with a continuous non-locking stitch. The skin is closed with two or three mattress sutures. The space in between is apposed with non-traumatic forceps for 5 minutes.

RESULTS

The basic philosophy is to work in harmony with the body's anatomy and physiology and not against them. The method is restrictive in the use of sharp instruments, preferring manual manipulation.

CONCLUSION

The method gives quicker recovery, less use of post-operative antibiotics, antifebrile medicines and analgesics. There is a shorter anesthetic and shorter working time for the operative team. It is suitable for both emergency and planned operations.

At least three genes account for familial papillary thyroid carcinoma: TCO and MNG1 excluded as susceptibility loci from a large Tasmanian family

Recent studies have mapped two susceptibility loci which appear to account for familial multinodular goitre (MNG1) and a variant of familial papillary thyroid cancer (PTC), with associated multinodular goitre (TCO). A Tasmanian family (Tas1) has been identified with an autosomal dominant form of PTC. This study has examined the MNG1 and TCO loci to determine if they are similarly predisposing the Tas1 family to PTC. Linkage analysis using identical microsatellite markers described in the two previous studies was used to determine the significance of these loci in the Tasmanian family. The resultant LOD scores were sufficiently negative using multipoint parametric analysis to exclude these two loci from involvement in the Tasmanian family. In addition, six candidate genes, RET, TRK, MET, TSHR, APC and PTEN were also excluded as susceptibility genes in Tas1 by using microsatellites that are positioned in or in close proximity to these genes. These results suggest that there are at least three susceptibility genes that predispose families to familial PTC.

Genetic heterogeneity in familial nonmedullary thyroid carcinoma: exclusion of linkage to RET, MNG1, and TCO in 56 families. NMTC Consortium

Epidemiological studies show a very high relative risk for first degree relatives of probands with thyroid cancer. The familial form of nonmedullary thyroid carcinoma (NMTC) gives a more severe phenotype and appears earlier than its sporadic counterpart. Moreover, benign thyroid pathologies are often observed in NMTC kindreds. Little is known about the genetic risk factors of the disease. To study them, an international consortium has been organized at the International Agency for Research on Cancer over the past 2 yr to collect biological samples from NMTC families. The only genes known to be directly involved in susceptibility to NMTC are MNG1 on chromosome 14q32 and TCO on chromosome 19q13.2, previously localized by us and others. In addition to those two genes, the genes for Cowden's syndrome and familial adenomatous polyposis are associated with thyroid cancer, but not as an indicative phenotype. Another important gene in thyroid carcinogenesis is RET, which is mutated in the majority of cases of hereditary medullary thyroid cancer and rearranged in an important fraction of sporadic cases of NMTC. Here we report the result of a linkage analysis performed on the 56 more informative kindreds we have collected through the international consortium. Linkage analysis using both parametric and nonparametric methods excluded MNG1, TCO, and RET as major genes of susceptibility to NMTC and demonstrated that this trait is characterized by genetic heterogeneity.

EVI2B, a gene lying in an intron of the neurofibromatosis type 1 (NF1) gene, is as the NF1 gene involved in differentiation of melanocytes and keratinocytes and is overexpressed in cells derived from NF1 neurofibromas

The EVI2B gene is one of three genes embedded in intron 27b of the neurofibromatosis type 1 (NF1; M. Recklinghausen) gene, which are transcribed in the direction opposite that of the NF1 gene. The function of EVI2B and its relation to NF1 symptoms is unknown. Here, the amounts of NF1 and EVI2B mRNA were investigated in detail in cells involved in NF1 manifestations as café-au-lait macules and neurofibromas. These investigations showed that aside from the NF1 gene, EVI2B is involved in melanocyte and keratinocyte differentiation. Whereas in NF1 melanocytes from café-au-lait macules, EVI2B expression was not altered, in fibroblast-like cells derived from neurofibromas, an increased level of EVI2B mRNA was found. We investigated whether this increase was attributable to an influence of NF1 gene expression on the expression of the EVI2B gene, as suggested by the fact that the EVI2B primary transcript is antisense to the NF1 primary transcript. Investigations of cells derived from patients with different amounts of NF1 pre-mRNA showed no correlation between the amount of NF1 pre-mRNA and the increased level of EVI2B mRNA.

