General or Spinal Anaesthetic for Vaginal Surgery in Pelvic Floor Disorders (GOSSIP): a feasibility randomised controlled trial

INTRODUCTION AND HYPOTHESIS

Spinal anaesthesia (SA) and general anaesthesia (GA) are widely used techniques for vaginal surgery for pelvic floor disorders with inconclusive evidence of the superiority of either. We conducted a randomised controlled trial (RCT) to assess the feasibility of a full scale RCT aiming to examine the effect of anaesthetic mode for vaginal surgery on operative, patient reported and length of hospital stay (LOHS) outcomes.

METHODS

Patients undergoing vaginal surgery, recruited through a urogynaecology service in a University teaching hospital, were randomised to receive either GA or SA. Patients were followed up for 12 weeks postoperatively. Pain was measured on a visual analogue scale; nausea was assessed with a four-point verbal rating scale. Patient's subjective perception of treatment outcome, quality of life (QoL) and functional outcomes were assessed using the International Consultation on Incontinence Modular Questionnaire (ICIQ) on vaginal symptoms and the SF-36 questionnaire.

RESULTS

Sixty women were randomised, 29 to GA and 31 to SA. The groups were similar in terms of age and type of vaginal surgery performed. No statistically significant differences were noted between the groups with regard to pain, nausea, quality of life (QoL), functional outcomes as well as length of stay in the postoperative recovery room, use of analgesia postoperatively and LOHS.

CONCLUSION

This study has demonstrated that a full RCT is feasible and should focus on the length of hospital stay in a subgroup of patients undergoing vaginal surgery where SA may help to facilitate enhanced recovery or day surgery.

Developing Objective Metrics for Unit Staffing (DOMUS) study

OBJECTIVE

Safe midwifery staffing levels on delivery suites is a priority area for any maternity service. Escalation policies are tools that provide an operational response to emergency pressures. The aim of this study was to assess the feasibility of using a scoring system to contemporaneously assess the required staffing level based on demand and use this to determine delivery suite escalation level and utilise the information generated regarding clinical activity (Demand) and staffing levels (Capacity) to generate unit-specific calculation for the actual number of midwifery staff required.

SETTING

A maternity unit of a university-affiliated tertiary referral hospital.

DESIGN

Over a 12-month period, specifically designed scoring sheets were completed by delivery suite shift co-ordinators four times a day (04:00, 10:00, 16:00 and 22:00). Based on the dependency score (Demand) and the number of midwifery staff available (Capacity), an escalation level was determined for each shift. The 80th centile of the demand was used to determine optimal capacity.

RESULTS

A total of 1160 scoring sheets were completed. Average staff number throughout the year on any shift was 7 (range 3-11). Average dependency score was 7 (range 1-14). The 80th centile for demand was calculated to be 11.

CONCLUSIONS

This study stresses the importance and usefulness of a simple tool that can be used to determine the level of escalation on delivery suite based on an objective scoring system and can also be used to determine the appropriate staffing on delivery suite.

Prioritisation of teaching topics in obstetrics and gynaecology: a Delphi survey of postgraduate trainees

Topics for theoretical teaching during the obstetrics and gynaecology specialty training programme are often chosen by tutors, with little input from the trainees. However, it is important to actively involve adults in their learning process to maintain their learning ownership and motivation. The Delphi methodology is a generic social science technique used to aggregate views and opinions of experts, the community and service users. In this study, we conducted a two generational Delphi study to achieve consensus between a group of trainees in obstetrics and gynaecology, regarding what they considered important topics for inclusion in their protected teaching programme. A total of 25 trainees from one deanery, participated in this study. We were able to produce a list of 26 topics in obstetrics and 30 in gynaecology, prioritised according to their importance for inclusion in the specialty protected teaching programme, as viewed by these trainees.

