Hollow CoP/carbon as an efficient catalyst for the peroxymonosulfate activation derived from phytic acid assisted metal-organic framework

The catalyst's composition and rationally designed structure is significantly interlinked with its performance for wastewater remediation. Here, a novel hollow cobalt phosphides/carbon (HCoP/C) as an efficient catalyst for activating peroxymonosulfate (PMS) was prepared. The ZIF-67 was synthesized first, followed by phytic acid (PA) etching and then heat treatment was used to get HCoP/C. The PA was used as an etching agent and a source of phosphorus to prepare HCoP/C. To analyze catalytic performance, another solid cobalt phosphides/carbon (SCoP/C) catalyst was prepared for comparison. In contrast to SCoP/C, the HCoP/C exhibited higher catalytic efficiency when used to activate PMS to degrade Bisphenol A (BPA). The results showed that about 98 % of targeted pollutant BPA was removed from the system in 6 min with a rate constant of 0.78 min-1, which was 4 times higher than the solid structure catalyst. The higher catalytic performance of HCoP/C is attributed to its hollow structure. In the study, other parameters such as BPA concentration, temperature, pH, and different catalyst amount were also tested. Moreover, the electron paramagnetic resonance (EPR) and radical quenching analysis confirmed that sulfate radicals were dominant in the HCoP/C/PMS system.

Mycorrhizosphere bacteria inhibit greenhouse gas emissions from microplastics contaminated soil by regulating soil enzyme activities and microbial community structure

Microplastics (MPs) accumulation in terrestrial ecosystems can affect greenhouse gases (GHGs) production by altering microbial and soil structure. Presently, research on the MPs effect on plants is not consistent, and underlying molecular mechanisms associated with GHGs are yet unknown. For the first time, we conducted a microcosm study to explore the impact of MPs addition (Raw vs. aged) and Trichoderma longibrachiatum and Bacillus subtilis inoculation (Sole vs. combination) on GHGs emission, soil community structure, physiochemical properties, and enzyme activities. Our results indicated that the addition of aged MPs considerably enhanced the GHGs emissions (N2O (+16%) and CO2 (+21%), respectively), C and N cycling gene expression, microbial biomass carbon, and soil physiochemical properties than raw MPs. However, the soil microbial community structure and enzyme activities were enhanced in raw MPs added treatments, irrespective of the MPs type added to soil. However, microbial inoculation significantly reduced GHGs emission by altering the expression of C and N cycling genes in both types of MPs added treatments. The soil microbial community structure, enzymes activities, physiochemical properties and microbial biomass carbon were enhanced in the presence of microbial inoculation in both type of MPs. Among sole and combined inoculation of Trichoderma and Bacillus subtilis, the co-applied Trichoderma and Bacillus subtilis considerably reduced the GHGs emission (N2O (-64%) and CO2 (-61%), respectively) by altering the expression of C and N cycling genes regardless of MPs type used. The combined inoculation also enhanced soil enzyme activities, microbial community structure, physiochemical properties and microbial biomass carbon in both types of MPs treatment. Our findings provide evidence that polyethylene MPs likely pose a high risk of GHGs emission while combined application of Trichoderma and Bacillus subtilis significantly reduced GHGs emission by altering C and N cycling gene expression, soil microbial community structure, and enzyme activities under MPs pollution in a terrestrial ecosystem.

Eco-friendly cultivation of microalgae using a horizontal twin layer system for treatment of real solid waste leachate

Solid waste leachate (SWL) requires dilution with water to offset the negative effects of high nutrient concentration and organic compounds for its microalgae-based treatment. Among attached cultivation systems, twin layer is a technology in which limited information is available on treatment of high strength wastewater using microalgae. Moreover, widespread application of twin layer technology is limited due to cost of substrate and source layer used. In the present study, potential of Scenedesmus sp. for the treatment of SWL was assessed on horizontal twin layer system (HTLS). Novel and cost-effective substrate layers were tested as attachment material. Wetland treated municipal wastewater (WMW) was used to prepare SWL dilutions viz, 5%, 10%, 15%, 20% and 25% SWL. Recycled printing paper showed maximum biomass productivity of 5.19 g m-2 d-1. Among all the SWL dilutions, Scenedesmus sp. achieved maximum growth of 103.05 g m-2 in 5% SWL which was 16% higher than WMW alone. The maximum removal rate of NH4+ -N, TKN, and PO43- P was obtained in 20% SWL which was 1371, 1588 and 153 mg m-2 d-1 respectively. Varying concentrations of nutrients in different SWL dilutions significantly affected lipid biosynthesis, with enhanced productivity of 2.28 g m-2 d-1 achieved in 5% SWL compared to 0.97 g m-2 d-1 in 20% SWL. Hence, it can be concluded that 5% SWL dilution was good for biomass and lipid production, while the highest nutrient removal rates were obtained at 20% SWL mainly attributed to biotic and abiotic processes. Based on these results HTLS can be a promising technology for pilot scale to explore industrialized application of wastewater treatment and algal production.

