Small size, big problems: insights and difficulties in prenatal diagnosis of fetal microcephaly

Microcephaly is a sign, not a diagnosis. Its incidence varies widely due to the differences in the definition and the population being studied. It is strongly related to neurodevelopmental disorders. Differences in definitions and measurement techniques between fetuses and newborns pose a great challenge for the diagnosis and prognostication of fetal microcephaly. A false positive diagnosis can result (in countries where it is legal) in erroneous termination of pregnancy, where a false negative diagnosis might lead to the birth of a microcephalic newborn. Microcephaly in growth restricted fetuses deserves special attention and separate evaluation as it is an important prognostic factor, and not necessarily part of the general growth retardation. Several genetic syndromes incorporating microcephaly and intrauterine growth retardation (IUGR) are discussed. Deceleration of the head circumference (HC) growth rate even when the HC is still within normal limits might be the only clue for developing microcephaly and should be considered during fetal head growth follow up. Combining additional parameters such as a positive family history, associated anomalies, and new measurement parameters can improve prediction in about 50% of cases, and thus should be part of the prenatal workup. Advances in imaging modalities and in prenatal genetic investigation along with the emergence of new growth charts can also improve diagnostic accuracy. In this article, we review the different definitions and etiologies of fetal microcephaly, discuss difficulties in diagnosis, investigate the reasons for the low yield of prenatal diagnosis, and provide improvement suggestions. Finally, we suggest an updated algorithm that will aid in the diagnosis and management of fetal microcephaly.

Entourage effect for phenolic compounds on production and metabolism of mammary epithelial cells

Primary culture of mammary epithelial cells (MEC) was exposed to ethyl-acetate, chloroform and hexane extracts of Pistacia lentiscus (lentisk). The hexane extract contained mainly ethyl gallate whereas the chloroform extract contained mainly ethyl-gallate with smaller amount of gallic acid, and the ethyl-acetate extract contained mainly rutin, gallic acid and myricetin. Ethyl acetate extract increased secretion of protein and fat and improved mitochondrial activity. The enhancing effect on protein production was attributed to myricetin, one of the polyphenols in the ethyl-acetate extract whereas gallic acid did not affect protein production or secretion. Interestingly, exposure to the isolated polyphenols did not improve mitochondrial productivity and activity as effectively as exposure to the complete plant extract. The results indicated that polyphenols improve production of milk constituents by MEC, through different modes of action for different polyphenols suggesting an additive or even synergistic effect on production traits of mammary cells.

Sudden cardiac death caused by migration of a TrapEase inferior vena cava filter: case report and review of the literature

CASE

A 43-year-old female presented with sudden onset of palpitations, chest pain, and shortness of breath associated with hypoxemia. A helical computed tomography (CT) scan of the chest revealed a large saddle pulmonary embolism. Intravenous tPA relieved the shortness of breath and improved the hypoxemia. Inferior vena cava (IVC) filter (TrapEase, Cordis Corp., Miami, FL, USA) was placed. On day 6 of her hospitalization, she went into cardiopulmonary arrest while walking back from the rest room. The patient died despite a prolonged attempt at cardiopulmonary resuscitation. At that time, ventricular tachycardia and then ventricular fibrillation were recorded. Autopsy of the heart showed the IVC filter entrapped within the tricuspid valve.

DISCUSSION

The incidence of IVC filter migration ranges from 0.3 to 6% with rare migration to the heart or lung (0.1-1.25%). Sudden cardiac death from migration of IVC filter is extremely rare. We report the first case of sudden cardiac death caused by migration of the TrapEase filter to the heart. There are two reports in the literature of death from migrating Greenfield and Antheor filters.

CONCLUSION

An IVC filter migration to the heart, although rare, can cause serious arrhythmia and sudden cardiac death.

Vaccination against influenza in rheumatoid arthritis: the effect of disease modifying drugs, including TNF alpha blockers

OBJECTIVE

To assess the efficacy and safety of vaccination against influenza virus in patients with rheumatoid arthritis, with special emphasis on the effect of disease modifying antirheumatic drugs (DMARDs), including tumour necrosis factor alpha (TNFalpha) blockers.

METHODS

82 rheumatoid patients and 30 healthy controls were vaccinated with a split-virion inactivated vaccine containing 15 mug haemagglutinin (HA) per dose of each of B/Hong Kong/330/2001 (HK), A/Panama/2007/99 (PAN), and A/New Caledonian/20/99 (NC). Disease activity was assessed by tender and swollen joint count, morning stiffness, evaluation of pain, Health Assessment Questionnaire, ESR, and C reactive protein on the day of vaccination and six weeks later. Haemagglutination inhibiting (HI) antibodies were tested by a standard WHO procedure. Response was defined as a fourfold or more rise in HI antibodies six weeks after vaccination, or seroconversion in patients with a non-protective baseline level of antibodies (<1/40). Geometric mean titres (GMT) were calculated to assess the immunity of the whole group.

RESULTS

Six weeks after vaccination, a significant increase in GMT for each antigen was observed in both groups, this being higher in the healthy group for HK (p=0.004). The percentage of responders was lower in rheumatoid patients than healthy controls (significant for HK). The percentage of responders was not affected by prednisone or any DMARD, including methotrexate, infliximab, and etanercept. Indices of disease activity remained unchanged.

CONCLUSIONS

Influenza virus vaccine generated a good humoral response in rheumatoid patients, although lower than in healthy controls. The response was not affected by the use of prednisone or DMARDs.

