Investigating the toxicology of intramuscular injected multiwalled carbon nanotubes conjugated antibody (CNT-Ab) in mice followed by microwave hyperthermia

Carbon nanotubes bound to tumor specific antibodies offer specific treatment for cancer cells without affecting surrounding tissue. The present study seeks to affirm the initial results of CNTs in cancer therapy by investigating the toxicological effect in mice injected with CNT-Ab followed by microwave hypothermia. We were particularly interested in evaluating the biodistribution, toxicity, and immune response that may be elicited from CNT-Ab exposure in mice. 4–5 week old mice (C57BL/6) were injected with various concentrations and combinations of multiwalled carbon nanotubes (MWCNT) conjugated with specific prostate-specific membrane antigen (PMSA) antibodies. After 1-week post-injection, mice were sacrificed followed by the collection of blood separated into serum, liver, kidney and other tissues for further analysis. Serum total protein concentration across the treatment groups was varied. No significant changes in albumin levels were detected when compared to the control group (No Treatment). Group YE (.125 mg/ml anti-PSMA-MWCNT + Microwave) was found to have consistently high blood serum analyte levels, indicating impaired liver and kidney function. Likewise, groups YB (Microwave only), YF [.5 mg/ml anti-PSMA-MWCNT (No Microwave)], and YG (.5 mg/ml plain MWCNT + Microwave) seemed to show indications of impaired liver function. Analysis of gene expression revealed a significant impact on the NF-KB inflammatory response pathway. NF-KB gene was up-regulated relative to controls in all treatment groups. These results seem to suggest marginal toxicity from the injection of CNT-Ab followed by microwave hyperthermia in mice subjects.

Early outcomes of fluorescence angiography in the setting of endorectal mucosa advancement flaps

BACKGROUND

Fistula-in-ano has a reported incidence of 31-34%. Besides fistulotomy, options for fistula repair are seton placement, endorectal advancement flap (ERAF), fibrin sealant, anal fistula plug and ligation of the intersphincteric fistula tract. Despite having a reported success rate as high as 75-98%, ERAF is not without complications, including flap breakdown, recurrence and fecal incontinence. Traditionally, maintaining a broad base to preserve blood supply has been advocated to reduce flap failure. And the aim of the present study was to evaluate outcomes of adult patients who underwent ERAF for complex fistula-in-ano with the use of intraoperative fluorescence angiography (FA) at our institution between July 2014 and July 2016.

METHODS

We retrospectively reviewed consecutive cases of complex fistula-in-ano repair with ERAF and FA from a prospectively maintained dataset of adult patients with complex fistula-in-ano. Demographics, intraoperative data and 60-day outcomes were recorded and reviewed.

RESULTS

Six patients [five males and one female with a mean age of 40 years (range 25-46 years)], with a total of seven fistulas, were identified. Six (85.7%) of these patients had undergone prior surgery for fistula-in-ano. No recurrences or complications of any type were noted at 2-week and 8-week follow-up. The majority of patients (71.4%) required flap revision based on intraoperative FA prior to flap fixation.

CONCLUSIONS

FA is safe and offers real-time assessment of flap perfusion prior to and after fixation in anal fistula repair. The rate of flap ischemia may be underestimated, and therefore, to improve outcomes in ERAF, intraoperative FA should be included in the surgical armamentarium.

Water Use and Management in the Bakken Shale Oil Play in North Dakota

Oil and natural gas development in the Bakken shale play of North Dakota has grown substantially since 2008. This study provides a comprehensive overview and analysis of water quantity and management impacts from this development by (1) estimating water demand for hydraulic fracturing in the Bakken from 2008 to 2012; (2) compiling volume estimates for maintenance water, or brine dilution water; (3) calculating water intensities normalized by the amount of oil produced, or estimated ultimate recovery (EUR); (4) estimating domestic water demand associated with the large oil services population; (5) analyzing the change in wastewater volumes from 2005 to 2012; and (6) examining existing water sources used to meet demand. Water use for hydraulic fracturing in the North Dakota Bakken grew 5-fold from 770 million gallons in 2008 to 4.3 billion gallons in 2012. First-year wastewater volumes grew in parallel, from an annual average of 1,135,000 gallons per well in 2008 to 2,905,000 gallons in 2012, exceeding the mean volume of water used in hydraulic fracturing and surpassing typical 4-year wastewater totals for the Barnett, Denver, and Marcellus basins. Surprisingly, domestic water demand from the temporary oilfield services population in the region may be comparable to the regional water demand from hydraulic fracturing activities. Existing groundwater resources are inadequate to meet the demand for hydraulic fracturing, but there appear to be adequate surface water resources, provided that access is available.