Surgical complications of segmental Le Fort I osteotomy

Segmental maxillary osteotomy is a useful adjunct in orthognathic surgery for the correction of vertical and transverse maxillary deformities, but we know of few published reports that document complications. We evaluated the complication rates associated with segmental maxillary surgery in our unit by retrospective review of medical records, radiographs, and study models of 85 consecutive patients (mean age 23.3 years, range 14-51; male:female ratio 1:2) treated from 1995 to 2009. Types of deformity were anterior open bite (n=30, 35%), transverse maxillary deficiency (n=24, 28%), anterior open bite with transverse maxillary deficiency (n=28, 33%), and anterior vertical maxillary excess (n=3, 4%). There were 70 tripartite (82%), 13 bipartite (15%), and two quadripartite (2%) maxillas. Twenty-one patients (25%) had bone grafts. Fixation was done using titanium miniplates in 80 patients (94%), and titanium miniplates and resorbable plates in five (6%). The overall complication rate was 27%. Three patients (4%) had devitalisation of teeth, three (4%) developed minor periodontal defects, and one had tooth loss. Eight patients (9%) had plates removed, and two patients developed persistent postoperative palatal fistula. There was no segmental loss of bone or teeth. Our results show that complications in this cohort were relatively low, and that segmental maxillary surgery is safe as an adjunct in carefully selected cases.

Structural studies on porphobilinogen deaminase

The X-ray crystallographic analysis of porphobilinogen deaminase (hydroxymethylbilane synthase, EC 4.3.1.8) shows the polypeptide chain folded into three domains, (1) N-terminal, (2) central and (3) C-terminal, of approximately equal size. Domains 1 and 2 have a similar overall topology, a modified doubly wound parallel beta-sheet. Domain 3 is an open-faced three-stranded antiparallel beta-sheet, with one face covered by three alpha-helices. The active site is located between domains 1 and 2. The dipyrromethane cofactor linked to cysteine 242 protrudes from domain 3 into the mouth of the cleft. Flexible segments between domains 1 and 2 are thought to have a role in a hinge mechanism, facilitating conformational changes. The cleft is lined with positively charged, highly conserved, arginine residues which form ion pairs with the acidic side chains of the cofactor. Aspartic acid 84 has been identified as a critical catalytic residue both by its proximity to the cofactor pyrrole ring nitrogen and by structural and kinetic studies of the Asp-84-->Glu mutant protein. The active site arginine residues have been altered by site-directed mutagenesis to histidine residues. The mutant proteins have been studied crystallographically in order to reconcile the functional changes in the polymerization reaction with structural changes in the enzyme.

Effects of changes to the stable environment on the exhalation of ethane, carbon monoxide and hydrogen peroxide by horses with respiratory inflammation

The aim of this study was to assess the effects of changes to the stable environment on exhaled markers of respiratory inflammation in six horses with clinical histories of recurrent airway obstruction. The horses were maintained for two weeks under conventional stable management (straw bedding and hay) and for two weeks on a reduced-dust regimen (paper bedding and ensiled grass), in a crossover study design. Exhaled ethane and carbon monoxide (CO) and exhaled breath condensate hydrogen peroxide (H(2)O(2)) were measured every three days under each regimen. The presence of clinical signs of airway inflammation (nasal discharge and cough) was monitored daily. The reduced-dust regimen was associated with fewer clinical signs of airway inflammation than the conventional regimen. Exhaled ethane and CO were significantly lower on the reduced-dust regimen and these markers were correlated with clinical signs of respiratory inflammation, but exhaled H(2)O(2) was not affected by the management regimen.

Noonan syndrome with giant cell lesions

Noonan syndrome is characterised by short stature, unusual facies, congenital heart disease, chest deformity and mild mental retardation. It may be sporadic or inherited as an autosomal dominant trait and occurs between one in 1000-2500. Cherubism is a giant cell lesion of the jaws thought to be transmitted as an autosomal dominant trait. It is usually recognised by age two to four years, follows a variable course, and is not known to be related to other genetic disorders. The purpose of this article is to report a case of multiple giant cell lesions of the mandible that occurred in a patient with phenotypic features of Noonan syndrome. The emerging relationship between these cherubism-like findings and Noonan syndrome will be discussed.