The anticoagulant therapy with bivalirudin to assist in the performance of percutaneous coronary intervention in patients with heparin-induced thrombocytopenia (ATBAT) study: main results

Up to 5% of patients given heparin develop heparin-induced thrombocytopenia (HIT). These patients may need anticoagulation for acute coronary syndromes (ACS) or percutaneous coronary intervention (PCI), a clinical challenge given the limited alternatives. In a prospective, open-label study, we evaluated the safety and efficacy of bivalirudin in patients with HIT or HIT with thrombotic syndrome (HITTS) undergoing PCI. Patients aged 18 years were enrolled in 24 centers in 2 countries. Bivalirudin was given 5 minutes before PCI (1 mg/kg bolus; 2.5 mg/kg/hour infusion for 4 hours [high-dose group] or 0.75 mg/kg bolus; 1.75 mg/kg/hour infusion [low-dose group]). Clinical and hematological measures were assessed within 24 hours after starting bivalirudin, just before PCI, just before sheath removal, and 48 hours after treatment or at discharge, whichever occurred first. The primary endpoint was major bleeding 48 hours after discontinuation or until discharge, whichever occurred first. From July 1999 to February 2003, 52 patients were recruited. Procedural success (TIMI grade 3 flow and < 50% stenosis) was achieved in 98% of patients, and clinical success (absence of death, emergency bypass surgery, or Q-wave infarction) was achieved in 96%. One high-dose patient who underwent elective bypass surgery had major bleeding (1.9%; 95% CI: 0.05 10.65%), and 7 patients had minor bleeding. No patient had significant thrombocytopenia (platelet count < 50 109/L) after treatment. One patient in the low-dose group died from cardiac arrest ~46 hours after uncomplicated PCI. Bivalirudin appeared safe and provided effective anticoagulation during PCI. These data, and extensive experience with bivalirudin in PCI, support its use in high-risk patients with HIT requiring PCI.

Endovascular intervention of aortoiliac occlusive disease in high-risk patients using the kissing stents technique: Long-term results

Endovascular intervention deploying a kissing stents (KS) technique has been used as an alternative to surgical intervention in treating symptomatic aortoiliac occlusive disease. However, the long-term results on high-risk patients are unknown. We retrospectively analyzed data on high-risk patients who underwent endovascular intervention using the KS technique at our institution. Fifty high-risk patients aged 62 +/- 6.4 years with severe aortoiliac stenosis underwent stent-supported angioplasty using the KS technique. Thirty percent of the patients had total occlusion of the distal aorta and/or the iliac arteries. Twelve patients received thrombolytics prior to stenting. The procedure was successful in all 50 patients. There was a 4% acute complication rate (distal embolization). However, there were no vascular complications, myocardial infarction, or perioperative death. Primary patency during follow-up of 20 +/- 12.3 months was 92%, while secondary patency rate was 100%. Amputation-free survival was 100%. Ninety-two percent remained free of lifestyle-limiting claudication.

Prospective randomized study of N-acetylcysteine, fenoldopam, and saline for prevention of radiocontrast-induced nephropathy

The objective of this study was to compare the efficacy of N-acetylcysteine (NAC), fenoldopam, and saline in preventing radiocontrast-induced nephropathy (RCIN) in high-risk patients undergoing cardiovascular procedures. We prospectively enrolled 123 patients who were scheduled for cardiovascular procedures and had a baseline creatinine > 1.6 mg/dl or creatinine clearance of < 60 ml/min. Patients were randomly assigned to receive either saline (0.45% normal saline at 1 cc/kg) for 12 hr before and 12 hr after the procedure, or fenoldopam (0.1 microg/kg/min) plus saline for 4 hr prior and 4 hr after the procedure, or NAC orally (600 mg) plus saline every 12 hr for 24 hr prior and 24 hr after the procedure. All the patients received low-osmolality nonionic contrast. RCIN was defined as an increase in creatinine level > 0.5 mg/dl after 48 hr. The incidence of RCIN was 17.7% in the NAC group, 15.3% in the saline group, and 15.7% in the fenoldopam group (P = 0.919). Of the 20 patients who developed RCIN, 2 required dialysis. Serum creatinine decreased after 48 hr (vs. baseline) in 38% patients in the NAC group, 18% in the fenoldopam group, and 15% in the saline group. In patients with chronic renal insufficiency, NAC or fenoldopam offered no additional benefit over hydration with saline in preventing RCIN.

Are singleton assisted reproductive technology pregnancies at risk of prematurity?

PURPOSE

Our purpose was to determine the risk of premature delivery among singleton pregnancies derived from assisted reproduction technology (ART).

METHODS

Ninety-five singleton ART pregnancies and 190 matched spontaneous pregnancies were assessed for preterm delivery rates, pregnancy complications, and cesarean section rates in a retrospective study at an academic medical center.

RESULTS

Among the ART singleton deliveries group (n = 95), 19 (20%) were preterm, which was statistically significantly higher than the 4% (8 of 190) found in the control group. Among the pregnancies achieved by intracytoplasmic sperm injection (ICSI) in the severe male-factor infertility subgroup (n = 22), only one preterm delivery occurred (4.5%).

CONCLUSIONS

Singleton ART pregnancies are at an increased risk of preterm delivery compared to singleton pregnancies after spontaneous conception. The higher rate may be attributed to various infertility cofactors, such as uterine malformations, previous operative procedures that involved cervical dilatation, and a history of pelvic infection. This is supported by the finding that ICSI-derived pregnancies in couples with strict male-factor infertility are not at an increased risk of preterm delivery.