The evidence for single-incision laparoscopic colectomy: is it time to adopt?

Laparoscopic colorectal surgery has advantages over open surgery including shorter postoperative length of hospital stay, early return of bowel function, decreased complications and reduced postoperative pain. Innovative minimally invasive surgery techniques such as single-incision laparoscopic surgery (SIL) have emerged to further enhance outcomes of conventional laparoscopy. This technique uses a single small incision for access of all instruments and specimen extraction. This concept has been proposed to improve cosmesis and enhance recovery. Technological advances have been introduced to overcome the challenges of co-axial instrument movement and collision that is inherent to SIL surgery. The application of SIL techniques to colorectal surgery is in its infancy, but gaining significant momentum. Early case reports and series have shown feasibility and safety. Emerging comparative studies of SIL colectomy to standard laparoscopic techniques are providing evidence of equivalency with potential benefit in outcomes such as reduced early postoperative pain and shortened length of hospital stay. The application of the SIL platform to robotics and transanal surgery demonstrates the broadening scope of this innovative field. However, we must be cognizant of the impact on surgeon training and resident education. In this review we present the current evidence supporting the application of SIL to colorectal surgery.

Nurse-led interventions used to improve control of high blood pressure in people with diabetes: a systematic review and meta-analysis

BACKGROUND

Previous reviews demonstrate uncertainty about the effectiveness of nurse-led interventions in the management of hypertension. No specific reviews in diabetes have been identified. We have systematically reviewed the evidence for effectiveness of nurse-led interventions for people with diabetes mellitus.

METHODS

In this systematic review and meta-analysis, searches of Medline, Embase, CINAHL and the Cochrane Central Trials register were undertaken to identify studies comparing any intervention conducted by nurses in managing hypertension in diabetes with usual doctor-led care. Additional citations were identified from papers retrieved and correspondence with authors. Outcome measures were absolute systolic and diastolic blood pressure, change in blood pressure, proportions achieving study target blood pressure and proportions prescribed anti-hypertensive medication.

RESULTS

  Eleven studies were identified. Interventions included adoption of treatment algorithms, nurse-led clinics and nurse prescribing. Meta-analysis showed greater reductions in blood pressure in favour of any nurse-led interventions (systolic weighted mean difference -5.8 mmHg, 95% CI -9.6 to -2.0; diastolic weighted mean difference -4.2 mmHg, 95% CI -7.6 to -0.7) compared with usual doctor-led care. No overall superiority in achievement of study targets or in the use of medication was evident for any nurse-based interventions over doctor-led care.

CONCLUSIONS

There is some evidence for improved blood pressure outcomes with nurse-led interventions for hypertension in people with diabetes compared with doctor-led care. Nurse-based interventions require an algorithm to structure care and there is some preliminary evidence for better outcomes with nurse prescribing. Further work is needed to elucidate which nurse-led interventions are most effective.

Herbal interventions for chronic asthma in adults and children

BACKGROUND

Herb and plant based preparations are a popular treatment for asthma, although there remain concerns as to their efficacy and safety. In Western societies, motivations for using such treatments may be both positive and negative, with their perceived safety and dissatisfaction with conventional medicine among them. In China such treatments are more commonly used and many compounds considered 'conventional' are derived from herbs or plants.

OBJECTIVES

To assess the efficacy and safety of herb and plant extracts in the management of chronic asthma.

SEARCH STRATEGY

The Cochrane Airways Group Trials Register, CENTRAL, MEDLINE, EMBASE and AMED were searched with pre-defined terms. Searches are current as of February 2007.

SELECTION CRITERIA

Randomised placebo controlled trials of any herb or plant extract were eligible. Study participants had to have a primary diagnosis of asthma. Studies in both adults and children were eligible for the review.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed studies for suitability. Data were extracted and double-checked.