Municipal wastewater treatment with corrugated PVC carrier anaerobic baffled reactor

The anaerobic baffled reactor (ABR) is a promising solution for decentralized wastewater treatment due to its low operation cost as compared to the activated sludge process, but it requires comparatively higher hydraulic retention time (HRT). This ultimately increases land requirement, capital and construction cost of treatment plant. This study investigates performance of ABR using polyvinyl chloride (PVC) corrugated pipe as carrier media to improve biomass retention capacity and treatment performance of reactor with the aim to reduce HRT. Comparative performance of two ABRs with and without carrier media was analyzed under mesophilic conditions (35 ± 1 °C) for organics and total suspended solids (TSS) removal at HRTs of 24, 18, 12, 8, 6 and 4 h. Results showed that at HRTs of 24-08 h, the organics removal performance of the carrier anaerobic baffled reactor (CABR) was better than ABR and was in the range of 77-81% for CABR as compared to 64-70% for ABR. However, on further decrease in HRT to 6 h, CABR sustained the treatment with organics removal of 80%, while ABR performance reduced to 58%, creating a performance difference of 38%. Average total suspended solids (TSS) removal was in the range of 76-83% at all HRTs for both reactors. Therefore, this study identified CABR with PVC carrier media as an effective low-HRT reactor for organics and SS removal with less land area requirement.

Application of material flow analysis for the assessment of current municipal solid waste management in Karachi, Pakistan

This article assesses the status of the solid waste management system (SWMS) in Karachi, the largest city of Pakistan, using the material flow analysis approach, a widely applied method in waste management (WM) studies. It involves a systematic assessment of the material flows of solid waste under the current WM system. A material flow diagram is developed to visualize the input and output waste flows. This study shows the quantification and identification of municipal solid waste (MSW) flow for the year 2019, from the point of generation to the end-use and disposal. Results show that the MSW generation increased from 10,435 to 15,600 metric tonnes per day (TPD) between 2017 to 2019. Approximately, 75% of the waste generated is collected: formally (50%); and informally (25%). The material recovery is low, accounting for only 26.28% of the total waste. There is no official material recovery and recycling facility. Therefore, material recovery solely depends on the informal sector. Results show that 70% of the daily waste ends up in landfills, which is 3120 TPD more than the formally collected waste. This estimated waste of 3120 TPD flows in either due to disposal activities of the backlogged waste or informally collected waste. Overall, Karachi's SWMS performs poorly with a significant need for improvement. This study recommends adopting integrated WM approaches and inclusion of the informal sector to ensure the affordability and sustainability of the WM system.

Introducing day case thyroid lobectomy at a tertiary head and neck centre

BACKGROUND

Thyroid lobectomy is considered to be a safe day case procedure by the British Association of Day Surgery. However, currently only 5.5% of thyroid surgeries in the UK are undertaken as day cases. We determine if and how thyroid lobectomy with same-day discharge could safely be introduced in our centre.

METHODS

We analysed all thyroid lobectomy surgeries performed between April 2015 and May 2019. Exclusion criteria included completion surgery, revision surgery, additional procedures and disseminated disease. Outcomes were benchmarked against surgeon-reported complications from the British Association of Endocrine and Thyroid Surgery's 5^th National Audit. Additionally, we reviewed the number of patients who met day case criteria currently in use at our hospital to determine accessibility to the service.

RESULTS

In total, 259 thyroid lobectomy surgeries were undertaken and of these 173 met the inclusion criteria. There was no mortality, return to theatre for evacuation of postoperative haematoma or readmission. There was one postoperative haematoma which was drained at the bedside. Some 47 of the 173 (27.2%) patients met day case criteria currently in use at our centre.

CONCLUSIONS

Day case surgery provides a cost-effective solution to rising bed pressures and a coherent protocol can optimise patient safety and experience.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Resolving Macrophages Counter Osteolysis by Anabolic Actions on Bone Cells