Effect of antibiotic therapy in preterm premature rupture of the membranes on neonatal mortality and morbidity

The objective of this study was to evaluate the effect of prophylactic antibiotic treatment on prenatal and neonatal outcome after preterm premature rupture of the membranes (P-PROM). The study population consisted of 172 pregnant women admitted to the Rabin Medical Center in Israel with P-PROM at 23-34 gestational weeks. The patients were divided into two groups by mode of expectant management-prophylactic ampicillin and erythromycin (study group, n = 121) or observation only (control group, n = 51) and compared for neonatal outcome. There were no significant differences between the groups in age, gravidity, parity, or gestational age at admission. Significantly more women in the study group had an interval of more than 24 hours from onset of P-PROM to delivery (98 women, 81%) than the control group (32 women, 63%) (p = 0.001). The neonatal mortality rate was significantly lower in the study group (6.6%) than the control group (1 7.6%) (p = 0.03). The lower neonatal mortality rate associated with prophylactic antibiotic treatment in P-PROM has important clinical implications for the effectiveness of this type of management.

Real-time intraoperative ultrasound guidance: the transrectal approach

OBJECTIVE

To assess the role of real-time transrectal ultrasound guidance in complicated gynecologic procedures.

DESIGN

In 1998-99, real-time guidance with transrectal ultrasound was utilized in our department to assist the gynecologic surgeon in two procedures: completing the evacuation of the uterine cavity after identification of uterine wall perforation during first trimester termination of pregnancy, and drainage of infected vaginal vault hematoma following hysterectomy.

RESULTS

The technique was applied for 11 patients, six abortions and five infected hematomas. All the procedures were completed without any further complications and the patients were discharged on the following day. Follow-up was uneventful.

CONCLUSIONS

On-line intraoperative transrectal ultrasound can effectively provide real-time assistance to the gynecologic surgeon during complicated pelvic procedures.

Outcome of pregnancies derived from assisted reproductive technologies: IVF versus ICSI

PURPOSE

To compare the course and outcome of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) pregnancies.

METHODS

A retrospective study was conducted in a university-affiliated IVF unit with 200 patients who conceived in 1996-1997, 100 with ICSI and 100 with IVF. Data were retrieved from our prospectively created computerized database. In addition, all patients were interviewed by telephone, and the interviewing physician completed a detailed questionnaire. Findings for the IVF and ICSI pregnancies were compared. The main outcome measures were maternal age, implantation rate, early pregnancy complications, clinical abortion rate, multiple pregnancy delivery rate, gestational age at delivery, mode of delivery, and birth weight.

RESULTS

In all, 238 children were born, including 104 singleton infants (45 IVF, 59 ICSI), 49 twin pairs (28 IVF, 21 ICSI), and 12 triplet sets (3 IVF, 9 ICSI). Statistically significant differences between the ICSI and IVF groups were noted for maternal age (31.3 +/- 4.4 vs. 33.4 +/- 4.8, respectively, P < 0.005) and clinical abortion rate (11% vs. 24%, respectively, P < 0.05).

CONCLUSIONS

ICSI pregnancies in our series were characterized by a lower clinical abortion rate than IVF pregnancies, probably because of the mean younger age of the ICSI group.

Carotid stenting in patients older than 65 years with inoperable carotid artery disease: a single-center experience

Carotid angioplasty and stenting to treat extracranial carotid stenosis is an alternative (as yet not widely accepted) to high-risk surgery, but its safety and efficacy are little known, especially in elderly patients. We reviewed our 3-year experience of treating 100 elderly patients (> 65 years old) considered to be inoperable (76 men, 24 women, mean age 76+/-10 years, mean follow-up 18+/-9.2 months) and present two case histories. Most (85%) were symptomatic (transient ischemic attacks in 60, stroke in 25); 80 had concomitant coronary artery disease (severe in 30 [defined by > 70% stenosis in two or more epicardial coronary arteries or the left main coronary artery]) and 25 had severe left ventricular dysfunction (ejection fraction < or =20%). The procedure was technically successful in all patients; there was one major stroke and no patient died. Postprocedure, 15% had minor complications: reversible neurological deficit (5%), pulmonary edema (3%), prolonged hypotension (3%), vascular access complications (3%), and neck hematoma (1%). Over 90% of patients were discharged home within 24 hr.

Pregnancy outcome in women with primary renal disease

BACKGROUND

The preconception and intraconception parameters that are relevant to outcome in women with underlying renal disease remain controversial.

OBJECTIVES

To analyze the types and frequencies of short- and long-term (2 years after delivery) maternal and neonatal complications in 38 patients with primary renal disease (46 pregnancies), most of them with mild renal insufficiency.

METHODS

Logistic regression models were formulated to predict successful outcome.

RESULTS

Successful pregnancy outcome (live, healthy infant without severe handicap 2 years after delivery) was observed in 98% of the patients with primary renal disease. Factors found to be significantly predictive of successful outcome were absence of pre-existing hypertension, in addition to low preconception serum uric acid level.

CONCLUSIONS

Most women with primary renal disease who receive proper prenatal care have a successful pregnancy outcome. Worse pregnancy outcome was observed in women with moderate or severe renal failure. Fitted logistic models may provide useful guidelines for counseling women with preexisting renal disease about their prospects for a successful pregnancy in terms of immediate and long-term maternal and neonatal outcome.