MAIN RESULTS

Twenty-seven studies (29 experimental groups) met the review entry criteria, randomising a total of 1925 participants. The studies identified assessed the effects of 21 different herbal preparations. Study quality varied considerably, and the sample sizes were often small. For primary outcomes (exacerbations, steroids use and lung function measurements): Two out of six studies reporting change in FEV1 were positive, with very few data available on the frequency of exacerbations. One study which did report these data was negative. Health-related quality of life was only measured in one trial.

AUTHORS' CONCLUSIONS

The evidence base for the effects of herbal treatments is hampered by the variety of treatments assessed, poor reporting quality of the studies and lack of available data. The data that are available from the studies provide only a small insight into the long-term efficacy and harm profiles of these treatments. The absence of common endpoint measurements limits the validity of our findings further. Positive findings in this review warrant additional well-designed trials in this area.

The interarm blood pressure difference as predictor of cardiovascular events in patients with hypertension in primary care: cohort study

Objectives of this study were to measure the prevalence of a difference in blood pressure (BP) between arms and determine whether a difference is associated with increased risk of cardiovascular events or death. A prospective cohort study of 247 patients with hypertension was undertaken in one rural general practice in England. The main outcome measures were mean difference in BP between arms and new episodes of myocardial infarction, cerebrovascular event, onset of angina or peripheral vascular disease or death. A total of 57/247 (23%) patients had a mean difference in systolic BP between arms of >or=10 mm Hg and 8/247 (3%) had a mean difference of >or=20 mm Hg. A total of 15/247 (6%) patients had a mean difference in diastolic BP between arms of >or=10 mm Hg. Survival analysis after 4.7 years (range 3.3-5.9) showed a shorter mean survival time without event or death for patients with a difference in systolic BP of >or=10 mm Hg compared with a difference of <10 mm Hg (3.7 (95% confidence interval, 3.2-4.2) versus 4.8 (4.6-5.1) years; P<0.001; hazard ratio 2.5 (1.5-4.2), P=0.001). Difference in systolic BP of >or=10 mm Hg between arms is common in this primary care population and is associated with a shorter survival time to death or new cardiovascular event. Detection of a difference between arms may identify hypertensive patients at increased risk of cardiovascular events. Such an approach would allow more effective targeting of resources in primary prevention strategies.

Prevalence and clinical implications of the inter-arm blood pressure difference: a systematic review

A blood pressure (BP) difference between arms was first reported over 100 years ago. Knowledge of its prevalence and relevance to the accurate measurement of BP remains poor. Current hypertension guidelines do not emphasise it. The objectives of this study were to establish the best estimate of prevalence of the inter-arm difference (IAD) in the population, to consider its implications for accurate BP measurement and treatment, and to discuss its aetiology and potential as a risk marker for cardiovascular disease. Systematic literature review was carried out. The data sources were Medline EMBASE and CINAHL databases, and Index of Theses. Studies reporting prevalence rates of IAD were retrieved and considered for inclusion against explicit methodological criteria. Point prevalence rates were extracted and weighted mean prevalence rates calculated. The main outcome measures were weighted mean prevalences of systolic IAD > or =10 and > or =20 mm Hg and of diastolic IAD > or =10 mm Hg. Thirty-one studies were identified. Most had methodological weaknesses; only four met the inclusion criteria. Pooled prevalences of the IAD from these four studies were 19.6% systolic > or =10 mm Hg (95% CI 18.0-21.3%), 4.2% systolic > or =20 mm Hg (95% CI 3.4-5.1%) and 8.1% diastolic > or =10 mm Hg (95%CI 6.9-9.2%). In conclusion, an IAD is present in a substantial number of patients and should be looked for whenever diagnosis and treatment depend on accurate measurements of BP. The importance of an IAD should be better emphasised in current hypertension management guidelines. There is evidence associating an IAD with peripheral vascular disease, raising the possibility that its presence may predict cardiovascular events.

Asthma after childhood pneumonia: six year follow up study

OBJECTIVE

To establish the long term cumulative prevalence of asthma in children admitted to hospital with pneumonia and to examine the hypothesis that some children admitted to hospital with pneumonia may be presenting with undiagnosed asthma.

