VNUS Closure radiofrequency ablation of varicose veins

Endovenous procedures are increasingly being used to eliminate epifascial variose veins. The radiofrequency therapies VNUS Closure and VNUS Closure FAST Catheter have established themselves and boast very good results compared to other endovenous procedures with regard to closure rates and postoperative quality of life. Equipment and method: Between February 2005 and December 2009, a total of 2413 patients comprising 3366 great and small saphenous veins were operated upon at the Vascular and Venous Diseases Department of DERMATOLOGIKUM HAMBURG. 2241 great and small saphenous veins were treated with the VNUS Closure FAST catheter, 1125 great and small saphenous veins were treated with the Closure PLUS catheter system. Additionally, 264 recurrent varicose veins were treated with the Closure FAST system. Ultrasound examinations were conducted 7 days after the treatment, again 6 weeks after the treatment, and at the follow-up examination one year after treatment. Any recanalisations were treated immediately. Between January 2007 and January 2009, 57 patients were also treated for perforant veins between stages C-4 and C-6. Gender and age distributions, as well as CEAP classifications corresponded to standard distributions. Compression stockings were only administered in the case of advanced chronic venous insufficiency (C-4 to C-6). The patients were anticoagulated before treatment by means of a low molecular weight heparin as a single shot prophylactic. Anticoagulation through thrombocyte aggregation inhibitors or dicumarin was continued. Results: 1089 great and small saphenous veins were examined after removal with Closure PLUS radiofrequency therapy. The primary closure rate after 6 weeks was 98.9%; after one year, 91.2%; after two years 99.0%; after three years, 98.2%; and after four years, 100%. 2241 great and small saphenous veins were treated with the VNUS Closure FAST Radiofrequency System. 2096 great and small saphenous veins were examined after treatment. The primary closure rate after 7 days was 99.7%; after 6 weeks, 99.6%; after one year, 98.8%; and after two years, 100%. The rate of minor complications after Closure FAST Radiofrequency catheter treatment of the great saphenous vein was 5.3%; after treatment of the small saphenous vein, 5.9% in total. No major complications – such as deep vein thromboses or pulmonary embolisms – were caused, and neither was burning of the skin. The closure rate one week after RFS treatment was 84.6%; after 6 weeks, 86.2%; and after one year, 78.3%. In all of the recurring varicose veins, the recirculation was successfully eliminated. Conclusion: The VNUS Closure FAST Radiofrequency catheter represents a standardised, established procedure for treating epifascial varicose veins to ensure the certain elimination of recirculation. The development of Closure PLUS 6-French and 8-French catheter into Closure FAST Radiofrequency catheter has led not only to a reduced operation duration but also a safe and high closure rate after follow-up. With the new concept of segmental ablation the Closure FAST system eliminates the catheter pullback variability and standardises and simplifies the procedure. The success of the treatment is shown by the complete decomposition of the vein underneath the inflow of the superficial epigastric vein or the inflow of the gastrocnemic veins. However, the long term results for the Closure FAST system are awaited eagerly. The current high closure rates and high patient satisfaction rates give us cause to look ahead with hope.

Decentralization, Privatization, and the Solvency of Local Governments in Reforming Economies: The Case of Budapest

In many reforming socialist economics like Hungary, the ownership of previously state-owned assets has been transferred to local governments as part of the decentralization and privatization reforms. The authors discuss these recent reforms in Budapest, and examine their impact on the solvency of local governments there. The analysis suggests that a continuation of the current pricing policies now in place in Budapest will pose serious long-run solvency problems for the new local governments that have been given ownership of the assets, effectively decapitalizing many of them. Even so, the privatization is unlikely to lead to a change in these pricing policies, and it may well lead the local governments to undertake actions that adversely affect the broader stabilization program.

Breastmilk fatty acids in relation to sensitization - the ALADDIN birth cohort

BACKGROUND

Breastmilk fatty acids (FAs) have been associated with childhood allergic disease. Children of families with an anthroposophic lifestyle have a low prevalence of sensitization compared to reference groups. This study aimed to investigate whether the lower prevalence of sensitization among these children can be explained by the differences in breastmilk FA composition.

METHODS

The prospective birth cohort ALADDIN included 330 children from anthroposophic, partly anthroposophic and nonanthroposophic families recruited between 2004 and 2007 in Sweden. In total, 245 breastmilk samples, collected at 2 months of age, were analysed for FA composition. Allergen-specific IgE levels against seven common allergens were measured in the blood samples at the ages of 6, 12 and 24 months. Data were analysed longitudinally using generalized estimating equations.

RESULTS

An inverse association was observed between total concentration of omega-3 PUFA in breastmilk and sensitization in the child up to 24 months of age (highest vs lowest quartile, RRadj 0. 49, 95% CI 0.23-1.05, P for trend 0.024). No associations were observed between omega-6 PUFAs or ruminant FAs and sensitization. Overall, we observed 56% lower risks of sensitization among the anthroposophic group compared to the nonanthroposophic group (RRadj 0.44, 95% CI 0.21-0.90). This association remained largely unchanged when breastmilk omega-3 PUFA was included in the model.

CONCLUSION

Our results indicate that a higher concentration of omega-3 PUFAs in breastmilk may be associated with a reduced risk of sensitization up to 24 months of age; however, this did not explain the lower risk of sensitization among children of anthroposophic families.