Validation of Doppler FloWire for measurement of coronary flow reserve in humans

Previous studies have validated the 133Xenon (133Xe) method to assess regional myocardial blood flow and coronary flow reserve (CFR). Doppler FloWire (DFW) has been used recently for measuring CFR to assess the physiological significance of coronary stenosis. Data obtained by DFW has never been correlated to 133Xe. Our study compared data from DFW measurement of CFR to that obtained by 133Xe in 31 consecutive patients with variable coronary stenosis. Regional myocardial blood flow was measured by assessing the rate constants of 133Xe washout using multicrystal gamma camera after injection (20 millicuries) in the right or left coronary artery. CFR was assessed by measuring resting and hyperemic coronary blood flow by 133Xe and DFW using i.v. adenosine (140 mcg/k/min x 3 min). CFR was also measured by DFW giving intracoronary (i.c.) adenosine (12 microg in the right coronary, 18 microg in the left). In both methods--133Xe and DFW--coronary flow reserve was defined as the ratio of maximal hyperemic-to-baseline flow. DFW and 133Xe assessment of CFR correlated highly, whether adenosine was used i.c.(r=0.87; P=0.0001) or i.v.(r=0.78; P=0.0001). CFR obtained by DFW following i.c. and i.v. adenosine correlated well (r=0.79; P=0.0001). i.c. adenosine has fewer side effects. Both DFW and 133Xe are comparable in measuring CFR in humans.

Pre-operative ultrasonographic evaluation of nongravid, enlarged uteri--correlation with bimanual examination

OBJECTIVE

To correlate the size of the nongravid uterus measured by ultrasound and bimanual examination before hysterectomy, with the actual size of the specimens.

PATIENTS AND METHODS

Uterine size of 49 consecutive patients, who underwent elective hysterectomy, was assessed by bimanual pelvic examination, preoperative ultrasonographic evaluation and actual postoperative size.

RESULTS

All preoperative ultrasonographic uterine dimensions significantly correlated with the corresponding actual dimensions of the uterine specimens. Furthermore, ultrasonographic uterine length had the best correlation with uterine size estimation by bimanual examination. A formula was established in an attempt to calculate clinical uterine size by gestational week, using preoperative ultrasonographic dimensions.

CONCLUSIONS

By using the aforementioned formula, ultrasonographic uterine dimensions can be extrapolated to uterine size in terms of gestational week, and therefore, be applicable to traditional clinical practice.

Randomized, double-blind comparison of hirulog versus heparin in patients receiving streptokinase and aspirin for acute myocardial infarction (HERO). Hirulog Early Reperfusion/Occlusion (HERO) Trial Investigators

BACKGROUND

Thrombolytic therapy improves survival after myocardial infarction through reperfusion of the infarct-related artery. Thrombin generated during thrombolytic administration may reduce the efficacy of thrombolysis. A direct thrombin inhibitor may improve early patency rates.

METHODS AND RESULTS

Four hundred twelve patients presenting within 12 hours with ST-segment elevation were given aspirin and streptokinase and randomized in a double-blind manner to receive up to 60 hours of either heparin (5000 U bolus followed by 1000 to 1200 U/h), low-dose hirulog (0.125 mg/kg bolus followed by 0.25 mg x kg(-1) x h(-1) for 12 hours then 0.125 mg x kg(-1) x h(-1)), or high-dose hirulog (0.25 mg/kg bolus followed by 0.5 mg x kg(-1) x h(-1) for 12 hours then 0.25 mg x kg(-1) x h(-1)). The primary outcome was Thrombolysis In Myocardial Infarction trial (TIMI) grade 3 flow of the infarct-related artery at 90 to 120 minutes. TIMI 3 flow was 35% (95% CI, 28% to 44%) with heparin, 46% (95% CI, 38% to 55%) with low-dose hirulog, and 48% (95% CI, 40% to 57%) with high-dose hirulog (heparin versus hirulog, P=.023; heparin versus high-dose hirulog, P=.03). At 48 hours, reocclusion had occurred in 7% of heparin, 5% of low-dose hirulog, and 1% of high-dose hirulog patients (P=NS). By 35 days, death, cardiogenic shock, or reinfarction had occurred in 25 heparin (17.9%), 19 low-dose hirulog (14%), and 17 high-dose hirulog patients (12.5%) (P=NS). Two strokes occurred with heparin, none with low-dose hirulog, and two with high-dose hirulog. Major bleeding (40% from the groin site) occurred in 28% of heparin, 14% of low-dose hirulog, and 19% of high-dose hirulog patients (heparin versus low-dose hirulog, P<.01).

CONCLUSIONS

Hirulog was more effective than heparin in producing early patency in patients treated with aspirin and streptokinase without increasing the risk of major bleeding. Direct thrombin inhibition may improve clinical outcome.

Caution: prenatal clubfoot can be both a transient and a late-onset phenomenon

Clubfoot (talipes equinovarus) is a common orthopaedic malformation that can be accurately diagnosed prenatally. The study was conducted to investigate possible in utero visualization of transient and late-onset clubfoot. Early (13-16 weeks' gestation) prenatal transvaginal sonographic diagnosis of clubfoot deformity was made in 36 cases during the study period. Only those cases where follow-up examination revealed different sonographic findings were considered. The results showed that seven cases of transient (as well as relapsing) clubfoot were identified. In 4 of 7 cases, the clubfoot resolved (all after more than 10 min of observation) during the same examination. In the fifth and sixth cases, it initially resolved, later reappearing in follow-up examinations (20 and 22 weeks' gestation). In the seventh case, the clubfoot persisted for two consecutive examinations (2 weeks apart each) and later disappeared. In addition, six late-onset (22-24 weeks' gestation) clubfoot cases were identified during the study period. Although infrequent, in utero clubfoot can be both a transient and a late-onset phenomenon. Over- and under-diagnosis are potential hazards in these situations.