DESIGN

Prospective study of a cohort of children previously admitted to hospital with pneumonia, followed up by postal questionnaires to their general practitioners and the children or their parents.

SETTING

General practices in southwest England.

PARTICIPANTS

78 children admitted to the Royal Devon and Exeter Hospital between 1989 and 1991 with a diagnosis of pneumonia confirmed on independent review of x ray films.

MAIN OUTCOME MEASURES

Any diagnosis of asthma, use of any treatment for asthma, and asthma symptom scores.

RESULTS

On the basis of a 100% response rate from general practitioners and 86% from patients or parents, the cumulative prevalence of asthma was 45%. A diagnosis of asthma was associated with a family history of asthma (odds ratio 11.23; 95% confidence interval 2.57 to 56.36; P=0.0002). Mean symptom scores were higher for all children with asthma (mean score 2.4; chi(2)=14.88; P=0. 0001) and for children with asthma not being treated (mean 1.4; chi(2)=6.2; P=0.01) than for those without asthma (mean 0.2).

CONCLUSIONS

A considerable proportion of children presenting to a district general hospital with pneumonia either already have unrecognised asthma or subsequently develop asthma. The high cumulative prevalence of asthma suggests that careful follow up of such children is worth while. Asthma is undertreated in these children; a structured symptom questionnaire may help to identify and reduce morbidity due to undertreatment.

Prognostic value of cardiac troponin-I levels following catheter-based coronary interventions

This study has examined the prognostic significance of troponin-I (Tn-I) levels after catheter-based coronary interventions in coronary arteries and saphenous vein grafts lesions. Tn-I and creatine kinase-MB (CK-MB) fraction levels were measured at 6 and 18 to 24 hours after catheter-based coronary intervention in 1,129 consecutive patients with normal preintervention plasma levels of Tn-I, and CK-MB levels below the cutoff for myocardial infarction. Patients were stratified according to maximal postangioplasty Tn-I levels. Group I (n = 784) had no elevated Tn-I (<0.15 ng/ml), group II (n = 170) had Tn-I at 0.15 to 0.45 ng/ml, and group III (n = 175) had Tn-I elevation >0.45 ng/ml. Major in-hospital complications (death, 0-wave infarction, and emergent coronary bypass grafting) and out-of-hospital intermediate-term (8 months) outcomes were compared between the 3 groups. Tn-I elevation >0.45 ng/ml was associated with increased risk of mortality (group III, 1.6%; group II, 0.6%; and group I, 0.1%; p = 0.019) and major in-hospital complications (3.2%, 1.7%, and 0.5%; p = 0.004). There was no difference in death (1.8%, 3.2%, and 2.4%; p = 0.74), Q-wave infarction (0.6%, 0%, and 0.3%; p = 0.66), or target lesion revascularization (10.1%, 9.0%, and 9.3%; p = 0.86) between the 3 groups at follow-up. Cardiac event-free survival was similar between groups (p = 0.3). By multivariate analysis, Tn-I >0.45 ng/ml was an independent predictor for major in-hospital complications (odds ratio 2.1, 95% confidence interval 1.2 to 3.9, p = 0.01). The degree of risk was also associated with the conjoint elevation of Tn-I and CK-MB levels (odds ratio 1.1, 95% confidence interval 1.02 to 1.2, p = 0.01). We conclude that Tn-I levels >3 times the normal limit and conjoint elevation of Tn-I and CK-MB levels after coronary angioplasty are associated with increased risk of major in-hospital complications, but have no incremental risk of adverse intermediate-term (8 months) clinical outcomes.

Geographic variation in allergic fungal rhinosinusitis

Allergic fungal rhinosinusitis (AFRS) has a worldwide distribution. This survey of 20 otolaryngologic practices throughout the United States confirmed a variation in the frequency of AFRS relative to endoscopic sinus procedures performed for all other diagnoses. The highest incidence occurred in Memphis, Tennessee at 23%, with three other southern practices reporting a frequency of at least 10%. In the northern locations the frequency ranged from 0 to 4%. No correlation with mould counts was demonstrated, possibly because of incomplete mould data relative to most of the surgical locations.

School based screening for hypothyroidism in Down's syndrome by dried blood spot TSH measurement

OBJECTIVE

To determine the feasibility of annual hypothyroid screening of children with Down's syndrome by measuring thyroid stimulating hormone (TSH) on dried blood spots at school, and to describe the outcome in positive children.