A leucine-supplemented diet improved protein content of skeletal muscle in young tumor-bearing rats

Cancer cachexia induces host protein wastage but the mechanisms are poorly understood. Branched-chain amino acids play a regulatory role in the modulation of both protein synthesis and degradation in host tissues. Leucine, an important amino acid in skeletal muscle, is higher oxidized in tumor-bearing animals. A leucine-supplemented diet was used to analyze the effects of Walker 256 tumor growth on body composition in young weanling Wistar rats divided into two main dietary groups: normal diet (N, 18% protein) and leucine-rich diet (L, 15% protein plus 3% leucine), which were further subdivided into control (N or L) or tumor-bearing (W or LW) subgroups. After 12 days, the animals were sacrificed and their carcass analyzed. The tumor-bearing groups showed a decrease in body weight and fat content. Lean carcass mass was lower in the W and LW groups (W = 19.9 0.6, LW = 23.1 1.0 g vs N = 29.4 1.3, L = 28.1 1.9 g, P < 0.05). Tumor weight was similar in both tumor-bearing groups fed either diet. Western blot analysis showed that myosin protein content in gastrocnemius muscle was reduced in tumor-bearing animals (W = 0.234 0.033 vs LW = 0.598 0.036, N = 0.623 0.062, L = 0.697 0.065 arbitrary intensity, P < 0.05). Despite accelerated tumor growth, LW animals exhibited a smaller reduction in lean carcass mass and muscle myosin maintenance, suggesting that excess leucine in the diet could counteract, at least in part, the high host protein wasting in weanling tumor-bearing rats.

Development of an in-vitro model system to investigate the mechanism of muscle protein catabolism induced by proteolysis-inducing factor

The mechanism of muscle protein catabolism induced by proteolysis-inducing factor, produced by cachexia-inducing murine and human tumours has been studied in vitro using C(2)C(12) myoblasts and myotubes. In both myoblasts and myotubes protein degradation was enhanced by proteolysis-inducing factor after 24 h incubation. In myoblasts this followed a bell-shaped dose-response curve with maximal effects at a proteolysis-inducing factor concentration between 2 and 4 nM, while in myotubes increased protein degradation was seen at all concentrations of proteolysis-inducing factor up to 10 nM, again with a maximum of 4 nM proteolysis-inducing factor. Protein degradation induced by proteolysis-inducing factor was completely attenuated in the presence of cycloheximide (1 microM), suggesting a requirement for new protein synthesis. In both myoblasts and myotubes protein degradation was accompanied by an increased expression of the alpha-type subunits of the 20S proteasome as well as functional activity of the proteasome, as determined by the 'chymotrypsin-like' enzyme activity. There was also an increased expression of the 19S regulatory complex as well as the ubiquitin-conjugating enzyme (E2(14k)), and in myotubes a decrease in myosin expression was seen with increasing concentrations of proteolysis-inducing factor. These results show that proteolysis-inducing factor co-ordinately upregulates both ubiquitin conjugation and proteasome activity in both myoblasts and myotubes and may play an important role in the muscle wasting seen in cancer cachexia.

Amelioration of CR-EAE with lisofylline: effects on mRNA levels of IL-12 and IFN-gamma in the CNS

CR-EAE is a Th1-mediated inflammatory autoimmune demyelinating disease of the CNS and serves as a model of human multiple sclerosis. Our previous studies have shown the protective effect of orally administered lisofylline in the prevention of active and passively induced acute EAE. In our present studies we have examined the efficacy and mechanism of action of lisofylline on CR-EAE. Lisofylline decreased the number and severity of paralytic attacks in mice with relapsing EAE. The reduction of clinical disease correlated with decreased levels of mRNA levels of IFN-gamma but not of mRNA levels of IL-12. These studies suggest that lisofylline may be an effective therapeutic for established Th1 mediated autoimmune disease and that it acts by blocking IL-12R signaling and not IL-12 production in vivo.

Unusual T cell receptor phenotype V gene usage of gamma delta T cells in a line derived from the peripheral nerve of a patient with Guillain-Barré syndrome

Guillain-Barré syndrome is considered to be an immune mediated disorder but the relative role of T cells and antibodies in its pathogenesis is unclear. As gut infection with Campylobacter jejuni is the most common antecedent infection it is possible that gut derived T lymphocytes might play a part in the development of the syndrome. The T cell receptor phenotype (TCR) of a nerve gamma delta T cell line obtained from a sural nerve biopsy taken from a patient with a demyelinating form of GBS was determined using polymerase chain reaction (PCR) and flow cytometry (FACS). This TCR was compared with the phenotype preferentially expressed in the peripheral blood of the same patient. The T cell nerve line was found to express V gamma 8/delta 1 which represents an unusual T cell subset normally found on lymphocytes resident in epithelial tissue such as the gut. The peripheral blood gamma delta T lymphocytes from the patient were of the V gamma 9/delta 2 subset, which is the phenotype predominantly expressed in the peripheral blood of healthy subjects. In conclusion, the presence of this unusual population of V gamma 8/delta 1(+) lymphocytes in nerve would be consistent with a pathogenetic role for gut associated lymphocytes in the pathogenesis of Guillain-Barré syndrome associated with C jejuni.