Increased incidence of chronic GvHD and CMV disease in patients with vitamin D deficiency before allogeneic stem cell transplantation

Vitamin D has emerged as a central player in the immune system, with its deficiency being implicated in the pathogenesis of several autoimmune diseases, including chronic GvHD. This is a retrospective cohort analysis of 166 patients, who underwent allogeneic hematopoietic stem cell transplantation (HSCT) at the Karolinska University Hospital, evaluating GvHD, graft failure, infectious complications and survival after HSCT in relation to pre-transplantation vitamin D levels. Most of the patients were deficient in vitamin D before HSCT (median 42 nmol/L). In multivariate analysis, vitamin D level before HSCT was identified as a significant independent risk factor for development of cGvHD. The increased incidence of cGvHD was not coupled to better disease-free survival; instead there was a trend towards lower overall survival in the vitamin D-deficient patients. In addition, we found a significant correlation between vitamin D deficiency and incidence of CMV disease, with no case of CMV disease occurring in patients with sufficient levels of vitamin D before HSCT. Our results support a role of vitamin D in immune tolerance following HSCT. These findings could be highly relevant for the care of HSCT patients, and prospective, randomized studies on the effect of vitamin D supplementation are therefore needed.

Use of antibiotics in infancy and childhood and risk of recurrent abdominal pain--a Swedish birth cohort study

BACKGROUND

The etiology of recurrent abdominal pain of functional origin (AP) is largely unknown. Antibiotic treatment influences the intestinal microbiota, and a few studies have indicated an increased risk of AP in adults after antibiotic treatment. Corresponding data in children are lacking. The aim of this study was to explore the association between antibiotic treatment during childhood and AP at 12 years.

METHODS

Two thousand seven hundred and thirty-two children from a Swedish, population-based birth cohort. Parents reported antibiotic use for the children between birth and 2 years. Antibiotic use between 9 and 12 years was collected from the Swedish Prescribed Drug Register. The children answered questionnaires regarding AP at age 12. We used logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for AP at 12 years as a function of antibiotic use.

KEY RESULTS

Antibiotic treatment between 9 and 12 years was not associated with AP at 12. Children who had received ≥3 courses, or broad-spectrum antibiotics between 9 and 12 years had an increased risk of AP at 12, but these associations failed to reach statistical significance. Antibiotic treatment during both the first and the second year of life increased the risk of AP in girls at 12 (OR 1.65; 95% CI: 1.09-2.49), but not in boys or the whole cohort.

CONCLUSIONS & INFERENCES

Antibiotic treatment does not seem to be a major risk factor for AP at 12 years. However, we cannot exclude that repeated courses, especially to infant girls, or use of broad-spectrum antibiotics between 9 and 12 years may be associated with an increased risk of AP.

Differences in exosome populations in human breast milk in relation to allergic sensitization and lifestyle

BACKGROUND

Breast-feeding has many beneficial effects on the developing immune system of the newborn. Breast milk contains immunoregulatory factors, such as nano-sized vesicles named exosomes. This study aimed at characterizing breast milk exosomes from human early milk and mature milk and to investigate whether allergic sensitization and an anthroposophic lifestyle could influence the exosome profile.

METHODS

Breast milk was collected from 22 mothers at day 3-8 and from 61 mothers at 2 months postpartum, all part of the ALADDIN birth cohort. Isolated exosomes were captured on anti-MHC-class II- or anti-CD63 beads and analyzed by flow cytometry. Exosomal phenotype was related to lifestyle and allergic sensitization of the mothers, and sensitization of the child at 2 years of age.

RESULTS

We found a higher content of exosomes in early milk compared with mature milk. Early milk exosomes were enriched in HLA-DR molecules and displayed significantly lower levels of HLA-ABC compared with those in mature milk. Phenotypically different subpopulations of exosomes were found in mature milk. Significantly lower levels of MUC1 were detected on CD63-enriched exosomes from sensitized mothers compared with nonsensitized. Furthermore, women with an anthroposophic lifestyle had significantly lower MUC1 expression on their HLA-DR-enriched milk exosomes and up-regulated levels of CD63 on CD63-enriched exosomes compared with nonanthroposophic mothers. Notably, mothers whose children developed sensitization had an increased amount of HLA-ABC on their milk exosomes enriched for CD63.

CONCLUSIONS

The phenotype of exosomes in breast milk varies with maternal sensitization and lifestyle, which might influence allergy development in the child.

Protein biomarkers in vernix with potential to predict the development of atopic eczema in early childhood

Background

Atopic eczema (AE) is a chronic inflammatory skin disease, which has increased in prevalence. Evidence points toward lifestyle as a major risk factor. AE is often the first symptom early in life later followed by food allergy, asthma, and allergic rhinitis. Thus, there is a great need to find early, preferentially noninvasive, biomarkers to identify individuals that are predisposed to AE with the goal to prevent disease development.

Objective

To investigate whether the protein abundances in vernix can predict later development of AE.

Methods

Vernix collected at birth from 34 newborns within the Assessment of Lifestyle and Allergic Disease During INfancy (ALADDIN) birth cohort was included in the study. At 2 years of age, 18 children had developed AE. Vernix proteins were identified and quantified with liquid chromatography coupled to tandem mass spectrometry.

Results

We identified and quantified 203 proteins in all vernix samples. An orthogonal projections to latent structures-discriminant analysis (OPLS-DA) model was found with R² = 0.85, Q² = 0.39, and discrimination power between the AE and healthy group of 73.5%. Polyubiquitin-C and calmodulin-like protein 5 showed strong negative correlation to the AE group, with a correlation coefficient of 0.73 and 0.68, respectively, and a P-value of 8.2 E-7 and 1.8 E-5, respectively. For these two proteins, the OPLS-DA model showed a prediction accuracy of 91.2%.

Conclusion

The protein abundances in vernix, and particularly that of polyubiquitin-C and calmodulin-like protein 5, are promising candidates as biomarkers for the identification of newborns predisposed to develop AE.

[Phlebology in German departments of dermatology. An analysis on behalf of the German Society of Phlebology]

BACKGROUND

Phlebologic diseases have become extremely common and have major socio-economic impact. However, the percentage of dermatologists working in phlebology appears to be decreasing according to the data of the German Society of Phlebology (DGP).

METHODS

To investigate the reasons for this development, we--on behalf of the DGP--sent a questionnaire to 120 German Departments of Dermatology in autumn 2012.