Development of a whole platelet ELISA to detect circulating activated platelets

P-selectin is a granule membrane protein that is expressed on the surface of activated endothelial cells and platelets. Flow cytometry has been used as a means of detecting activated platelets in the circulation by using antibodies to P-selectin and other surface markers. In the study reported here, we developed a whole platelet ELISA for measuring P-selectin on platelets in platelet-rich plasma. Platelet-rich plasma samples for analysis were isolated from fresh blood by centrifugation, fixed with 1.0% paraformaldehyde, and used within 3 hours or after storage at -70 degrees C for up to 10 months. Paraformaldehyde-fixed, phorbol myristate acetate-activated or thrombin receptor peptide-activated platelets were used to construct a standard calibration curve. These platelets were stable after 10 months of storage at -70 degrees C. Interassay variability showed a high degree of correlation, with r = 0.98 +/- 0.03 (n = 12). The accuracy and specificity of the ELISA was verified by using fluorescence-activated flow cytometric analysis and is as sensitive (< or = 0.5%) as flow cytometry for detecting P-selectin expression on platelets. To assess the ability of the platelet ELISA to detect platelet activation in the systemic circulation, we examined 24 patients with unstable angina and 12 age-matched control subjects. Patients with unstable angina demonstrated significantly higher levels of circulating activated platelets than did age-matched control subjects. Although storage-dependent differences in absolute platelet activation levels were found, platelet ELISA results of samples evaluated within either 3 hours or after 10 months of storage were comparable to results obtained by fluorescence-activated flow cytometric analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary air embolism: incidence, severity, and suggested approaches to treatment

Because no well-controlled study of inadvertent coronary air embolism has been done to truly quantify the incidence of this cardiac catheterization complication, we wanted to determine its incidence and severity in an active teaching medical center and assess approaches to treatment. We retrospectively reviewed 3,715 coronary angiogram and PTCA reports performed over 32 months. Further, we classified severity based on angiographic findings and symptoms as minimal, mild, moderate, and massive. Two independent angiographers reviewed 764 consecutive cines performed in the first 2 months of training of each new fellow and 740 cines performed in the last 2 months of training. We found that during the first 2 months of training the overall incidence for significant intracoronary air embolism was 0.19% (7 documented cases) compared with 0.2% (3 cases) for non-reported, minimal asymptomatic air embolism. The estimated incidence for total air emboli events was 0.27% (10/3,715). We did not find coronary air emboli in the 740 cines performed at the end of fellowship training. Additionally, the incidence of coronary air emboli during PTCA training was much higher compared with coronary angiography training (0.84 vs. 0.24%). Although there is no best technique to restore blood flow after blockage by air emboli, we suggest as options aspirating the air or forcefully injecting saline, with auxiliary supportive measures like 100% oxygen, IABP, CPR, and DC cardioversion.

Percutaneous balloon aortic valvuloplasty in high-risk elderly patients

From 1987 to mid-1994 we performed 16 percutaneous balloon aortic valvuloplasties. All patients (mean age 80 years; 53% female, 47% male) had significant congestive heart failure from aortic valve stenosis; the majority were categorized as New York Heart Association Class IV (shortness of breath at rest). Twelve patients were not surgical candidates; four patients refused surgery. After valvuloplasty, all patients became asymptomatic (NYHA Class I & II), the average preprocedure valvular gradient of 59 mm Hg decreased to 31 mm Hg, and valve area increased from 0.8 cm2 (0.3 cm2-0.98 cm2) to 1.3 cm2 (0.6 cm2-1.44 cm2). The only complications were two minor groin hematomas (2 patients). Within 6 months, 50% of the patients were symptomatic again; the overall survival rate was 23 months. We conclude that in the proper environment this procedure can be effective and safe--even in high-risk elderly patients. Although symptom improvement is transient, valvuloplasty provides a valuable opportunity to treat intercurrent medical conditions and possibly follow up with surgery.

Modulation of prostaglandin synthesis in mammalian sperm acrosome reaction

Exogenous arachidonic acid induces the acrosome reaction and the production of the prostaglandins PGE2 and PGF2 alpha in bovine spermatozoa. Exogenous PGE2 also induces the acrosome reaction and PGF2 alpha synthesis. To understand better the role of PGE2 in the induction of PGF2 alpha synthesis through modulation of phospholipase A2, inhibitors of this enzyme were used. The effects of PGE2 were blocked by phospholipase A2 inhibitors and this inhibition was reversed by addition of arachidonic acid. These data indicate that PGE2 activates phospholipase A2 to produce arachidonic acid. To determine whether protein kinase C modulates phospholipase A2 activity in this process, staurosporin, an inhibitor of protein kinase C, was used. The effect of PGE2 on PGF2 alpha production is inhibited by staurosporin and this inhibition was reversed by addition of arachidonic acid indicating that protein kinase C is involved in phospholipase A2 activation. The effect of exogenous arachidonic acid or PGE2 on the acrosome reaction is blocked by lipoxygenase inhibitors but not by inhibitors of cyclo-oxygenase, indicating that lipoxygenase products are involved in the mechanism of the acrosome reaction. The presented data shed light on the cross-talk between cyclo-oxygenase and lipoxygenase and their involvement in the sperm acrosome reaction. It is suggested that cyclo-oxygenase products modulate the activity of lipoxygenase which is a key enzyme in the mechanism leading to the acrosome reaction. Stimulation of cyclo-oxygenase to synthesize PGE2 activates phospholipase A2 to release arachidonic acid which is the substrate for lipoxygenase activity.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital clavicular pseudoarthrosis associated with vascular thoracic outlet syndrome: case presentation and review of the literature

Thoracic outlet syndrome (TOS) associated with congenital clavicular pseudoarthrosis is rare in adults and often misdiagnosed. In this case report, we describe an adult female who was found to have thrombosis of the subclavian and axillary arteries with embolization documented by invasive angiography. This unusual vascular manifestation of TOS should remind physicians that anatomic derangements may predispose to upper extremity ischemia.