DESIGN

Establishment of a register of school children with Down's syndrome, and procedures for obtaining permission from parents, annual capillary blood samples, TSH measurement, and clinical assessment of children with TSH values > 10 mU/litre.

SUBJECTS

All school age children with Down's syndrome within Lanarkshire and Glasgow Health Boards during 1996-7 and 1997-8.

RESULTS

200 of 214 school children with Down's syndrome were screened. Four of the unscreened children were receiving thyroxine treatment, and only 5 remained unscreened by default. 15 of the 200 children had capillary TSH > 10 mU/litre, and all but 1 had evidence of Hashimoto's thyroiditis. Seven of the 15 children started thyroxine treatment immediately, 6 with a pronounced rise in venous TSH and subnormal free thyroxine (fT4), and one with mildly raised TSH and normal fT4 but symptoms suggesting hypothyroidism. Eight children with mildly raised venous TSH and normal fT4 were left untreated; 1 year after testing positive, fT4 remained > 9 pmol/litre in all cases, but 4 children were started on thyroxine because of a rise in TSH. TSH fell in 3 of the 4 remaining children and there was a marginal rise in 1; all remain untreated. The prevalence of thyroid disease in this population is >/= 8.9%.

CONCLUSION

Dried blood spot TSH measurement is effective for detecting hypothyroidism in Down's syndrome and capillary sampling is easily performed at school. The existing programme could be extended to the whole of Scotland within a few years.

Late-developing infection in instrumented idiopathic scoliosis

STUDY DESIGN

This is a retrospective review of all patients requiring either Cotrel-Dubousset or Moss Miami rod removal. All initial spinal instrumentations were for adolescent idiopathic scoliosis from 1985 through 1994. Twenty-two patients who underwent rod removal for late-developing infection constitute the study group.

OBJECTIVES

To determine the bacteriology and treatment of patients with late-developing infection after posterior spinal instrumentation for scoliosis.

SUMMARY OF BACKGROUND DATA

There have been conflicting reports regarding this entity, some reporting a high percentage of positive cultures and others a low yield. The latter have attributed the entity to fretting corrosion. Much literature describes late appearance of infection with large foreign bodies (implants). Glycocalyx, a membrane that surrounds bacteria adjacent to surgical implants, results in poor antibiotic penetration, poor macrophage action, and difficulty in culturing bacteria.

METHODS

One thousand two hundred forty-seven patients who underwent posterior instrumentation from 1985 through 1994 were reviewed. Those requiring implant removal were further studied. Those with late-developing infection (more than 1 year after the initial procedure) were further reviewed. Culture reports, presence of pseudarthrosis, and antibiotic regimen after implant removal were the primary parameters studied.

RESULTS

Twenty-two patients (1.7%) experienced development of late infection a mean of 3.1 years after the initial procedure. In specimens from these patients cultured only 72 hours, only 1 of 10 was positive. Of those cultured for 7-10 days (the last 12) 11 were positive, usually for low-virulence skin organisms. After surgery, patients received antibiotics parenterally for 48 hours and orally for 7 days. All wounds were closed primarily. Four patients had pseudarthroses, two underwent revised procedures with titanium implants without signs of infection at more than 2 years' follow-up.

CONCLUSIONS

Late-appearing infection with spinal instrumentation can be treated with device removal, primary skin closure, and short-term oral antibiotics. The infections affect soft tissue, not the bone.

Effects of dopamine and aminophylline on contrast-induced acute renal failure after coronary angioplasty in patients with preexisting renal insufficiency

In phase 1 of this study, 60 patients undergoing coronary angioplasty were randomized to receive saline, dopamine, or aminophylline; the overall incidence of contrast-induced renal failure was 38%, without difference among the 3 groups. In phase 2 of this study, 72 patients with established contrast-induced renal failure were randomized to receive saline or dopamine; dopamine had a deleterious effect on the severity of renal failure, prolonging the course.