RESULTS

In 76 returned questionnaires, the number of physicians with additional fellowship training in phlebology averaged 1.5; the average number of those who fulfill the criteria for training fellows in phlebology was 0.9. In 71.1 % of the departments there was a phlebologist. A special phlebologic outpatient clinic existed in 73.7 % of the departments. Sonography with Doppler (89.5 %) and duplex (86.8 %) was used as the most frequent diagnostic tool. For therapy, compression (94.7 %), sclerotherapy (liquid 78.9 %, foam 63.2 %, catheter 18.4 %), endoluminal thermic procedures (radio wave 28.9 %, laser 17.1 %) and surgery (especially crossectomy and stripping 67.1 %, phlebectomy of tributaries 75 %) were used. The average number of treatments was very heterogenous in the different departments.

CONCLUSIONS

Phlebology definitely plays an important role in dermatology. Most departments fulfill the formal criteria for the license to conduct advanced training in phlebology. A wide spectrum of phlebological diagnostic and therapeutic procedures is available.

Growth in Long-Chain 3-Hydroxyacyl-CoA Dehydrogenase Deficiency

Long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency is an inborn error of fatty acid metabolism that affects the degradation of long chain fatty acids and causes insufficient energy production and accumulation of toxic intermediates. The treatment consists of a diet low in fat, with supplementation of medium-chain triglycerides that bypass the metabolic block. In addition, frequent feeds and extra carbohydrates are given during febrile illnesses to reduce lipolysis. Hence, this diet differs from the general dietary recommendations for growing children. Furthermore, the Swedish dietary instructions for fat intake in LCHAD deficiency are given in grams, which differ from most guidelines that recommend fat intake as percentage shares of total caloric intake.

AIMS

To assess growth in patients with LCHAD deficiency, in relation to dietary treatment and to evaluate if overweight/obesity is more common than in the normal population.

RESULTS

The growth velocity showed acceleration after diagnosis and the start of treatment, followed by a period of stable or decelerated growth. The majority of the patients developed overweight to a greater extent than children without LCHAD deficiency. Several patients also went through a phase of obesity. Data on final height (FH) showed that three out of five patients had grown according to their genetic potential.

CONCLUSIONS

Regular and frequent follow-up and careful monitoring of weight are essential to avoid the development of overweight and obesity. The Swedish dietary instructions defining fat intake in total grams per day may be an alternative approach to achieve a moderate total caloric intake.

Lifestyle factors and sensitization in children - the ALADDIN birth cohort

BACKGROUND

Several cross-sectional studies indicate that an anthroposophic lifestyle reduces the risk of allergy in children. We initiated the Assessment of Lifestyle and Allergic Disease During Infancy (ALADDIN) birth cohort to elucidate the role of specific factors supposed to mediate this effect. The aims of this study are to describe the ALADDIN cohort and to report patterns of exposure and allergic sensitization during the first years of life.

METHODS

The ALADDIN study is a prospective birth cohort study of 330 children from families with an anthroposophic, partly anthroposophic, or nonanthroposophic lifestyle. The children and their parents were following an extensive data collection scheme, including repeated questionnaires and biological samples. Blood samples were collected from the parents and from the child at birth as well as at 6, 12, and 24 months of age.

RESULTS

Several lifestyle factors differed between the groups, such as diet, medication, and place of delivery. Children of families with an anthroposophic lifestyle had a markedly decreased risk of sensitization during the first 2 years of life compared with children of nonanthroposophic families with adjusted OR 0.25 (95% CI 0.10-0.64) and P-value 0.004. A similar situation held true for children from families with a partly anthroposophic lifestyle, adjusted OR 0.31 (95% CI 0.15-0.54), and P-value 0.002.

CONCLUSIONS

The anthroposophic lifestyle comprises several factors of interest for allergy development and is here shown to be associated with reduced risk of IgE sensitization already in infancy. Identifying the factors responsible for this association would be of significant clinical importance.

Placental macrophage (Hofbauer cell) polarization is independent of maternal allergen-sensitization and presence of chorioamnionitis

BACKGROUND

Macrophages can polarize in which M1/classically activated and M2/alternatively activated macrophages are considered to be the extremes. M1 macrophages are involved in inflammatory reactions, while M2 macrophages are suggested to be involved in homeostasis, parasite killing, tumor promotion, tissue remodeling and in allergic reactions. We hypothesized that polarization of placental macrophages (Hofbauer cells) is influenced by the allergen-sensitization status of the mother and/or the presence of chorioamnionitis, a placental inflammation. This Hofbauer cell polarization might be associated to the intrauterine environment and influence the risk of allergy development for the child. Therefore we aimed to determine the polarization status of Hofbauer cells in health and disease.

METHODS

We determined the expression of CD68, CX3CR1, IL-7R, DC-SIGN/CD209 and CD163 in placentas of sensitized versus non-sensitized mothers (n = 17), and placentas with or without histological chorioamnionitis (n = 10) by means of immunohistochemical analysis and quantitative real-time PCR (qPCR).

RESULTS

Protein expression of the M1 markers (CX3CR1, IL-7R and CCR7) could not be detected in any of the analyzed samples while the M2 markers (DC-SIGN, CD163 and mannose receptor/CD206) were readily detected. Significant differences between non-sensitized versus sensitized mothers and uncomplicated versus chorioamnionitis complicated pregnancies were not detected at protein or at mRNA expression level.

CONCLUSIONS

These results suggest that Hofbauer cells have an M2 phenotype, and that their polarization is not affected by maternal allergen-sensitization or by presence of chorioamnionitis.

Lifestyle and parental allergen sensitization are reflected in the intrauterine environment at gene expression level

BACKGROUND

Environmental factors, including the intrauterine environment, can influence the risk of allergy development. In the present study, we investigated whether lifestyle and parental allergen sensitization status are reflected at gene expression level in the intrauterine environment.

METHODS

  mRNA expression of 17 genes was determined by means of quantitative real-time PCR in term placenta of 36 families participating in the ALADDIN study (Assessment of Lifestyle and Allergic Disease During Infancy). Data were analysed using a linear regression model to estimate the influence of lifestyle and parental allergen sensitization on the relative mRNA expression levels. Immunohistochemistry on placenta biopsies was used to verify protein expression.