[Operative laparoscopy in pregnancy]

The development of laparoscopic surgery in gynecology and general surgery has greatly advanced over the past decade, and recently has been successfully performed in pregnancy. In the English literature we found that of the 518 cases reported (mean age 32 years) the most common was for cholecystectomy (45%), followed by operations on the adnexae (34%), appendectomy (15%) and others (6%). To these we add 3 cases of cholecystectomy and 1 of an adnexal tumor. Of all the reported cases, 33% were performed in the 1st trimester, 56% in the 2nd and 11% in the 3rd. This review demonstrates a definite trend to laparoscopy in pregnancy. It appears to be safe when performed by experienced surgeons, but further studies addressing safety of laparoscopic surgery during pregnancy are needed to reach definitive conclusions.

Immunocytochemically detected free peritoneal tumour cells (FPTC) are a strong prognostic factor in gastric carcinoma

We prospectively investigated the prognostic significance of free peritoneal tumour cells (FPTC) in a series of 118 patients with completely resected gastric carcinoma. Immunocytochemistry with the monoclonal antibody Ber-Ep4 was performed on cytospins from intraoperative peritoneal lavage specimens. Twenty-three patients (20%) had FPTC which was significantly correlated with pT and pN categories, stage, tumour size, lymphatic invasion, Laurèn and WHO classifications and perigastric adipose tissue metastases. The median survival time for all FPTC positive compared with negative patients was significantly shorter (11 compared with >72 months), with estimated 5-year survival rates of 8% vs. 60%. None of the patients with FPTC had an early gastric cancer. In advanced tumour subgroups without and with serosal invasion (n = 59 and 35), there were 19% and 34% with FPTC. Multivariate survival analysis showed nodal status, FPTC, mesenteric lymphangiosis, and lymph node metastasis to the compartment III to be independent prognostic factors with relative risks of 6.6, 4.5, 2.9 and 2.2 respectively. Recurrent disease occurred in 91% of FPTC-positive and in 38% of FPTC-negative patients. FPTC had a positive predictive value of 91% and a specificity of 97% for tumour recurrence. FPTC is a strong negative, independent prognostic indicator for survival in gastric carcinoma.

Analysis of umbilical artery flow parameters during fetal variable decelerations using computerized Doppler waveforms

Umbilical artery velocity waves were obtained by Doppler ultrasonography before, during, and after 20 episodes of fetal heart rate (FHR) variable decelerations (VD) during the active stage of labor in 8 women. During 50% of the VD periods, the umbilical artery resistance flow parameters increased significantly (p < 0.01). The increase in resistance preceded the decrease in FHR in six episodes (30%) of VD (AR-VD group; arterial resistance VD) and did not precede the change in FHR in another ten episodes (50%) of VD (VR-VD group; venous resistance VD). In the AR-VD group the FHR accelerations occurred before the decelerations in only 1 case (17%), while in the VR-VD group FHR accelerations preceded the decelerations in 8 out of the 10 episodes (80%). Using these Doppler studies, it may be possible to differentiate between two groups of VD: AR-VD - which are caused by umbilical artery occlusion and thus preceded by a measurable increase in umbilical artery resistance - and VR-VD - which are not preceded by a measurable increase in umbilical artery resistance and may be caused by fetal hypoxia.