Effect of wide posterior release on correction in adolescent idiopathic scoliosis

Wide lumbar posterior release, consisting of partial excision of spinous process, excision of interspinous ligament and ligamentum flavum, and excision of facet in plane of facet from both outside and within the spinal canal has been employed to increase coronal correction and improve the production of lumbar lordosis (10). Adolescent idiopathic patients with fusion into the lumbar spine were studied. Pre- and postsurgical coronal and sagittal Cobb measurements as well bending measurements were done. Intraoperative biplanar radiographs were done after positioning, after lumbar rod placement, and finally after wide release and placement of the same rod. Statistical analysis was by paired Student's t-test. Significantly (p < 0.005), improved correction was attained in the coronal plane with release (76% vs. 64%). Total lordosis and instrumented segment lordosis was also significantly (p < 0.025) improved with release (12 degrees vs. 3 degrees). Coronal and sagittal plane correction in the lumbar spine is improved significantly with a wide posterior lumbar release.

Beam me up, nurse! Educational technology supports distance education

The Intercollegiate Center for Nursing Education (ICNE) has recently added a second technology to its earlier distance education program. Orientation of nursing faculty to effectively use the new two-way video and audio interactive microwave system has been a challenge, and the reward for meeting that challenge is satisfied distant learners. The author discusses the planning, implementation, and evaluation of this new technology.

Thoracolumbar osteotomy for postsurgical sagittal imbalance

A prospective study of 12 patients with sagittal plane imbalance after multiple surgeries for scoliosis is reported. Reconstruction was attempted by posterior thoracolumbar junction osteotomy. Eighty-seven degrees of thoracic kyphosis (ending at L3) was improved to forty-one degrees (ending at T12). Lumbar lordosis was increased from 21 to 30 degrees, beginning at L1 afterward (L3 before). 8.7 cm posterior displacement of the sagittal weight-bearing axis was achieved. No permanent complications ensued. The procedure, without anterior surgery, corrects the deformity at the apical area. Cotrel-Dubousset instrumentation secured correction and fixation.

Prevention of the crankshaft phenomenon

Factors favoring development of the crankshaft phenomenon after posterior spinal fusion include immaturity and large residual deformity. Eight patients at high risk to develop the crankshaft phenomenon underwent periapical anterior growth arrest and fusion before posterior instrumentation and fusion. With follow-up to skeletal maturity, 0% developed crankshaft phenomenon. Anterior growth arrest and fusion before a posterior procedure is recommended in scoliosis patients at high risk to develop the crankshaft phenomenon.

Fusion levels and hook patterns in thoracic scoliosis with Cotrel-Dubousset instrumentation

This study reports the results of treatment of adolescents with King Types 2, 3, and 4 idiopathic curves using Cotrel-Dubousset instrumentation. Imbalance was seen in Types 2 and 4 curves when distraction direction hook patterns crossing the thoracolumbar junction were employed. Imbalance was not seen when a modified hook pattern employing compressing forces across the thoracolumbar junction was employed. No imbalance was observed in Type 3 curves using the basic right thoracic curve hook pattern. In Type 4 curves, a second modified hook pattern is required to obtain improved correction and balance. The mechanism of production of imbalance is explained by a three dimensional analysis of the deformity and of the forces generated by the Cotrel-Dubousset system.

Telecourses for nursing staff development

Instructional television is a viable option for meeting staff development needs in health care agencies. Telecourses produced by the Intercollegiate Center for Nursing Education provide staff development educators with an efficient and effective alternative for meeting selected educational needs of staff within health care institutions, as well as interested nurses throughout the community. Use of this instructional methodology is described.

Cotrel-Dubousset instrumentation

Cotrel-Dubousset Instrumentation (CDI) presents a diversified posterior implant system applicable in any situation requiring posterior spinal instrumentation. It acts in the three dimensions of the spine, frontal-sagittal-axial. Correct hook site selection and direction provide spinal balance in three dimensions. The double major idiopathic scoliosis is an appropriate model on which to learn the principles of usage of CDI Results of CDI in a wide variety of spinal pathology have been excellent. There is a learning curve for CDI, hook placement being the most significant. Pitfalls and complications can be avoided.