RESULTS

Significant differences in mRNA expression levels were detected at the foetal side of the placenta, where CD14 was expressed at higher levels in placentas from families living on a farm compared to not living on a farm, and IL-12(p40) was expressed at lower levels when the father was sensitized compared to nonsensitized. At the maternal side of the placenta, higher expression of STAT4 and lower expression of GATA3 were detected in families with sensitized compared to nonsensitized mothers, and IL-12(p40) was lower expressed when the families were living on a farm compared to not living on a farm. Immunohistochemistry performed for STAT4 and GATA3 showed that protein and mRNA levels correlated well.

CONCLUSION

Living on a farm and parental allergen sensitization are reflected in the intrauterine environment at the gene expression level.

Evidence for allergen-specific IgE of maternal origin in human placenta

BACKGROUND

Immunoglobulin E (IgE) has been identified on macrophage-like cells in the villi of human placenta, irrespective of the serum IgE levels or allergy status of the mother. The origin of placental IgE is debated and it is not known if it is spontaneously produced, so-called 'natural IgE', or if it has any specificity for certain allergens. The aim of this study was to investigate if placental IgE originates from mother or child and to analyse its specificity.

METHODS

Immunoglobulin E was eluted from placenta by lowering the pH. Total and allergen-specific IgEs were measured in placenta eluate, maternal and cord blood plasma by means of ImmunoCAP (Phadia AB). The levels of natural antibodies were determined with an anti-phosphorylcholine (PC) enzyme-linked immunosorbent assay, as natural IgE has been shown in one previous publication with this assay.

RESULTS

Detectable amounts of IgE were eluted from 11/12 full-term placentas. Natural (anti-PC) IgE antibodies were detected in low amounts in maternal plasma but not in the placental eluate or in cord blood plasma. There was a significant correlation between the amount of total IgE eluted from placenta and the levels of total IgE in maternal plasma; however, not between maternal and cord blood plasma. Allergen-specific IgE was only found in placental eluates from mothers with specific IgE towards these allergens. Furthermore, there was a significant correlation between the amount of allergen-specific IgE eluted from placenta and the levels of allergen-specific IgE in maternal plasma. Allergen-specific IgE could not be detected in cord blood.

CONCLUSION

These results suggest a maternal origin of placental IgE, which can be allergen-specific.

Family conditions and dietary control in phenylketonuria

OBJECTIVE

This investigation is an attempt to describe coping with phenylketonuria (PKU) in order to understand some aspects underlying good compliance.

METHODS

The coping concept was applied to PKU in two questionnaires. Self- and parental ratings were combined with assessments of phenylalanine levels and the severity of the disease. All Swedish patients with PKU born in 1980-91, a total of 53 children and youths with their parents, were invited to participate in the study and 41 (77%) of them did so.

RESULTS

The patients turned out to have good compliance with the diet. The main result was that patients with separated or divorced parents were more likely to have higher phenylalanine levels and this association was not diminished by adjustment for the potential confounding factors.

CONCLUSION

Patients' need for support must be judged individually according to different family conditions.

A trial with N-carbamylglutamate may not detect all patients with NAGS deficiency and neonatal onset

N-acetylglutamate synthase (NAGS) deficiency is a rare urea cycle disorder. An effective treatment, N-carbamoyl-L-glutamic acid (NCGA), is now available, increasing the importance of identifying and treating these patients early. We describe a case with genetically verified NAGS deficiency and neonatal onset of severe hyperammonaemia. The ammonia levels increased above 1400 micromol/L. The patient did not respond to NCGA treatment during the first 15 h, indicating that a delayed response or no response cannot be used as a safe indicator for excluding NAGS deficiency in the acute situation. Hence, conventional treatment should not be delayed by a diagnostic procedure, such as a loading test. Furthermore, at 3 years of age this patient has normal psychomotor development, underlining the possibility of a favourable outcome despite markedly elevated ammonia levels, coma, and seizures in the neonatal period. Including NCGA early in the treatment of patients with hyperammonaemia may be of clinical importance. In order to detect patients with NAGS deficiency and neonatal onset and to optimize care, it is important to use the available treatment strategies to reduce plasma ammonia concentrations without delay. We propose the use of combined symptomatic treatment, i.e. glucose infusion, sodium benzoate, arginine or citrulline, and when indicated haemodialysis, as well as NCGA treatment in all neonates presenting with severe hyperammonaemia. The treatment should be continued until laboratory investigations are complete or indicate another disorder.

Bacterial and fungal components in house dust of farm children, Rudolf Steiner school children and reference children--the PARSIFAL Study

BACKGROUND

Growing up on a farm and an anthroposophic lifestyle are associated with a lower prevalence of allergic diseases in childhood. It has been suggested that the enhanced exposure to endotoxin is an important protective factor of farm environments. Little is known about exposure to other microbial components on farms and exposure in anthroposophic families.

OBJECTIVE

To assess the levels and determinants of bacterial endotoxin, mould beta(1,3)-glucans and fungal extracellular polysaccharides (EPS) in house dust of farm children, Steiner school children and reference children.

METHODS

Mattress and living room dust was collected in the homes of 229 farm children, 122 Steiner children and 60 and 67 of their respective reference children in five European countries. Stable dust was collected as well. All samples were analysed in one central laboratory. Determinants were assessed by questionnaire.

RESULTS

Levels of endotoxin, EPS and glucans per gram of house dust in farm homes were 1.2- to 3.2-fold higher than levels in reference homes. For Steiner children, 1.1- to 1.6-fold higher levels were observed compared with their reference children. These differences were consistently found across countries, although mean levels varied considerably. Differences between groups and between countries were also significant after adjustment for home and family characteristics.