Transient changes in the synthesis of nitric oxide result in long-term as well as short-term changes in acetic acid-induced writhing in mice

A single injection of nitric oxide (NO) synthase (NOS) inhibitors prevents the development of persistent hyperalgesia induced by various manipulations, suggesting that NO precipitates long-term changes in nociception. We examined the possibility that inhibition of NOS may also be sufficient to produce long-term decreases in nociceptive assays, such as writhing, that are known to be sensitive to the short-term effects of NOS inhibitors. We characterized short- and long-term effects of NOS inhibitors, N(omega)-nitro-L-arginine (L-NAME) or 7-nitro indazole (7-NI) injected intrathecally (i.t.) in mice on acetic acid-induced writhing. Doses of L-NAME that had no effect on hot plate or tail flick latencies inhibited writhing (0. 01-30 nmol) as well as spinal nNOS activity (5 and 100 nmol) when injected i.t. 60-90 min before testing. Anti-nociception was not mimicked by D-NAME but was prevented by co-administration with the NO precursor, L-arginine. Injection i.t. of 7-NI (30 min), a selective inhibitor of neuronal NOS (nNOS), inhibited NOS activity in the spinal cord and produced anti-nociception, confirming that writhing is sensitive to inhibition of nNOS. Although the acute action of both NOS inhibitors dissipated completely by 3-6 h, a delayed and prolonged inhibition of writhing was again observed 24 h after L-NAME (5-100 nmol), a time when spinal NOS activity was no longer inhibited by L-NAME (5 and 100 nmol) or 7-NI (25 nmol). This novel effect appears to be initiated by the transient inhibition of nNOS as delayed anti-nociception was mimicked by 7-NI at doses (10-100 nmol) that no longer inhibited spinal nNOS (25 nmol) at 24 h. Co-administration with L-arginine prevented the delayed (24 h) anti-nociceptive effects of L-NAME (30 nmol). L-Arginine (30 and 100 nmol) was without effect on nociception when administered alone 60 min or 24 h prior to testing. Together these data indicate that brief changes in the activity of nNOS induce both long- as well as short-term changes in nociception.

Regulation of major histocompatibility complex and TAP gene products in preimplantation mouse stage embryos

PROBLEM

To determine the ontogeny of major histocompatibility complex (MHC) expression and TAP products in mouse embryos.

METHOD OF STUDY

mRNAs encoding MHC and associated molecules were identified by reverse transcriptase-polymerase chain reaction, and the protein products were localized by confocal microscopy.

RESULTS

mRNAs encoding class Ia (H-2Db) and class Ib (Q7/9) were present in one-cell embryos, whereas beta 2-microglobulin (beta 2-m) transcripts were not detected until the two-cell stage. Transporter TAP1, but not TAP2, transcripts were detected only in blastocysts. H-2 class Ia (classical) protein was detected on the surface of two-cell embryos, H-2 class Ib (nonclassical) protein was detected on one-cell embryos, and beta 2-m transcripts were detected on eight-cell embryos; TAP1 protein was present at low levels in the cytoplasm from the one-cell stage onward, increasing in expression in blastocysts.

CONCLUSIONS

In mice, MHC class I mRNAs encoding the heavy chain of H-2- and Q7/9-encoding Qa2 molecules are synthesized soon after conception prior to implantation. Similarly, the nonpolymorphic MHC class I-associated molecule beta 2-m also is expressed before implantation. TAP1, but not TAP2, is first detected at the blastocyst stage, thus preceding the onset of TAP2 in embryonic development.

Maternal plasma levels of vascular endothelial growth factor in normotensive pregnancies and in pregnancies complicated by pre-eclampsia

We have measured the level of vascular endothelial growth factor (VEGF) in maternal plasma during normotensive pregnancy and in pregnancies complicated by pre-eclampsia. VEGF was measured using a competitive enzyme immunoassay. Plasma VEGF was significantly elevated (P < 0.0001) in the pre-eclamptic group (median value 32.7 ng mL-1, range 10.3-64.0), compared with the normotensive group (median value 11.7 ng mL-1, range 6.3-24.3). VEGF is a potent regulator of endothelial cell function. The increased level found in women with pre-eclampsia indicates that VEGF may be involved in the maternal endothelial cell dysfunction associated with this condition. An increase in VEGF, a potent regulator of microvascular permeability, may also contribute to the extravasation of plasma proteins and the subsequent development of proteinuria, both characteristic features of pre-eclampsia.