Dual effect of spermine on acrosomal exocytosis in capacitated bovine spermatozoa

The influence on spermine on the acrosomal exocytosis of capacitated bovine spermatozoa was studied. Dual effect of spermine was observed, depending on its concentration. It was shown that 10 microM spermine stimulated acrosomal exocytosis and prostaglandin F2 alpha production, whereas higher concentrations of spermine inhibited these processes. Acrosomal exocytosis induced by spermine was inhibited by staurosporine, a specific protein kinase C (PKC) inhibitor, indicating that PKC may be involved in this stimulation. Also, acrosomal exocytosis induced by the PKC activator phorbol 12-myristate-13-acetate was inhibited by 10 mM spermine. Therefore, these data indicate that spermine is involved in signal transduction events leading to exocytosis. We suggest that the concentration-dependent reversal of the stimulatory action of spermine could be explained by the existence of two binding sites for spermine: high affinity sites involved in inducing acrosomal exocytosis by low spermine concentration and low affinity sites mediating inhibition of acrosomal exocytosis by high concentration of spermine.

Does the electrocardiographic pattern of "anteroseptal" myocardial infarction correlate with the anatomic location of myocardial injury?

The current electrocardiographic (ECG) definition of anteroseptal acute myocardial infarction (AMI) is a Q wave or QS wave > 0.03 second in leads V1 to V3, with or without involvement of lead V4. To verify whether there is a correlation between the ECG pattern of anteroseptal AMI and the location of an AMI, we compared ECG, echocardiographic, and cardiac catheterization findings of 80 patients who fit the traditional definition of anteroseptal AMI. We found that 48 of 52 patients (92%) who presented with ST elevation in leads V1 to V3 had an anteroapical infarct and a normal septum. The culprit narrowing was more frequently found (in 85% of patients) in the mid to distal left anterior descending artery. We conclude that there is no correlation and that the ECG pattern traditionally termed anteroseptal AMI should be called an anteroapical AMI; the term anteroseptal AMI should be defined as extensive anterior wall AMI associated with diffuse ST changes involving the anterior, lateral, and occasionally, inferior leads.

Localization of cyclooxygenase and production of prostaglandins in bovine spermatozoa

Ejaculated bovine spermatozoa were examined for their capacity to synthesize prostaglandins E2 and F2 alpha (PGE2, PGF2 alpha). It was found that in the absence of exogenous substrate, arachidonic acid, basal PGF2 alpha production was less than that of PGE2. However, addition of 61 mumol arachidonic acid I-1 resulted in at least a twofold increase in PGE2 and PGF2 alpha above control values (1.3 ng and 0.3 ng per 10(8) spermatozoa, respectively). Addition of calcium and the calcium ionophore A23187 to the incubation medium did not cause a significant increase in the production of either PG. The presence of indomethacin (100-200 micrograms ml-1) caused a 50-70% inhibition of the production of both PGs. Activity of cyclooxygenase was determined by western blot analysis, using a specific polyclonal antiserum, and by fluorescence immunohistochemistry using a monoclonal antibody. The western blot displayed a clear signal for the presence of cyclooxygenase in ejaculated and epididymal spermatozoa. The immunohistochemical studies showed that the enzyme is localized in the apical region of the head, the post-acrosomal region and the mid-piece of the tail. Since the synthesis of PGs in the absence of exogenous arachidonic acid is low, the effect of melittin, a known phospholipase A2 activator, on PG production was examined. Incubation of spermatozoa with melittin produced a threefold increase in PGE2 and a sixfold increase in PGF2 alpha. Staurosporine, a protein kinase C inhibitor, inhibited the effect of melittin indicating that activation of phospholipase A2 by protein kinase C is an obligatory step in PG synthesis by bovine spermatozoa.(ABSTRACT TRUNCATED AT 250 WORDS)

Successful delivery following myocardial ischemia during the second trimester of pregnancy

Acute myocardial infarction during pregnancy is considered to be associated with approximately 50% mortality of both mother and fetus. However, there are not enough data regarding the role of acute myocardial ischemia. We present a 36-year-old, pregnant, white female who was admitted twice at 18 and 20 weeks of gestation with acute myocardial ischemia. Cardiac catheterization revealed 70-80% stenosis of the mid left anterior descending artery (LAD) with normal antegrade flow and very good retrograde filling of the LAD from distal collaterals of the right coronary artery. Therefore, due to angiographic suggestion of protected LAD territory, we recommended medical therapy and scheduled a vaginal delivery that was successfully completed without cardiovascular complications. A stress thallium test performed 6 months later was normal, supporting our clinical judgment. In conclusion, every case of a pregnant woman with coronary insufficiency should be treated according to individual coronary anatomy and blood supply to the territory of the diseased artery, and should not be based on the old data in the literature. The decision for revascularization prior to delivery versus medical therapy, or Caesarean section versus natural delivery, should be made by a team of a cardiologist and an obstetrician.