CONCLUSION

Farm children are not only consistently exposed to higher levels of endotoxin, but also to higher levels of mould components. Steiner school children may also be exposed to higher levels of microbial agents, but differences with reference children are much less pronounced than for farm children. Further analyses are, however, required to assess the association between exposure to these various microbial agents and allergic and airway diseases in the PARSIFAL population.

Adjustment and intelligence among children with phenylketonuria in Sweden

In this investigation we present a recent survey of treatment effects among 8 to 19-y-old Swedish children and youths with phenylketonuria (PKU). The results from intelligence tests and a questionnaire comprising four scales, work capacity, social competence, and internalising and externalising problems, were used. Severity of disease, early treatment, and contemporary phenylalanine levels were assessed. The results showed that development of the patients' intelligence was normal. Adjustments were rated by the patients, their parents and their teachers, and the results were compared with those of a healthy reference group. The PKU patients did not differ from the reference group except for externalising problems judged by the children themselves. None of the patients with PKU showed signs of externalising problems in contrast to the reference group, where such behaviour was observed. Patients with severe PKU, however, showed less social competence compared with patients with a milder form of the disease, according to their own and their parents' ratings. Phenylalanine level in blood tests was in accordance with treatment norms, although the teenagers had higher levels of phenylalanine than the younger patients.

CONCLUSION

Normal intelligence and adjustment is found among patients with PKU when plasma phenylalanine levels are within treatment norms.

Greenhouse gases in non-oxygenated and artificially oxygenated eutrophied lakes during winter stratification

Concentrations of dissolved methane (CH4), carbon dioxide (CO2), and nitrous oxide (N2O) were measured in the water columns of non-oxygenated and artificially oxygenated, ice-covered eutrophied lakes in the mid-boreal zone in Finland during late winter 1997 and 1999. Sampling was conducted during winter stratification, the critical period for oxygen (O2) deficiency in seasonally ice-covered, thermally stratified lakes. Oxygen concentrations were maintained at least at a moderate level throughout the oxygenated water columns, whereas the non-oxygenated columns suffered anoxic hypolimnia. The mean concentrations of dissolved CH4 exceeding the atmospheric equilibrium were greater in the non-oxygenated water columns (20.6-154 microM) than in the oxygenated ones (0.01-1.41 microM). In contrast, the mean excess CO2 concentrations varied less between the non-oxygenated and oxygenated sites (0.28-0.47 and 0.25-0.31 mM, respectively). Oxygenated water columns had greater mean excess concentrations of N2O (0.018-0.032 microM) than the non-oxygenated ones (0.005-0.024 microM). If the accumulated greenhouse gas stores in the water columns during winter are assumed to be released to the atmosphere during the spring overturn, the global warming potentials (GWP, time horizon 100 yr) of these potential emissions at the non-oxygenated, eutrophic study sites ranged from 177 to 654 g CO2 equivalent (CO2-e) m-2 compared with 144 to 173 g CO2-e m-2 at the oxygenated sites. The increase in the accumulation of CH4 was the main reason for the higher GWP of the non-oxygenated sites. Anthropogenic eutrophication of lake ecosystems can generate increased CH4 emissions due to associated O2 depletion of their sediment and water column.

Response to treatment in patients with partial androgen insensitivity due to mutations in the DNA-binding domain of the androgen receptor

The androgen insensitivity syndrome is a disorder caused by deficient function of the androgen receptor, characterized by varying degrees of undermasculinization in karyotypic males. We have identified four mutations in the androgen receptor gene, in the region encoding the DNA-binding domain of the protein. Two mutations, R607X and R615G, were found in patients with complete insensitivity to androgens, whereas the other two, S578T and A596T, were found in patients with partial insensitivity. The functional consequences of the three missense mutations were assayed in vitro after transient expression of the receptors in COS cells. All mutants showed normal androgen binding but abnormal abilities to stimulate transcription of an androgen-responsive reporter gene. R615G abolished transactivation whereas S578T and A596T were partially malfunctional. The function of A596T, but not of S578T, was normalized at high androgen concentrations in vitro, reflecting the in vivo situation. Thus, patients with specific mutations in the DNA-binding domain of the androgen receptor may benefit from androgen treatment.

Prevalence of coeliac disease in Turner syndrome

This study was undertaken to investigate the prevalence of coeliac disease in children and adolescents with Turner syndrome. Eighty-seven children and adolescents with Turner syndrome were screened for IgA-antiendomysium antibodies (EMA) and IgA-antigliadin antibodies (AGA), 5% (4/87) being found to be EMA-positive, and 15% (13/87) to have AGA levels above normal. Of the 10 patients who were either AGA- or EMA-positive and further investigated with intestinal biopsy, four manifested villous atrophy (i.e. all three of the EMA-positive patients, but only one of the seven AGA-positive patients). The results suggest EMA-positivity to be a good immunological marker for use in screening for coeliac disease, and such screening to be justified in patients with Turner syndrome.

Income taxes and the timing of marital decisions

"In this paper we estimate the impact of the [U.S.] federal individual income tax on the timing of marital decisions.... Using household data from the Panel Study on Income Dynamics, we estimate various models of the probability of delaying marriage as a function of the change in tax burden caused by marriage (as well as several other variables). We find that there is a significant positive relationship between the marriage penalty in a year and the probability of delaying marriage until the following year. The magnitude of the effect, however, is small."