VEGF mRNA levels in placentae from pregnancies complicated by pre-eclampsia

OBJECTIVE

To measure the mRNA levels of vascular endothelial growth factor and its receptor in the placenta following delivery after uncomplicated pregnancy and after pregnancies complicated by pre-eclampsia.

SETTING

Rosie Maternity Hospital, Cambridge.

MATERIAL

Placental biopsies were obtained following delivery by caesarean section in 23 cases of pregnancy presenting at a range of gestational ages with pre-eclampsia. These were compared with biopsies from 20 appropriately matched women with uncomplicated pregnancies.

MAIN OUTCOME MEASURE

mRNA levels of vascular endothelial growth factor (VEGF) and its receptor the fins-like tyrosine kinase (flt), were quantified in total RNA isolated from placental biopsies using the RNAse protection assay. The amount of RNA was compared with that of the housekeeping gene glyceraldehyde 3-phosphate dehydrogenase (GAPDH), used as a standard. Results were expressed as arbitrary optical density units of VEGF/GAPDH and flt/GAPDH.

RESULTS

In both control and pre-eclamptic women regression analysis showed that the level of mRNA encoding VEGF declined significantly with gestational age (P < 0.0001). However, levels of VEGF mRNA were significantly lower in the pre-eclamptic women compared with the control women (P < 0.023).

CONCLUSIONS

This study provides evidence of an abnormality of growth factor expression in the placenta during pregnancies complicated by pre-eclampsia. Such placentae exhibit deficient growth and differentiation of terminal villi and reduced fetal capillary branching and reduced levels of VEGF could well account for these morphometric changes. This finding provides a molecular explanation for this abnormal placental development and points to VEGF as a factor in the aetiology of pre-eclampsia and its complications.

Expression of prostacyclin and thromboxane synthases in placenta and placental bed after pre-eclamptic pregnancies

Prostacyclin and thromboxane are potent antagonistic regulators of vascular tone and platelet aggregation. In pre-eclampsia, the ratio of their metabolites is decreased. Little is known about the local regulation of intrauterine prostacyclin and thromboxane production in this condition. Placenta and placental bed biopsies were obtained from uncomplicated and pre-eclamptic pregnancies. Prostacyclin synthase (PCS) and thromboxane synthase (TXS) and their mRNA's were localized by immunohistochemistry using monoclonal antibodies and in situ hybridization. Protein and mRNA levels were quantified by immunoblot and RNase protection assay. PCS-like immunoreactivity was found in endothelial cells and leiomyocytes, whereas fetal and maternal macrophages showed positive staining for TXS. Their mRNA was localized to trophoblast and endothelium, and TXS mRNA could also be detected in macrophages. Quantitative analysis showed no significant difference in intrauterine protein or mRNA expression after pre-eclampsia. The prostacyclin and thromboxane production seems to be compartmentalized within the uteroplacental unit. The expression of their synthesizing enzymes might be regulated post-transcriptionally. Additional regulation of prostaglandin production could be metabolically or on the substrate level and requires further elucidation.

Pharmacology of the nicotinic acetylcholine receptor from fetal rat muscle expressed in Xenopus oocytes

The fetal rat muscle nicotinic acetylcholine receptor was expressed in Xenopus oocytes. Using the voltage-clamp technique, the response to a range of agonists was measured, listed in order of (decreasing) activity efficacy: anatoxin > or = epibatidine > acetylcholine > DMPP (1,1-dimethyl-4-phenylpiperazinium) > > cytisine > pyrantel > nicotine > coniine > tubocurare > lobeline. The agonist responses were compared with the steric and electrostatic properties of the molecules, using molecular modelling. Single-channel current were measured in outside-out patches for acetylcholine, nicotine, cytisine, anatoxin and epibatidine. The conductance of the single channels was independent of the type of agonist. The mean open times were characteristic of the agonist applied. Tubocurare, better known for its antagonist properties, was also a partial agonist. Single-channel currents were also observed for tubocurare, and for methyllycaconitine in patches with a very high density of the muscle nicotinic acetylcholine receptor, and these were blocked by alpha-bungarotoxin. The agonist properties of physostigmine, galanthamine and their methyl derivatives were also investigated. The conductance of the channels observed in outside-out patches was similar to that obtained for the classical agonists. The single-channel currents observed for physostigmine, galanthamine and their methyl derivatives were blocked by alpha-bungarotoxin, methyllycaconitine and mecamylamine, in contrast to previously reported studies on neuronal and adult muscle nicotinic acetylcholine receptors.