Giant left main pseudoaneurysm obstructing the left anterior descending coronary artery demonstrated by transesophageal echocardiography and coronary angiography

Left main pseudoaneurysm is a rare angiographic finding in young adults. We describe a 23-year-old male who presented with an acute anterior wall myocardial infarction. Coronary angiography and transesophageal echocardiography reveal a huge aneurysm of the distal left main obstructing the left anterior descending artery (LAD), which was defined by history as a pseudoaneurysm. The pseudoaneurysm was successfully resected and mammary artery was used to repair the distal left main and to bypass the LAD.

Complete atrioventricular block complicating inferior acute wall myocardial infarction: short- and long-term prognosis

The incidence of complete atrioventricular block (AVB) in a large group of patients with Q-wave inferior acute myocardial infarction (AMI) was 251 (11%) of 2273 patients. This incidence was significantly higher in women (14%) and patients > 70 years old (15%) than in men and patients < 70 years old (10% and 9%, respectively). Patients with complete AVB exhibited more serious arrhythmic and mechanical complications during hospitalization and included more patients with very high enzyme levels than their counterparts without AVB. The in-hospital mortality rate was 92 (37%) of 251 patients with complete AVB versus 200 (11%) of 1890 in those without AVB (p < 0.0001). After adjustment for age, gender, and important anamnestic, medical, and enzymatic findings, complete AVB emerged as an independent predictor of in-hospital mortality, yielding an odds ratio of 2.0 (90% confidence interval 1.12 to 3.57). The long-term (5-year) mortality rate in hospital survivors was slightly but not significantly higher in patients with complete AVB (28%) during hospitalization than in their counterparts with no AVB (23%). In view of these data, patients with inferior AMI in whom complete AVB develops are at increased risk and may benefit from urgent revascularization; the postdischarge management of survivors with complete AVB should be no different from that of patients without AVB.

A new approach for the treatment of interstitial pregnancy

The surgical treatment of interstitial pregnancy consists of either cornual resection or hysterectomy, which may seriously impair future fertility. We report a new approach that avoids surgical intervention. This presents a major breakthrough in the management of interstitial pregnancy.

Long-term prognostic value of a normal dipyridamole thallium-201 perfusion scan

In a 4-year period, 84 patients who were referred for a dipyridamole thallium-201 stress test to rule out significant coronary artery disease had normal scans. A dipyridamole study was recommended instead of exercise because of arthritis, severe obesity, peripheral vascular disease, pulmonary disease, other chronic illnesses, or combinations of these problems. All patients had three-view (i.e., anterior, shallow left anterior oblique, and steep left anterior oblique) planar thallium-201 imaging 10 minutes and 3.5 hours after administration of 0.6 mg/kg of intravenous dipyridamole. The patients were followed for 42 +/- 13 (range 1-58) months to document the cardiac event rate. Of the 84 patients with normal results, 14 died during the follow-up period from noncardiac causes. Three other patients died 29-51 months after the test due to an acute myocardial infarction, a probable acute myocardial infarction, and sudden cardiac death, respectively. Of the survivors, 5 suffered an acute myocardial infarction 28-50 months after the dipyridamole thallium scan and 1 had coronary artery bypass grafting due to increasing angina pectoris 58 months after the scan (overall cardiac event rate of 0.4% per year). Of the remaining 61 patients, 39 (64%) were asymptomatic, 20 (33%) had the same symptoms they had at the time of testing without significant deterioration, while 2 patients (3%) had deterioration of their chest pains but no cardiac complication. Thus, in this group of patients, a normal dipyridamole thallium-201 perfusion scan predicted a good cardiovascular outcome for at least 24 months following the test.

Echocardiographic demonstration of decreased left ventricular dimensions and vigorous myocardial contraction during syncope induced by head-up tilt

Two-dimensional echocardiography was performed during a head-up tilt test in 11 control subjects (group I) and 18 patients with recurrent unexplained syncope. In four patients (group II), the head-up tilt test was negative at baseline and after isoproterenol infusion. Syncope was induced during baseline head-up tilt in nine patients (group III) and after isoproterenol challenge in five (group IV). The echocardiographic variables assessed were left ventricular end-systolic and end-diastolic areas and percent fractional shortening. At the end of head-up tilt, end-systolic area decreased by 4.5 +/- 1.3 and 3.0 +/- 1.2 cm2 in groups III and IV, respectively, compared with 0.5 +/- 0.7 and 0.2 +/- 0.1 cm2 in groups I and II, respectively (p less than 0.04). Similarly, end-diastolic area decreased by 5.5 +/- 2.6 cm2 in group III compared with 2.7 +/- 1.9 and 1.75 +/- 0.4 cm2 in group I and II, respectively (p less than 0.04). Additionally, at the end of the baseline study, fractional shortening was significantly greater in group III and group IV (43 +/- 5%) than in groups I and II (p less than 0.01). In conclusion, syncope induced by head-up tilt is associated with vigorous myocardial contraction and a significant decrease in left ventricular end-systolic dimensions. This left ventricular hypercontractility may play an important role in the pathogenesis of syncope induced by head-up tilt.