Improved final height in girls with Turner's syndrome treated with growth hormone and oxandrolone

The spontaneous growth process in Turner's syndrome is characterized by a progressive decline in height velocity during childhood and no pubertal growth spurt. Therefore, therapy aimed at improving height during childhood as well as increasing final height is desirable for most girls with Turner's syndrome. Forty-five girls with Turner's syndrome, 9-16 yr of age (mean age, 12.2 yr), were allocated to three study groups. Group 1 (n = 13) was initially treated with oxandrolone alone; after 1 yr of treatment, GH without (group 1a; n = 6) or with (group 1b; n = 7) ethinyl estradiol was added. Group 2 (n = 17) was treated with GH plus oxandrolone. Group 3 (n = 15) was treated with GH, oxandrolone, and ethinyl estradiol. The dosage were: GH, 0.1 IU/kg.day; oxandrolone, 0.05 mg/kg.day; and ethinyl estradiol, 100 ng/kg.day. A height of 150 cm or more was achieved in 61%, 75%, and 60% of the girls in groups 1, 2, and 3, respectively. The most impressive increase in height was seen in group 2. In this group the mean final height was 154.2 cm (SD = 6.6), which is equivalent to a mean net gain of 8.5 cm (SD = 4.6) over the projected final height. In group 3, in which ethinyl estradiol was included from the start of therapy, the initially good height velocity decelerated after 1-2 yr of treatment. Their mean final height was 151.1 (SD = 4.6) cm, equivalent to a mean net gain of 3.0 cm (SD = 3.8). A similar growth-decelerating effect of ethinyl estradiol was seen in group 1b. We conclude that in girls with Turner's syndrome who are older than 9 yr of age, treatment with GH in combination with oxandrolone results in significant growth acceleration, imitating that in normal puberty, leading to a more favorable height during childhood. This mode of treatment also results in a significantly increased final height, permitting a great number of the girls to attain a final height of more than 150 cm. However, early addition of estrogen decelerates the height velocity and reduces the gain in height.

Does the income tax affect marital decisions?

"This paper discusses new empirical evidence on the role of income tax incentives in marital decisions [in the United States]. Time-series evidence suggests that taxes have a small but statistically significant effect on the aggregate marriage rate; however, this evidence is sensitive to the time period and the measure of marriage. Additional evidence, based on household longitudinal data, indicates that the probability of marriage falls and that of divorce rises with an increase in the so-called marriage tax, and that the timing of marriage (though not of divorce) is also affected by taxes. In short, there is strong evidence that taxes affect some marital decisions."

3-Hydroxydicarboxylic aciduria--a fatty acid oxidation defect with severe prognosis

We describe five patients with a suspected defect in the beta-oxidation of fatty acids characterized by a massive excretion of 3-hydroxydicarboxylic acids in the urine and accumulation of 3-hydroxy fatty acids in serum during acute illness. Long-chain and medium-chain acyl-coenzyme A dehydrogenases in fibroblasts were normal in all patients. Four of them died of cardiomyopathy and liver insufficiency at 3 to 14 months of age. Two of the patients had elder siblings who had died unexpectedly in early infancy. These patients differ from previously described patients with beta-oxidation defects.

Growth factors and the thyroid: effects of treatment for hyper- and hypothyroidism on serum IGF-I and urinary epidermal growth factor concentrations

We investigated the impact of thyroid hormone levels on serum concentrations of IGF-I and urinary epidermal growth factor (EGF) in hyper- and hypothyroid patients before and during medical treatment. Serum IGF-I levels measured with radioreceptor-assay decreased in 12 hyperthyroid patients from 1.25 (1.02-1.80) to 1.02 (0.77-1.78) X 10(3) U/l (P less than 0.01), whereas a non-significant increase in 8 hypothyroid patients--from 1.14 (0.85-1.40) to 1.39 (1.08-1.80) X 10(3) U/l was recorded. Urinary EGF, measured with radioimmunoassay decreased in 10 hyperthyroid patients from 68.0 (38.0-122.9) to 40.9 (23.6-100.3) micrograms/g creatinine (P less than 0.001) and increased in 7 hypothyroid subjects from 23.8 (17.5-35.8) to 36.1 (24.7-60.1) micrograms/g creatinine (P less than 0.05). In hyperthyroidism, but not in hypothyroidism, the urinary excretion of creatinine changed significantly from 0.66 (0.26-1.21) to 1.52 (0.81-2.59) g/l (P less than 0.001) during treatment, thus affecting the EGF excretion values. However, a comparison of untreated hyperthyroid with untreated hypothyroid patients showed a highly significant difference in EGF excretion (P less than 0.001) despite a non-significant difference in creatinine excretion between the two groups. FT4 I concentrations correlated significantly (r = 0.83) (P less than 0.001) to EGF values in untreated hyper- and hypo-thyroid patients. Data from the present study thus conform with the view that the growth promoting effect of thyroid hormones involves a stimulated synthesis or release of classic growth factors.

Neonatal hyperthyroidism alters hepatic epidermal growth factor receptor ontogeny in mice

Epidermal growth factor (EGF) liver receptor ontogeny and somatic growth were studied in mice from day 7 to day 70 postnatally to assess long-term effects of short-term postnatal thyroxine treatment. The mice were given 0.4 micrograms thyroxine/g body weight/day for the 1st wk of life. EGF receptor binding in liver tissue was studied on days 7, 15, 20, 30, and 70 postnatally. Treated animals had accelerated eyelid opening and tooth eruption, and permanent growth retardation was obvious from the second week of life. Hepatic EGF receptor-binding capacity increased markedly in control mice with increasing age in contrast to a very slow increase in treated mice, making the difference statistically significant (P less than 0.01) from day 30. The affinity of EGF receptor binding initially was similar in the two groups of animals (1.09 x 10(9) M-1 and 1.02 x 10(9) M-1) and increased by day 30 in controls (2.57 x 10(9) M-1), an increase that was not observed in treated animals either at day 30 or 70. These results suggest a sensitive period of imprinting during the first 7 days postnatally, a period when thyroxine can exert a permanent effect on later growth and later hepatic EGF receptor number.