Localization of vascular endothelial growth factor and its receptor, flt, in human placenta and decidua by immunohistochemistry

Vascular endothelial growth factor is a secreted angiogenic growth factor the mRNA of which is present in the placenta. The mRNA encoding the vascular endothelial growth factor receptor, flt, has also been demonstrated in placenta, with trophoblast appearing to be a novel site of flt expression. We investigated the expression of both vascular endothelial growth factor and flt-like immunoreactivity in first trimester and term placentae. In the first trimester, vascular endothelial growth factor immunoreactivity was localized to placental macrophages (Hofbauer cells), and in decidua, to glandular epithelium and maternal macrophages. In the term placenta, vascular endothelial growth factor immunoreactivity was present in extravillous trophoblast and in extracellular material. Flt immunoreactivity was demonstrated on extravillous trophoblast in first trimester and term, and on Hofbauer cells within placental villi. This complex pattern of both vascular endothelial growth factor and flt-like immunoreactivity suggests that vascular endothelial growth factor may be involved not only in the regulation of placental angiogenesis, but also in trophoblast invasion.

Physostigmine, galanthamine and codeine act as 'noncompetitive nicotinic receptor agonists' on clonal rat pheochromocytoma cells

The acetylcholine esterase inhibitor (-)-physostigmine has been shown to act as agonist on nicotinic acetylcholine receptors from muscle and brain, by binding to sites on the alpha-polypeptide that are distinct from those for the natural transmitter acetylcholine (Schröder et al., 1994). In the present report we show that (-)-physostigmine, galanthamine, and the morphine derivative codeine activate single-channel currents in outside-out patches excised from clonal rat pheochromocytoma (PC12) cells. Although several lines of evidence demonstrate that the three alkaloids act on the same channels as acetylcholine, the competitive nicotinic antagonist methyllycaconitine only inhibited channel activation by acetylcholine but not by (-)-physostigmine, galanthamine or codeine. In contrast, the monoclonal antibody FK1, which competitively inhibits (-)-physostigmine binding to nicotinic acetylcholine receptors, did not affect channel activation by acetylcholine but inhibited activation by (-)-physostigmine, galanthamine and codeine. The three alkaloids therefore act via binding sites distinct from those for acetylcholine, in a 'noncompetitive' fashion. The potency of (-)-physostigmine and related compounds to act as a noncompetitive agonist is unrelated to the level of acetylcholine esterase inhibition induced by these drugs. (-)-Physostigmine, galanthamine and codeine do not evoke sizable whole-cell currents, which is due to the combined effects of low open-channel probability, slow onset and slow inactivation of response. In contrast, they sensitize PC12 cell nicotinic receptors in their submaximal response to acetylcholine. While the abundance of nicotinic acetylcholine receptor isoforms expressed in PC12 cells excludes identification of specific nicotinic acetylcholine receptor subtypes that interact with noncompetitive agonists, the identical patterns of single-channel current amplitudes observed with acetylcholine and with noncompetitive agonists suggested that all PC12 cell nicotinic acetylcholine receptor subtypes that respond to acetylcholine also respond to noncompetitive agonist. The action of noncompetitive agonists therefore seems to be highly conserved between nicotinic acetylcholine receptor subtypes, in agreement with the high level of structural conservation in the sequence region harboring major elements of this site.

Growth factors in pregnancy

The role of growth factors in pregnancy is a rapidly expanding subject. With the advent of molecular biological techniques more and more detailed information is available to the researcher. This review does not attempt to be exhaustive in its coverage of growth factors in pregnancy, rather it tries to give a brief taste of the possible roles that they may play in pregnancy by considering three specific factors, leukaemia inhibitory factor, colony stimulating factor-1 and vascular endothelial growth factor.