Determination of proteins, phosphatidylethanolamine, and phosphatidylserine in organic solvent extracts of tissue material by analysis of phenylthiocarbamyl derivatives

Amino acid analysis of organic solvent extracts of tissue material has been evaluated for determination of protein content. Conventional ninhydrin-based analysis does not allow determination of a large number of lipid-rich samples. Therefore, the hydrolyzed samples were treated with phenylisothiocyanate and the phenylthiocarbamyl (PTC) derivatives obtained were separated by reverse-phase HPLC. With this method, analysis of many lipid-rich samples is feasible. In addition, phosphatidylethanolamine and phosphatidylserine can then be determined together with the amino acid constituents. The PTC/reverse-phase HPLC method was used for analysis of chloroform/methanol extracts of spinal cord, lung, and bile after chromatography on Lipidex 5000 in methanol/ethylene chloride, 4:1 (v/v). The chromatography profiles show that in all tissue samples the proteins elute before the phospholipids. Consequently, a single step of Lipidex 5000 chromatography can be used to purify polypeptides present in organic solvent extracts. Using pulmonary surfactant extracts (with about 98% phospholipids and 1-2% proteins), we find that individual contents of surfactant proteins B and C can be determined by amino acid analysis.

A new candidate region for the positional cloning of the XLP gene

X-linked lymphoproliferative disease (XLP) is an inherited immunodeficiency characterised by selective susceptibility to Epstein-Barr virus and frequent association with malignant lymphomas chiefly located in the ileocecal region, liver, kidney and CNS. Taking advantage of a large bacterial clone contig, we obtained a genomic sequence of 197620 bp encompassing a deletion (XLP-D) of 116 kb in an XLP family, whose breakpoints were identified. The study of potential exons from this region in 40 unrelated XLP patients did not reveal any mutation. To define the critical region for XLP and investigate the role of the XLP-D deletion, detailed haplotypes in a region of approximately 20 cM were reconstructed in a total of 87 individuals from 7 families with recurrence of XLP. Two recombination events in a North American family and a new microdeletion (XLP-G) in an Italian family indicate that the XLP gene maps in the interval between DXS1001 and DXS8057, approximately 800 kb centromeric to the previously reported familial microdeletion XLP-D.

Strong prognostic impact of tumor-associated urokinase-type plasminogen activator in completely resected adenocarcinoma of the esophagus

The serine protease system has been shown to play an important role in the invasive potential of a variety of tumors. To date, however, there are little data about the expression of these proteases in esophageal carcinoma. To determine the level of expression and the significance of urokinase-type plasminogen activator (uPA) and its plasminogen activator inhibitor type 1 (PAI-1) in adenocarcinoma of the esophagus, we studied 54 tumor cases and a control group of normal gastric mucosa cases with ELISA using detergent-extracted samples. uPA and PAI-1 were significantly elevated as compared to control tissue by factors of 16 and 14, respectively. Median levels of both uPA and PAI-1 showed significant correlation with tumor pT, pN, and pM categories, whereas the presence of lymphatic invasion correlated only with the uPA content and tumor grade correlated only with PAI-1 content. Using maximally selected statistics, a cutoff value was found for uPA (2.85 ng/mg protein) but not for PAI-1, which divided the study group into significantly poorer and better survival subgroups. By univariate analysis, depth of tumor invasion (pT), lymph node involvement (pN), number of involved lymph nodes, lymph node ratio, distant nodal metastases [pM1(Iym)], lymphatic invasion, and uPA showed significant correlations with patient survival. By multivariate analysis, uPA (first rank), pN, and pM (lym) were identified as independent prognostic factors, with relative risks of 8.4, 4.1, and 4.3, respectively. In a second survival analysis method, a prognostic model was developed using classification and regression trees analysis, in which a significant difference among three patient survival groups was distinguished using the variables "number of involved lymph nodes" and "uPA content." In summary, tumor uPA content as determined by ELISA appears to be a powerful, independent prognostic factor for survival in adenocarcinoma of the esophagus.