Effect of thyroid hormone and sex status on epidermal growth factor concentrations in the submandibular gland of a congenitally hypothyroid mouse model

Studies were performed to explore the role of thyroid hormone and sex status on epidermal growth factor concentrations in the submandibular gland of a congenitally hypothyroid mouse model designated hyt/hyt. The animals were studied at 20, 30 and 40 days of postnatal age. The euthyroid animals were homozygous or heterozygous for the hypothyroid gene. The homozygous euthyroid animals displayed a pattern of submandibular gland epidermal growth factor concentrations similar to those previously described in other mouse species and showed the expected sex differences. The hypothyroid animals had measurable but very low submandibular gland epidermal growth factor concentrations without sexual dimorphism. Serum thyroxine concentrations in the heterozygotes were comparable to those in the homozygous euthyroid animals, yet the animals had a delayed increase in epidermal growth factor concentrations combined with a later expression of female-male differences. The timing of the sex differences in submandibular gland epidermal growth factor concentrations followed a pattern similar to that seen for the timing of the first litter in these three genetically distinct groups. This infers the timing of the onset of puberty and suggests a role of androgens in the changes seen in epidermal growth factor concentrations. We conclude that thyroid hormone and sex status in this mouse model influence the pattern and concentrations of submandibular gland epidermal growth factor concentrations.

Epidermal growth factor receptor ontogeny in mice with congenital hypothyroidism

To assess the effect of endogenous thyroid hormone on hepatic EGF receptors in developing mice we measured EGF binding to plasma membrane receptors in liver and brain of mice with congenital hypothyroidism and in euthyroid controls at 20, 30 and 40 days of age. At 20 days hepatic EGF receptor binding was low in both hypothyroid and control animals. Between 20 and 30 days the hepatic binding increased dramatically in the euthyroid animals, an increase that was greater in males than females. The increase in binding was due to an increase in the high affinity receptor population. Among hypothyroid animals there were no changes in hepatic EGF receptor binding with increasing age. In cerebral cortex EGF binding was similar in euthyroid and hypothyroid animals at all ages. These results suggest that thyroxine has regulatory effects on the postnatal ontogeny of hepatic EGF receptors.

Sexual dimorphism and testosterone effects on liver epidermal growth factor receptors in mice

A sexual dimorphism (M greater than F) for liver EGF receptor binding capacity has been observed in developing mice. To assess the aetiology of this sexual dimorphism we studied the effect of exogenous testosterone administration on liver EGF receptors in adult mice. In control animals the maximal binding capacity of liver EGF receptors in females was 57% of that in males. The affinity konstant (Ka) was 1.59 X 10(9) l/mol in females compared with 3.11 X 10(9) in males. Treatment with testosterone every second day for 14 days resulted in an increase in the binding capacity with 17% in males and 80% in females making the maximal binding capacity in females equal to that in untreated males. Receptor Ka was unchanged by treatment in males, but Ka in treated females was increased to the level of males (2.96 X 10(9) l/mol). These results indicate that the sexual dimorphism of hepatic EGF receptors involves receptor affinity and capacity; both are increased by testosterone in females.

Maternal TSH-receptor antibodies and TSH antibodies in screening for congenital hypothyroidism

Serum samples from 30 mothers who had given birth to at least one child with a positive neonatal thyrotropin (TSH) screening test were analysed for TSH-receptor antibodies. One mother with hypothyroidism after thyroiditis who had two sons who had had transient congenital hypothyroidism, showed significantly elevated concentrations of TSH receptor blocking IgG antibodies in her serum. The three daughters of another mother had neonatal hyperthyrotropinaemia but normal thyroid hormone levels. This woman had elevated serum levels of TSH but was clinically and biochemically euthyroid. The apparent hyperthyrotropinaemia in this family was due to an artifact in the TSH radioimmunoassay caused by maternal anti-TSH IgG antibodies. It is obvious that placental transfer of maternal IgG antibodies to the thyroid TSH receptor is one cause of transient congenital hypothyroidism. Likewise, maternal IgG directed against TSH interferes with radioimmunoassays of TSH and the results may be falsely interpreted as hyperthyrotropinaemia. It is concluded that in neonatal hyperthyrotropinaemia analysis of the mother's serum is indicated, and that maternal TSH receptor blocking antibodies must be considered as a cause of congenital hypothyroidism, especially if the mother has a history of thyroid dysfunction.

Children with inborn errors of phenylalanine metabolism: prognosis and phenylalanine tolerance

Twenty-three children, who were detected by neonatal PKU screening, were followed for 8-18 years in one paediatric centre. Dietary treatment was started if the blood phenylalanine level exceeded 0.72 mmol/l. All 23 infants were initially given a low phenylalanine diet. The growth and development rates of the children did not differ significantly from those in a reference population, although one child had mild mental retardation and another had a short attention span. Fourteen children were still on a strict phenylalanine-restricted diet on their last follow-up (at 8-18 years of age). In nine children who were initially put on a low phenylalanine diet, it was possible to normalize the diet between 1/2 and 10 years of age, while maintaining the blood phenylalanine levels between 0.25 and 0.72 mmol/l. It seems likely that those of our patients who markedly increased their phenylalanine tolerance during childhood had a regulatory mutation of the phenylalanine hydroxylase system. A continuous reevaluation of each child treated with a low phenylalanine diet reduces the use of unnecessarily restricted diets.

Neonatal hyperthyroidism in mice has different effects on epidermal growth factor levels in submandibular gland, urine, and blood

We examined long-term effects of neonatal hyperthyroidism in female mice by measuring the epidermal growth factor levels in the submandibular gland, urine, and serum at the age of 31 days. Hyperthyroxinemia was induced by thyroxine injections (0.4 microgram/g/day) on days 0-6. Littermate controls received the alkaline saline vehicle. The treatment accelerated incisor eruption and eyelid opening. It also retarded growth. The elevation of plasma thyroxine concentration which normally occurs during wk 2 to reach a peak around day 15 was abolished. Submandibular gland epidermal growth factor levels on day 31 were markedly subnormal, indicating maturational delay. In contrast, epidermal growth factor levels were unaffected in urine and supranormal in serum. These differences in response suggest that the regulatory mechanisms governing epidermal growth factor levels in tissues and fluids may acquire thyroid hormone dependence at different stages.