Progression of inflammatory osteolytic diseases, including rheumatoid arthritis and periodontitis, is characterized by increased production of proinflammatory mediators and matrix-degrading enzymes by macrophages and increased osteoclastic activity. Phenotypic changes in macrophages are central to the healing process in virtually all tissues. Using a murine model of periodontitis, we assessed the timing of macrophage phenotypic changes and the impact of proresolving activation during inflammatory osteolysis and healing. Proinflammatory macrophage activation and TNF-α overproduction within 3 wk after induction of periodontitis was associated with progressing bone loss. Proresolving activation within 1 wk of stimulus removal and markers of resolving macrophages (IL-10, TGF-β, and CD206) correlated strongly with bone levels. In vivo macrophage depletion with clodronate liposomes prevented bone resorption but impaired regeneration. Induction of resolving macrophages with rosiglitazone, a PPAR-γ agonist, led to reduced bone resorption during inflammatory stimulation and increased bone formation during healing. In vitro assessment of primary bone marrow-derived macrophages activated with either IFN-γ and LPS (proinflammatory activation) or IL-4 (proresolving activation) showed that IL-4-activated cells have enhanced resolving functions (production of anti-inflammatory cytokines; migration and phagocytosis of aged neutrophils) and exert direct anabolic actions on bone cells. Cystatin C secreted by resolving but not inflammatory macrophages explained, in part, the macrophage actions on osteoblasts and osteoclasts. This study supports the concept that therapeutic induction of proresolving functions in macrophages can recouple bone resorption and formation in inflammatory osteolytic diseases.

Rare case of accidental fire and burns caused by e-cigarette batteries

E-cigarettes have become very popular among adult smokers, and many users carry e-cigarette devices and their components on their person. We present a case of a 35-year-old man who was admitted to our regional burns unit after his clothing was set-alight following the self-combustion of an e-cigarette lithium battery that was in his pocket. The patient had sustained a 1.5% mixed depth burn to the lateral aspect of his right thigh. Ward debridement under local anaesthetic was performed to remove clothing residue and reduce the risk of tattooing. Following conservative management with outpatient dressings, the burn wound healed by day 56.

In vivo measurement of the surface energy of human fingernail plates

The surface energy of the human nail plate is expected to influence the adhesion of microorganisms (and subsequent colonization and infections) as well as that of medicines (and subsequent drug permeation) and of cosmetics. The aim of the study was therefore to measure the surface energy of nail plates in vivo. The surface energy of healthy human fingernails (untreated, hydrated and abraded) and of hoof membranes (often used as a model for the nail plate) was estimated from contact angle measurements of liquids (water, formamide, diiodomethane and glycerol) on the nail plate and subsequent computation using the Lifshitz-van der Waals/acid-base (LW-AB) approach. The surface energy of untreated fingernail plates was found to be 34 mJ m(-2) . Most of this total energy was from the apolar Lifshitz-van der Waals component. When the polar component of the surface energy was analysed, the electron donor component was considerably larger than the electron acceptor one. Hydrating the nail plate had no significant influence on the surface energy. In contrast, abrasion caused a small, but statistically significant increase in the apolar surface energy component. The surface energy of bovine hoof membrane was similar to that of the fingernail plate. We conclude that the human fingernail plate is a low-energy surface and that bovine hoof membranes may be used as a substitute for the nail plate in certain experiments.

Tick infestation rate of sheep and their distribution in abdanan county, ilam province, iran, 2007-2008

BACKGROUND

Ticks are hematophagous arthropod belonging to the Class of Arachnids. Ticks are also one of the major vectors of pathogens to animal and human. This study was conducted to determine tick infestation rate of sheep in Abdanan during 2007-2008.

METHODS

Sampling was performed seasonally in 19 villages during spring 2007 until winter 2008. A total of 1095 sheep were selected and tested for tick infestation. After collection, all ticks were transported to laboratory of Medical Entomology and were identified with appropriate identification keys.

RESULTS

Totally, 864 hard ticks were collected. The ticks were classified into two genera and 5 species including: Hyalomma marginatum (44.67%), Hy. anatolicum (43.17%), Hy.asiaticum (6.37%), Hy. dromedarii (5.55%), Heamaphysalis sulcata (0.24%). The highest seasonal activity was observed in spring (36.46 %) and the lowest seasonal was in winter (11.57%). The rate of tick frequency in mountainous region was 48.15% and it was 51.85% in plateau regions. In this study, tick infestation of sheep was 11.41%.

CONCLUSION

Hy.marginatum has the more frequent density in the study area.

Role of liver function tests in predicting common bile duct stones in acute calculous cholecystitis

BACKGROUND

The role of liver function tests (LFTs) in evaluating common bile duct (CBD) stones in patients with cholelithiasis has been studied widely. However, it is not clear whether these predictive models are useful in inflammatory gallstone disease.

METHODS

A review was undertaken of 385 consecutive patients admitted as an emergency for acute calculous gallbladder disease. The diagnosis of calculous cholecystitis was confirmed by ultrasonography or histological confirmation of acute or chronic inflammation of the gallbladder. Patients with obvious jaundice, defined as a bilirubin level above 80 micromol/l, and gallstone pancreatitis were excluded.