Mitral regurgitation: parameters that affect the correlation between Doppler echocardiography and contrast ventriculography

The correlation between Doppler and contrast angiographic estimation of severity of mitral regurgitation was assessed retrospectively in 60 patients with native mitral valve disease. Results showed r = 0.82. Among 15 parameters (demographic, clinical, echocardiographic and hemodynamic) 3 were found to be associated with overestimation of the severity by Doppler: low left ventricular ejection fraction, low cardiac output, and high mean pulmonary artery capillary wedge pressure. On the other hand, a large left atrium was associated with underestimation of mitral regurgitation by Doppler. Based on that data, Doppler results were adjusted in a prospective group of 30 patients with native mitral valve disease. The correlation between contrast ventriculography and uncorrected Doppler results showed r = 0.83, while the corrected Doppler results showed r = 0.91. The study implies that although a good correlation is found between the two modalities for estimation of mitral regurgitation, a better correlation can be achieved by adjusting the Doppler results according to the above-mentioned parameters.

Exophthalmus--prenatal ultrasonic features for diagnosis of Crouzon syndrome

Prenatal real-time ultrasonographic diagnosis of exophthalmus is presented. Diagnosis was made at the 35th week of gestation in a fetus of a patient affected with Crouzon syndrome (craniofacial dysotosis). Recognition of exophthalmus as a part of Crouzon syndrome and the easy visualization of the eye balls and palpebrae in the third trimester made the diagnosis possible.

Complete atrioventricular block in Shone's syndrome

A rare case of an adult patient with Shone's syndrome is presented in whom Lev's disease seems to be the major pathology underlying the development of complete A-V block.

Analysis of antigen specific T cell helper function in first degree relatives of patients with systemic lupus erythematosus (SLE)

Fourteen families with first degree relatives of patients with systemic lupus erythematosus (SLE) were studied for the ability of their members to respond to the synthetic polypeptide antigen (T,G)-A-L. The family members were also tested for their HLA determinants. All SLE patients tested responded to (T,G)-A-L as measured by the production of (T,G)-A-L specific T cell helper factors by their antigen activated T cells, confirming our previous findings that 100% of SLE donors responded to (T,G)-A-L in contrast to 50% responders in a control population of healthy donors. The general defect in the regulation of immune responses in SLE patients was further indicated by the demonstration that an SLE patient who is a daughter of non-responder parents to (T,G)-A-L, responded to this genetically regulated antigen. In contrast to our observations with SLE patients, the genetic regulation of the ability to respond to (T,G)-A-L was shown not to be impaired in healthy first degree family members of SLE patients and the segregation of the immune response potential in these families was as expected from an inherited dominant trait.

Antigen specific immune response potential and HLA typing of Israeli patients with thyroid autoimmune diseases (TAD)

The immune response potential to the synthetic polypeptide antigen (T,G)-A--L was studied in 35 patients with thyroid autoimmune diseases (TAD). For this purpose the ability of their antigen activated peripheral blood lymphocytes (PBL) to generate a (T,G)-A--L specific helper factor was tested. In addition, the patients were typed for their HLA determinants. The results of the study have shown that 20/35 (57%) patients responded to (T,G)-A--L, a similar proportion to that found among healthy donors that were tested as control. No significant difference was found in the rate of responses between patients with Graves' disease and Hashimoto's thyroiditis. The responses in these groups of patients were shown to be 13/22 (59%) and 7/13 (54%) respectively. HLA typing of 26 patients with TAD did not demonstrate any association of the disease or the immune response potential with any specific HLA determinant. It is proposed that unlike the general lack of regulation that we have previously observed in patients with systemic lupus erythematosus, the abnormal autoimmune reaction in TAD and probably in other organ-specific autoimmune diseases, is towards a specific organ without affecting other arms and functions of the immune system.

(T,G)-A-L specific immune response potential and HLA typing of Israeli patients with systemic lupus erythematosus

Thirty-three Israeli patients with systemic lupus erythematosus (SLE) were studied for their ability to respond to the synthetic polypeptide poly (Tyr,Glu)-poly (DLAla)-poly(Lys) [( T,G]-A-L) as measured by the production of a T cell helper factor by their antigen activated T cells. Twenty-seven of the patients were typed for their HLA phenotypes. Nineteen patients were with more active disease and 14 with a milder non-active disease. All the patients of the two groups responded to (T,G)-A-L by the production of an antigen specific helper T cell factor, in contrast to only 50% responders among healthy donors. Thus, lack of normal regulation of T cell helper function was observed among all patients with SLE, independently of their disease activity and/or treatment. A higher frequency of DR5 (75%) was observed in patients with a milder non-active disease (vs 46.6% in normal healthy control individuals) while 53.3% of patients with active disease possessed DR7 (21.8% in controls). These findings may suggest a possible association between the severity of the disease and a specific DR determinant.

HLA-Dw"SHY": a new lymphocyte defined specificity associated with HLA-DRw10

HLA-DRw10 is a relatively new class II serologically-defined alloantigen first described in the 8th International Histocompatibility Workshop. To date the HLA-Dw related to the DRw10 specificity has not been detected. We have studied a Jewish family ("SHY") of Yemenite origin, in which the parents are first cousins who share one HLA haplotype: A29,Cw2,B7,BfF,DRw10,GL02. Two of the offspring in this family are homozygous for this haplotype. MLC family study confirmed that each of the two individuals was homozygous for HLA-Dw. No currently defined HLA-Dw specificity could be assigned to "SHY" using a selected panel of Caucasoid and local HTcs. HLA-Dw"SHY" was shown to segregate with DRw10 positive/Dw blank haplotypes in two families and in 64% (7/11) of DRw10 positive unrelated positive/Dw blank haplotypes in two families and in 64% (7/11) of DRw10 positive unrelated individuals. HTC"SHY" thus expresses the first HLA-Dw specificity associated with DRw10.