Nerve growth factor in mouse milk during early lactation: lack of dependency on submandibular salivary glands

Using a specific and sensitive nerve growth factor radioimmunoassay we show measurable quantities of beta nerve growth factor in mouse milk during the period of early lactation. Partial purification by cationic exchange resin yielded a preparation which exhibited biological activity in a PC-12 cell bioassay system. Submandibular-sublingual sialoadenectomy had no influence on the breast milk NGF concentrations. These results support the presence of bioactive NGF in mouse milk during early lactation, but do not clarify the source.

Epidermal growth factor in mouse milk during early lactation: lack of dependency on submandibular glands

Using a specific and sensitive radioimmunoassay, we found epidermal growth factor (EGF) in mouse milk during early lactation in normal and sialoadenectomized mice. Levels of EGF peaked around the 6th day postpartum and decreased thereafter up to day 12. Sephadex G-50 column chromatography of milk from normal and sialoadenectomized mice showed a single immunoreactive component comigrating with purified 6045 dalton EGF from the mouse submandibular gland. The concentrations of EGF were similar in milk collected from the breast and the stomach of the offspring immediately after feeding. The molecular profiles, concentrations, and ontogeny of EGF in milk of control and sialoadenectomized mice were also similar, suggesting that the submandibular gland is not the major source of EGF in mouse breast milk.

Incidence of congenital hypothyroidism: retrospective study of neonatal laboratory screening versus clinical symptoms as indicators leading to diagnosis

Filter paper blood samples taken routinely from 100 239 newborn infants were radioimmunoassayed five years later for plasma thyrotrophin concentrations. In 32 cases (0.03%) these were found to be raised. Thirty one of these children were traced and subjected to follow up examination by a paediatrician and a psychologist. Of the 31 children, 15 were found to have been receiving treatment for congenital hypothyroidism since a median of 5 months of age (diagnosed group). Of the 16 others, seven children were found to have raised serum thyrotrophin concentrations and were classified as hypothyroid (undiagnosed group). The remaining nine children were euthyroid. Children in the diagnosed group had a mean Griffiths developmental quotient of 87 (control value 103; p less than 0.01), and five out of 13 showed impaired neurological development. Of the remainder, those in the undiagnosed group had a mean developmental quotient of 100 and those in the euthyroid group a mean developmental quotient of 107. In this study achieving a detection rate of congenital hypothyroidism of one in 3000 in a neonatal screening programme resulted in overdiagnosis of about a quarter of patients considered to have true positive findings. This was outweighed, however, by the early identification of all infants with the disease.

Congenital hypothyroidism and changes in the enamel of deciduous teeth

Deciduous teeth from children with congenital hypothyroidism were collected and ground sections were prepared. The sections were analysed by means of polarized light and microradiography. The enamel in ground sections of deciduous teeth from children with congenital hypothyroidism showed an increase in areas with elevated pore volume distribution in both the pre- and postnatal enamel. The findings suggest that thyroid hormone influences enamel maturation. Further, alterations in enamel structure, presumably due to prenatal thyroid deficiency, were found to be more common among children with neurological abnormalities at the age of 7 to 9 years.

Health economic analysis of the Swedish neonatal metabolic screening programme. A method of optimizing routines

A benefit-cost analysis was carried out to optimize the routines for neonatal metabolic screening. The basis of the study was provided by results of the Swedish neonatal screening programme from 1965 to 1979. During this period over one million infants were screened by the Guthrie test for phenylketonuria and galactosaemia, and for limited periods also for tyrosinaemia, homocystinuria and histidinaemia. The benefit-cost ratio was calculated for combinations of different screening tests, recall routines, and varying degrees of coverage. The largest benefit-cost ratio was obtained with combined screening for phenylketonuria and galactosaemia, using a borderline blood phenylalanine level of 0.50 mmol/L in the Guthrie test for phenylketonuria. However, the inaccuracy of this test necessitated the use of a lower blood phenylalanine level of 0.25 mmol/L and the acceptance of a lower benefit-cost ratio. An increase in the present 98% coverage of newborns by the screening programme was found to be an effective means of improving the benefit-cost ratio in the present programme.

Congenital hypothyroidism in Sweden. Psychomotor development in patients detected by clinical signs and symptoms

Thirty-nine children at 7 to 9 years of age with congenital hypothyroidism have been studied with respect to their intellectual, neurological and social functions. Their intellectual achievement as assessed by the WISC test, was significantly lower than in a reference population (mean IQ 88, range 50-113). In children who showed signs and symptoms of hypothyroidism during their first four weeks of life, there was a negative correlation between the age when therapy was started and intellectual development. No such correlation was found in children who showed signs and symptoms after the first four weeks of life. Nine children of 26 with signs of hypothyroidism in the neonatal period, were found to have neurological abnormalities consisting of fine and gross motor disturbances. The neurological abnormalities seriously affected daily life in only the two most severely mentally retarded. No correlation was found between the age when the therapy was started and neurological abnormalities. Three children attended special schools because of mental retardation and six attended normal schools but required additional teaching assistance for learning disabilities. Our results suggest that the risk of future intellectual handicaps may be reduced by early treatment in children with hypothyroidism presenting during the neonatal period.

Evaluation of a nation-wide neonatal metabolic screening programme in Sweden 1965-1979

In Sweden, neonatal screening for phenylketonuria was started in 1965 and a total of 1 326 000 infants were studied up to 1979. During various periods of time, screening was also carried out for galactosaemia, hereditary tyrosinaemia, histidinaemia, and homocystinuria. In screening for phenylketonuria and galactosaemia no false-negative results were obtained and the incidences were 1/30 850 and 1/81 100, respectively. In screening for hereditary tyrosinaemia only 1 out of 6 patients was identified by screening and the incidence was 1/106 710. Two cases of histidinaemia were detected, which corresponds to an incidence of 1/36 840. Both children developed normally without any treatment. No child with homocystinuria was detected in the screened population of more than 300 000 newborn infants. A screening programme involving phenylketonuria and galactosaemia was considered to be optimal among the tested disorders.