Dose-effect relationship of idebenone in an experimental cerebral deficit model. Pilot study in healthy young volunteers with piracetam as reference drug

Within a general cerebral deficit model--inspiratory hypoxia-the dose--effect relationship of idebenone (CAS 58186-27-9), an antioxidant, was studied with regard to selected electrophysiological and psychometric parameters. Seventeen healthy male volunteers (mean age = 32 years, mean BW = 75 kg) received three different oral medications: placebo, idebenone and piracetam (CAS 7491-74-9) as reference. The test drug idebenone was administered in five different dosages, ranging--in 60 mg steps--from 60 to 300 mg t.id. Piracetam was given at a dose level of 800 mg t.i.d. A strict dose-regimen was used in idebenone for safety reasons. Each dosage/medication--except idebenone 300 mg t.i.d.--was given for one week without washouts in between. On each 7th treatment day, pharmacodynamic assessments comprising electroretinography (ERG), auditory evoked potentials (AEP) and visual analogue scales (VAS) were run. Immediately after the phases with the lower dosages, the study was continued with the highest dosage of idebenone (300 mg t.i.d.) for a period of four weeks with pharmacodynamic assessments on the 7th, 14th and 28th day. In this pilot study, the target variable, the amplitude of the ERG b-wave indicated a definite antihypoxidotic effect after the highest dosage of idebenone. With 300 mg idebenone t.i.d., ERG b-wave amplitudes increased linearily with increasing duration of treatment. The 'central' AEP P2-amplitude demonstrated a different dose-effect relationship. AEP P2-amplitudes increased with increasing dosages of idebenone. The prolongation of treatment with 300 mg t.i.d. resulted in no further improvement of this parameter (ceiling effect). Subjective ratings (VAS) by the volunteers confirmed the results seen in electrophysiological variables. The findings, however, remain to be confirmed within an adequate double-blind, crossover study design.

Prenatal sonographic appearance of congenital fibrosarcoma

Congenital fibrosarcoma is a rare soft tissue sarcoma. A 22-year-old woman in the 22nd week of her first pregnancy underwent sonographic examination, which revealed a soft tissue swelling of the fetus's left thigh. The pregnancy was terminated, and congenital fibrosarcoma was diagnosed by pathologic examination. To our knowledge, this is the first published report of the intrauterine sonographic observation of this tumor in a fetal extremity.

Phosphatidate phosphatase--a key enzyme in glycerolipid biosynthesis. Studies on the yeast enzyme

Phosphatidate phosphatase is an important enzyme in glycerolipid biosynthesis, but difficult to purify. A purified preparation of N-ethylmaleimide-sensitive phosphatidate phosphatase from the yeast Saccharomyces cerevisiae was obtained by a five-step protocol, using chromatography on DE-53/DEAE FF, Affi-Gel Blue, hydroxyapatite, Mono-Q, and Superdex 200. A protease-deficient yeast strain gave preparations similar to those of the wild-type strain. In exclusion chromatography, the enzyme activity of all preparations eluted at approximately the same position as albumin. However, the behavior on SDS/PAGE differed considerably among preparations, suggesting a multimeric subunit structure or degradation during purification. A 35-kDa and a 40-kDa protein band which coincided with activity were found in all preparations. Glycerol in the buffers could be excluded without rapid loss of enzyme activity, and Tris could be substituted for ammonium bicarbonate, while at least 0.6% sodium cholate in the buffers was essential.

Familial nontoxic multinodular thyroid goiter locus maps to chromosome 14q but does not account for familial nonmedullary thyroid cancer

Thyroid goiter is a common condition that is often associated with iodine deficiency. Familial forms of goiter in areas not known to feature iodine deficiency are much less common. We have performed a genomic search on a single large Canadian family with 18 cases of nontoxic multinodular goiter in which 2 individuals also had papillary lesions highly suggestive of papillary carcinoma. A locus on chromosome 14q (MNG1 [multinodular goiter 1]) has been identified, with a maximal two-point LOD score of 3.8 at D14S1030 and a multipoint LOD score of 4.88 at the same marker, defined by D14S1062 (upper boundary) and D14S267 (lower boundary). The gene encoding thyroid-stimulating hormone receptor (TSHR), which is located on chromosome 14q, is outside the linked region. To determine the role of this gene in familial nonmedullary thyroid cancer (NMTC), we studied 37 smaller pedigrees each containing at least two cases of NMTC. Analysis by both parametric and nonparametric methods indicates that only a very small proportion of familial NMTC (point estimate 0.001, support intervals 0-.6 under a dominant model) is attributable to MNG1.