Surgical treatment for malignant exophthalmos of endocrine origin

Endocrine exophthalmos is a poorly understood disease process thought to be related to a dysfunction of the thyroid-pituitary axis. Initial therapy for symptomatic endocrine exophthalmos is medical. Failure to respond to medical management is heralded by progressive exophthalmos, exposure keratitis, and decreasing visual acuity. The pathophysiologic processes involved and an historical review of the various surgical procedures used are discussed. The results of 28 patients surgically decompressed by a transantral transethmoid approach are presented. Preservation or improvement in visual acuities were observed in all but one patient. Diplopia was generally not improved and may be worsened in some patients.

Effects of toxicants on populations: a qualitative approach II. First order kinetics

System level effects exhibited by a population subjected to a chronic or an acute dose of toxicant are the emphasis of this study. A three dimensional model of a toxicant and a population, with state variables (the population biomass, the concentration of toxicant in an organism, and the concentration of toxicant in the environment) coupled by a linear dose-response function, is analyzed analytically. One of the main results presents sufficient conditions, in terms of a system level parameter, for the persistence, and for the extinction, of a population exposed to a chronic dose of toxicant. When depuration and degradation are negligible processes, the effects of toxicant accumulation associated with an acute exposure of a population are analyzed in some detail. Both persistence and extinction are shown to be viable behavior modes of a population in this biochemical setting.

Value of serial sonography in the in utero detection of duodenal atresia

Duodenal atresia can be fatal unless promptly diagnosed and treated surgically. Death occurs in the newborn secondary to emesis, aspiration, and electrolyte imbalance. Serial ultrasound scans were obtained for 2 patients, but duodenal atresia was not detected until 29 and 32 weeks' gestation, respectively. With prior knowledge of an infant with Down syndrome and duodenal atresia, management of fetal distress with subsequent operative delivery can be altered. Early prenatal diagnosis by ultrasonography and subsequent amniocentesis plays an important role in the antenatal and postpartum counseling and management of these patients and neonates.

Ullrich-Turner syndrome (45,X/46,X,i[Xq]) in a child with a familial inversion of chromosome 3

We report a girl with shortness of stature and minor anomalies representing a mild form of the Ullrich-Turner syndrome. Cytogenetic studies showed 3 distinct anomalies: 1) a familial pericentric inversion, inv(3) (p25q21)pat, in all cells examined; 2) monosomy X (45,X) in 70% of cells; 3) isochromosome X (46,X,i(Xq)) in 30% of cells. The karyotype designation is: 45,X,inv(3) (p25q21)pat/46,X,i(Xq), inv(3) (p25q21)pat. The pedigree, which was originally interpreted as representing the segregation of a 2;3 translocation, is corrected and updated. Reproductive risks in families with pericentric inversions are discussed.

Brief clinical report: dup(4p15 leads to 4pter) in a 19-year-old woman resulting from a maternal 4;14 translocation

We describe a 19-year-old woman who has a duplication of 4p. The karyotype is 46,XX, - 14, + der(14),t(4;14) (p15;p12)mat in lymphocytes and skin fibroblasts. The patient has coarse hair, prominent forehead and tip of nose, coloboma, scoliosis, and mental retardation.

Risk factor analysis of intraventricular hemorrhage in low-birth-weight infants

Sixty of 63 newborn infants weighing less than 1,250 gm, admitted consecutively to the Intensive Care Nursery during a 15-month period, were prospectively investigated for the incidence of intraventricular hemorrhage by early computerized tomography or by autopsy. Nineteen of the 60 infants had evidence of IVH. The incidence of IVH was correlated with the presence of possible neonatal, obstetrical, asphyxial, or therapeutic risk factors. There was a significant difference in only one of the risk factors: birth outside the perinatal center. Fifteen of 27 outborn infants (56%) developed IVH, whereas only four of 33 inborn infants (12%) developed IVH (P less than 0.001). There were no statistically significant differences in maternal obstetrical risk factors, infant risk factors, or indices of birth asphyxia in the inborn compared with the outborn infants. However, perinatal therapeutic risk factors differed between the two groups. Outborn infants were less likely to have received betamethasone (P less than 0.001), were less likely to have their arterial blood gases monitored and stabilized during the first 20 minutes after birth (P less than 0.001), and were given more bicarbonate (P less than 0.001) and more boluses of fluid intravenously (P less than 0.02). The risk of IVH in very low birth-weight infants may be significantly decreased by therapeutic factors at birth. Maternal transport to a perinatal center and intensive neonatal resuscitation may contribute to decreasing the incidence of intraventricular hemorrhage.