Health and Nutrition Examination Survey of 1971-75: Part II. Tinnitus, subjective hearing loss, and well-being

The Health and Nutrition Examination Survey of 1971-75 contains valuable information because it provides unbiased estimates of the state of hearing in the general population. Here, three facets of the subjective aspects of hearing loss are examined: frequent and bothersome tinnitus, ratings of hearing, and general well-being. The period prevalence of frequent, bothersome tinnitus varied with race and gender (13 to 17%) with higher rates among blacks and females. The mean air-conduction thresholds (0.5 to 4 kHz) of those reporting frequent and bothersome tinnitus did not exceed 32 dB HL. Mean audiograms associated with those who rated both ears good, fair, poor, or deaf were significantly different from each other. Mean poorer ear audiograms for those rating one ear as good were significantly better than those for comparable symmetrical ratings. Last, there was no clear, consistent relationship between audiometric thresholds and measures of well-being.

Health and Nutrition Examination Survey of 1971-75: Part I. Ear and race effects in hearing

The Health and Nutrition Examination Survey of 1971-75 contains unique hearing data because its design permits generalization to noninstitutionalized civilians in the continental United States. Air-conduction thresholds and their relationships to age, ear, gender, frequency, and race were examined in unscreened 25- to 74-year-olds. Although the observed effects of age, gender, and frequency were expected, three aspects of the results were remarkable. First, there was support for previous observations that older females have poorer low-frequency hearing. Second, there was an ear effect among white males who had poorer 2 and 4 kHz mean thresholds on the left at all ages. Third, there was a pattern of poorer mean thresholds for blacks that was particularly evident in comparisons between black and white females.

Isolated duodenal varices as a cause of massive gastrointestinal bleeding

Portal hypertension and the development of varices in areas of portosystemic venous anastomoses can lead to dramatic and life-threatening haemorrhage. Varices most commonly occur in the gastro-oesophageal region but ectopic varices can arise at other sites in the gastrointestinal tract. This report describes a patient with massive haemorrhage from duodenal varices. We believe the case highlights the importance of considering ectopic varices as a cause of gastro-intestinal haemorrhage especially when oesophageal varices are absent.

Otologic complaints in temporomandibular joint syndrome

Complaints of diminished hearing or reduced speech discrimination frequently accompany temporomandibular dysfunction. There is no consensus as to the mechanism of their occurrence or the alteration of these symptoms with the treatment. We studied 12 subjects with internal derangement of the temporomandibular joint (treated surgically) and nine subjects with myofascial pain disorder (treated medically), and we found no difference between the groups in pretreatment audiometric findings or in their degree of otologic symptoms. Similarly, there were no differences in posttreatment audiometric measures and there were no significant treatment effects. Furthermore, there was no correlation between subjects' complaints of reduced hearing sensitivity or discrimination and audiometric results. The apparently significant reduction in symptoms experienced by some subjects in the absence of audiometric change suggests the operation of unmeasured factors in their response to treatment.

Central auditory processing disorders in the elderly: the effects of pure tone average and maximum word recognition

We previously examined central auditory processing disorders and the effect of age in 1026 64- to 93-yr-olds. Here, we correlated three indices of central auditory processing disorders with age, pure tone averages (PTA) and maximum word recognition scores. With one exception, correlations of indices with PTA equaled or exceeded those with age. With one exception, correlations with word recognition scores were insignificant or smaller than those with age. Although statistically significant, the magnitudes of most effects were small (0.003 less than r2 less than 0.146). However, PTA accounted for approximately 30% of the variability in corrected Staggered Spondaic Word test error scores.

Variance analysis refines overhead cost control

Many healthcare organizations may not fully realize the benefits of standard cost accounting techniques because they fail to routinely report volume variances in their internal reports. If overhead allocation is routinely reported on internal reports, managers can determine whether billing remains current or lost charges occur. Healthcare organizations' use of standard costing techniques can lead to more realistic performance measurements and information system improvements that alert management to losses from unrecovered overhead in time for corrective action.