The mouse atlas and graphical gene-expression database

The large amounts of gene-expression data on mouse development are now too extensive to be stored in any format other than that of a database. Furthermore, as this data is intrinsically graphical and as, in the early developmental stages at least, its boundaries do not map directly to those of anatomical tissues, the natural way to store it is in graphical format. We are therefore constructing a database able to handle such graphical gene-expression data by mapping it onto 3-D reconstructions of mouse embryos whose tissues have been delineated. This article reviews the progress that has been made in this project and describes its two major components, CD-ROMs of the 3-D reconstructions to be held on the user's computer and a gene-expression database that will be maintained at a host site, the two being linked over the internet by a complex Java-based interface for submitting data and querying the database.Copyright 1997 Academic Press Limited Copyright 1997Academic Press Limited

A multisite study of sexual orientation and injection drug use as predictors of HIV serostatus in out-of-treatment male drug users

The risk groups of men who have sex with men and injection drug users (IDUs) together account for 90% of all male AIDS cases. The extent to which each risk behavior contributes to seroprevalence among IDUs has not been determined and is critical for intervention development. Analysis of data on sexual orientation, injection drug use, and HIV serostatus was undertaken in a multisite study of 3002 male drug injectors and crack smokers recruited for HIV prevention projects. Overall HIV seroprevalence was 8.4%; 57.1% for gay men, 25.4% for bisexual men, and 7.4% for heterosexuals (p = 0.001). Logistic regression analyses indicated being gay (OR = 24.08) and coming from an area where seroprevalence is high among IDUs (OR = 4.07) were the best predictors of serostatus. Ever having injected was significant only in interaction with moderate (OR = 3.09) or high (OR = 4.71) IDU seroprevalence areas. Among this multisite sample of drug users, being a gay drug user is the strongest predictor of serostatus. Drug injection is significant only in areas of moderate or high seroprevalence among injectors. This indicates the importance of targeted outreach and intervention efforts.

A multicentre evaluation of the CA 15-3 assay, CA 19-9 assay and CA 125 II assay on the Bayer Immuno 1 System

The analytical performance of the tumour markers CA 15-3 assay, CA 19-9 assay and Ca 125 II assay on the Bayer Immuno I System was studied according to a revised version of the ECCLS guidelines (Haeckel R. In: Evaluation methods in laboratory medicine, Weinheim, VCH Verlag 1993:47-69) in a multicentre evaluation involving five laboratories. Determination of the 3 analytes generated more than 6000 data. On the Bayer Immuno I System, the imprecisions of the CA 15-3 assay, CA 19-9 assay and CA 125 II assay were better than those found for comparison methods. The median recovery over all five laboratories of system assigned values in control sera was within the 1-s range for the three tumour marker assays. No deviation of linearity could be detected experimentally for all assays. Results for patients' samples showed acceptable agreement between the Bayer Immuno 1 system and several different comparison methods in most cases. One exception was the CA 15-3 assay in comparison with the MCA assay from Roche Diagnostic Systems, where the large difference in values is due to the use of different antibodies and calibrators in the two assays. No carry-over effects could be detected. The selective Bayer Immuno 1 system is fully automated; its practicability was rated as high.

Analysis of fused maxillary incisor dentition in p53-deficient exencephalic mice

Out of a total of 21 exencephalic p53-deficient embryonic and newborn mice, 6 (28.6%) possessed fused maxillary incisor teeth. On histological analysis of the 5 examples seen on day 19.5 of gestation and newborn mice, 3 varieties were observed: an example of 'simple' fusion, 3 examples of simple fusion each of which contained a 'dens in dente' ('tooth within a tooth'), and a single example in which the fused teeth were associated with a median supernumerary incisor tooth which, while deeply indenting the labial surface of the fused teeth, was in all locations a completely separate unit. 3-D reconstructions of the fused teeth demonstrated that they were all of the fusio subtotalis variety. No gross abnormalities were observed in the other dentition in these mice. It is noted that in mice fused maxillary incisor teeth are relatively commonly associated with both hypervitaminosis A-induced and trypan blue-induced exencephaly. It is believed that the presence of dens in dente within fused maxillary incisor teeth has only once been reported in mice, and the association between fused maxillary incisor teeth and a median supernumerary incisor tooth has not previously been reported in this species.