46,XY/48,XXY, +8 in a male with clinical and dermatoglyphic features of mosaic trisomy 8 syndrome

A 15-year-old male was referred for management of scoliosis secondary to congenital vertebral anomalies. Cytogenetic analysis was performed because of multiple congenital malformations. The patient was found to have a mosaic 46,XY/48,XXY,+8 chromosome complement with the characteristic clinical and dermatoglyphic features of mosaic trisomy 8 syndrome.

Long arm deletion of chromosome 13 with exclusion of esterase D from 13q32 leads to 13qter

A de novo partial 13q monosomy is reported in a severely affected 8-year-old female with the karyotype 46,XX,del(13)(q32). Abnormal features included mental retardation, delayed development, microcephaly, encephalocele, hearing loss, hypertelorism, ptosis, flat nasal bridge, protruding upper incisors, facial asymmetry, short neck, hypoplastic thumbs, scoliosis and clubfeet. The deletion was demonstrable by R-banding but was not apparent by GTG banding. The locus for esterase D (EC 3.1.1.1) is excluded from the deleted segment 13q32 leads to 13qter.

Trisomy 6q25 leads to 6qter in two sisters resulting from maternal 6;11 translocation

Chromosome banding was used to define a partial duplication of the long arm of chromosome 6 (6q25 leads to 6qter) in two profoundly affected sisters and to identify their phenotypically normal mother and sister as balanced translocation carriers whose karyotypes were interpreted as 46,XX,t(6;11) (q25;q25). Prominent clinical features included profound mental retardation, hypertelorism, micrognathia, down-turned mouth, dental anomalies, clubfeet, webbed neck, late progressive scoliosis, flexion contractures, and low total finger ridge count. By comparison with published reports, it has been possible to establish a trisomy 6q25 leads to 6qter syndrome.

Cytogenetic abnormalities in orthopedic patients

Patients with orthopedic problems may also have chromosomal abnormalities. Individuals who present with subtle clinical findings suggestive of a known syndrome resulting from a chromosomal abnormality, such as Klinefelter syndrome, Turner syndrome, or any of the known trisomiers, should be investigated further in order to confirm the diagnosis. In addition, those patients who have multiple congenital abnormalities in several systems should also have chromosome analysis. This should be done not only to gain new information in regard to chromosome abnormalities, but also to establish a diagnosis for the individual and thus provide proper genetic counseling for the family. If the clinical picture strongly suggests a chromosomal abnormality, and routine karyotyping does not demonstrate one, it is imperative that one or more banding techniques be utilized before a chromosomal abnormality can be ruled out.

Electrocardiographic findings in patients with obstructive and nonobstructive hypertrophic cardiomyopathy

One hundred and thiry-four patients with hypertrophic cardiomyopathy were evaluated by standard 12-lead electrocardiography. Normal electrocardiograms were extremely uncommon, occurring in less than 7% of each subgroup of patients (i.e., those with or without either symptoms or obstruction to left ventricular outflow), with the exception of those who were both asymptomatic and had no left ventricular outflow obstruction. Even in this subgroup, however, normal electrocardiograms occurred in only 27% of patients. Repolarization abnormalities and left ventricular hypertrophy were the most common abnormalities, occurring in 81% and 62%, respectively, of the total population. A broad spectrum of other electrocardiographic abnormalities was found, but none was unique to hypertrophic cardiomyopathy. Patients with vs those without electrocardiographic left ventricular hypertrophy or left atrial abnormality had significantly (P less than 0.005) greater mean ventricular septal thickness (22 +/- 0.6 vs 19 +/- 0.6 mm) and left atrial dimension (48 +/- 1 vs 40 +/- 1 mm) measured by echocardiography, and signficantly (P less than 0.01) higher mean pulmonary capillary wedge pressure (16 +/- 1 vs 10 +/- 1 mm Hg) and left ventricular end-diastolic pressure (20 +/- 1 vs 15 +/- 1 mm Hg). The high prevalence and diverse nature of electrocardiographic abnormalities suggest that any patient with an unusual and unexplained electrocardiogram should be suspected of having hypertrophic cardiomyopathy even if the physical examination is normal, as is often the case in patients without obstruction.