Hearing in the elderly--the Framingham cohort, 1983-1985: Part II. Prevalence of central auditory processing disorders

The relation between central auditory processing disorders (CAPD) and age has been described in selected subjects. However, the prevalence of CAPD in the general population has not been established. We tested 1026, 64- to 93-yr-old members of the Framingham Heart Study cohort with Central Institute for the Deaf W-22 lists (CID W-22) in quiet, the Synthetic Sentence Identification test with ipsilateral competing message (SSI-ICM), and the Staggered Spondaic Word test. The presence or absence of CAPD could be established with at least one of three indices in 1018 subjects. The CID W-22 performance-intensity function rollover index was greater than 0.20 in 1.4% of 1009 subjects. The difference between maximum CID W-22 and SSI-ICM (0 dB message-to-competition ratio) scores was greater than 20% in 18.2% of 816 subjects. The Staggered Spondaic Word category was moderately, severely, over-corrected moderately, or over-corrected severely abnormal in 10.7% of 941 subjects (using 12-59-yr-olds' norms and adjusting scores when appropriate). Abnormal results on any one index occurred in 22.6% of the subjects. Thus, we conclude that the prevalence of CAPD in the elderly is less common than previous studies would suggest. Furthermore, although the rate of CAPD increased with age, age accounted for no more than 15% of the variability of any of the three indices. Therefore, its presence is dominated by factors other than chronological age.

The role of percutaneous transluminal angioplasty in the treatment of critical ischaemia

In an attempt to establish the overall role played by percutaneous transluminal angioplasty in the treatment of critical ischaemia we studied 101 consecutive patients (110 limbs) who presented to one vascular unit over an 18 month period with this diagnosis. All patients underwent assessment with Doppler waveform analysis and arteriography and decisions about further management were made jointly by the surgical team and vascular radiologist. Results showed that only 24/110 limbs (22%) had lesions that were suitable for treatment with angioplasty alone. In addition one patient underwent angioplasty in conjunction with a distal bypass. Forty-one of the 110 limbs (37%) underwent reconstructive surgery, 18/110 (16%) primary amputation and 26/110 (24%) conservative treatment. Of those 24 limbs undergoing angioplasty, four were technically unsuccessful, and six were technically successful but without clinical improvement and all required alternative treatment. Only 12/110 limbs (11%) showed clinical improvement during their admission following angioplasty. We conclude that although angioplasty can be used successfully to treat critical ischaemia the overall numbers of patients who are suitable for treatment and who gain benefit from it is small.

The use of computed tomography in the evaluation of large multinodular goitres

This study reports one unit's experience of the value of computed tomography (CT) in the evaluation of 24 patients with large cervical and retrosternal goitres. Of these patients, 17 were thought clinically to have symptoms of tracheal compression, but the CT demonstrated significant narrowing in only 12 cases. In the other five patients, surgery was deferred and other causes for their symptoms sought and treated. Seven patients were asymptomatic and CT failed to reveal any evidence of tracheal compression in six. In the remaining patient, however, CT revealed gross narrowing and urgent surgery was performed. When compared with CT, chest/thoracic inlet radiographs were misleading in 48% of patients, with tracheal narrowing being overestimated and underestimated. We conclude that CT gives useful information about tracheal compression in patients with large multinodular goitres, and is more accurate than chest/thoracic inlet radiographs.

Incidence of hearing decline in the elderly

Pure-tone audiometry was done on 1475 persons on two occasions 6 years apart by the same audiologist in the same facility. The age of the subjects ranged from 58 to 88 years at the initial testing and 63 to 95 at the second. The average 6-year threshold change ranged from 1 to 8 dB at 250-6 kHz and 10-15 dB at 8 kHz. The differences in thresholds fell into two patterns, one for low frequencies (250-1 kHz) and the other for high frequencies (4-8 kHz). For the lows, thresholds worsened at an increasing rate with increasing age independent of the initial hearing level, and women's thresholds worsened more than men's. For the highs, the rate of threshold change decreased with age and with the initial threshold at rates that did not differ between genders. Using a change in PTA (0.5, 1, 2 kHz) of greater than 10 dB as a criterion, significant worsening occurred in the right ear in 8.5%, in the left ear in 13.5%, and in both ears of 4.1% of the subjects over the 6 year period. The rate of significant worsening increased with age. Although hearing loss increased with age, age alone accounted for less than 10% of the variance. Therefore, factors that co-vary with age may be responsible. The difference in phenomena between the low frequencies and the highs suggests that two different processes are occurring. Hair-cell degeneration is the most likely cause for the change in the high frequencies. Strial atrophy or other intracochlear processes may be the cause of the low frequency changes.