Cloning and sequence of a region of Vibrio cholerae O139 Bengal and its use in PCR-based detection

We isolated and characterized a Vibrio cholerae O139 Bengal-specific DNA region by arbitrary PCR. The fragment contains open reading frames encoding two potential glycosyltransferases possibly involved in capsular polysaccharide or lipopolysaccharide biosynthesis. In order to evaluate the possibility that this region could be used for the specific detection of V. cholerae O139 Bengal, a PCR system was established. The specificity and sensitivity of the PCR were investigated by analyzing 240 strains within the family Vibrionaceae and 178 stains of other gram-negative bacteria. All V. cholerae O139 Bengal strains tested were positive, and none of the 384 control strains were amplified. The sensitivity of the assay was 10(2) CFU/ml.

Difficulties in the assay of phosphatidate phosphohydrolase activity. Influence of ionic strength, detergent, and selection of substrate

In the present paper, problems in connection with assay of the activity of magnesium-dependent rat liver phosphatidate phosphohydrolase (PAP) are discussed. PAP activity is usually measured by following the production of diacylglycerol or inorganic phosphate from the substrate phosphatidate. These two methods may give widely different results due to a number of factors that may affect the assay. One such factor is the composition of the substrate. Higher apparent enzyme activity was observed with dioleoyl-phosphatidate than with dipalmitoyl-phosphatidate. This substrate-dependent difference in apparent PAP activity was 2-2.5-fold in the absence and 10-fold in the presence of Triton X-100, respectively. Triton X-100 reduced the activity as measured with the dipalmitoyl-phosphatidate substrate. In contrast, the activity of PAP as measured with dioleoyl-phosphatidate was stimulated by Triton X-100. The stimulatory effect of Triton was reduced or abolished when the ionic strength in the assay mixture was increased. Assays based on 32P-labeled substrate are rapid and sensitive. It is shown here that 33P can be used as an alternative. This radionuclide has a longer half-life and also emits particles with lower energy, thus posing less potential health hazards for the user.

How can the bioavailability of timolol be enhanced? A pharmacokinetic pilot study of novel hydrogels

BACKGROUND

Carbomerbased hydrogels with timolol maleate (T-Gel) were chosen to study the vehicle effect on ocular bioavailability. Pharmacokinetic profiles of T-Gel 0.05% (0.05% timolol), T-Gel 0.025% (0.025% timolol) and commercial timolol ophthalmic solution (TOS 0.1%; 0.1% timolol) were determined and compared.

METHODS

A single dose was administered to rabbits' eyes. Timolol was determined by HPLC in aqueous humour, blood samples and washings of the ocular surface (as a measure of residence time). Sampling times were 0.5 h, 1 h and 4 h after instillation.

RESULTS

Concentration versus time curves (AUC) of timolol in aqueous humour demonstrate no significant differences between TOS 0.1% and T-Gel 0.025% (P = 0.19), whereas the difference between T-Gel 0.05% and TOS 0.1% is significant (P = 0.006); the AUC ratio of T-Gel 0.05%:TOS 0.1%:T-Gel 0.025% was 2.14:1:0.87. Timolol blood levels were highest with TOS 0.1% at every time point. Peak levels occurred after 0.5 h with all test products; the ratio of peak levels (Cmax) for T-Gel 0.05%:TOS 0.1%:T-Gel 0.025% was 0.55:1:0.17. Timolol was detected in the washings up to 1 h after instillation of test products; the highest levels were observed after T-Gel 0.05%.

CONCLUSION

The new vehicle obviously improves the bioavailability of topically applied timolol.