RESULTS

Some 216 patients met the inclusion criteria, of whom 28 (13.0 per cent) were found to have CBD stones. LFT results were not significantly different in patients with chronic, acute or complicated acute cholecystitis. Using several cut-off levels, gamma-glutamyl transpeptidase (GGT) had the highest specificity, positive predictive value and negative predictive value, comparable to a scoring system that combined all LFTs. Bilirubin was the least specific and predictive. A cut-off point for GGT at 90 units/l produced a sensitivity of 86 per cent (24 of 28), specificity of 74.5 per cent (140 of 188), and positive and negative predictive values of 33 per cent (24 of 72) and 97.2 per cent (140 of 144) respectively. This represented a one in three chance of CBD stones when the GGT level was above 90 units/l and a one in 30 chance when the level was less than 90 units/l.

CONCLUSION

Selection criteria based on GGT can be used in acute calculous cholecystitis to identify high-risk patients who would benefit most from further imaging to exclude choledocholithiasis.

Combined epidural/spinal anaesthesia: needle-through-needle or separate spaces?

BACKGROUND AND OBJECTIVE

This prospective, randomized and blinded study compared the performance of a new needle-through-needle (NTN) kit (Epistar; Medimex, Germany) with the double-space technique for providing combined spinal epidural anaesthesia during Caesarean section.

METHODS

Following local Ethics Committee approval and patient consent, 200 females were randomized to receive combined spinal epidural anaesthesia by the double-space (n = 100) or NTN (n = 100) technique. The frequency with which the intrathecal component could achieve a T5 block to touch for Caesarean section without the need for epidural augmentation or an alternative technique was determined. The time from start of procedure to achieving a block height to T5 was recorded. Pain and backache at insertion, and at 24 h follow-up were recorded using a visual analogue scale. To remove any bias due to posture, 50% of each group were further randomized to receive their block in the sitting or in the left lateral position. To evaluate improvement of performance over time the success in the first 100 study patients were compared to the success in the second 100.

RESULTS

A successful block to T5 with the double-space and NTN techniques were 80 vs. 54, odds ratio 0.29. Failure to enter the intrathecal space once the epidural space had been located occurred in 29 patients in the NTN group. Time to readiness for surgery was 15 min (95% confidence interval (CI): 12.7-17.4) and 12.9 min (95% CI: 11.5-14.3) for the double-space and NTN techniques, respectively. The median (interquartile range) visual analogue scores for discomfort at insertion were 30 (12.5-51.5) and 32 (12.75-60) and for postoperative backache 0 (0-10) and 0 (0-10.75) in the double-space and NTN groups, respectively. The number of epidural augmentations was similar in both the groups and posture made no difference. There was a tendency to increased success in the second half of the study.

CONCLUSION

The double-space technique had a greater success rate than the NTN technique.

Role of laparoscopic cholecystectomy in the early management of acute gallbladder disease

Background

This study evaluated the role of laparoscopic surgery in the early management of acute gallbladder disease in a single large UK teaching hospital.

Methods

Details of all emergency admissions for acute gallbladder disease from January 2000 to December 2001 were identified and additional information from the hospital records was reviewed retrospectively.

Results

Three hundred and eighty-five patients with gallstone disease (243 acute biliary pain, 142 acute cholecystitis) and 15 with acalculous disease were identified. The conversion rate was higher during early laparoscopic surgery for acute calculous cholecystitis than in operations for acute biliary pain (19 versus 4 per cent; P = 0·002). In patients with acute calculous cholecystitis the conversion rate was significantly lower in operations within 48 h of admission (one of 26) than when surgery was delayed beyond 48 h (14 of 52) or subsequently carried out electively (seven of 21) (P = 0·014). Elective surgery for previous acute cholecystitis was associated with a higher conversion rate (seven of 21 patients) than elective surgery for biliary pain (three of 65) (P = 0·002).

Conclusion

Laparoscopic cholecystectomy for acute calculous cholecystitis should be performed, where possible, within the first 48 h of admission.

Value of radiologically guided fine needle aspiration cytology (FNAC) in the diagnosis of spinal tuberculosis: a study of 29 cases

FNAC is a simple diagnostic tool for the initial evaluation of various deep seated pathological lesions. This study describes the applicability and practical aspects of the technique in establishing the diagnosis of spinal tuberculosis (TB) with the aid of radiographic guidance. The study was conducted in a major teaching hospital in Kuwait between the years 1985 and 1994. Twenty-nine patients (M:F = 18:11 and age range 8-72 years) with clinically and/or radiologically suspected spinal TB were seen in the Department of Cytology, Mubarak Al Kabeer Hospital. The patients were re-examined by either computed tomography (CT) scanning (n = 19) or fluoroscopy (n = 10) to localize the lesion for FNAC. FNAC smears were routinely stained with Papanicolaou and Diff Quik stains and one smear of each case was stained with Ziehl-Neelsen (Z-N) stain for acid-fast bacilli (AFB). Aspirated purulent material or syringe washings of dry aspirates were also submitted for microbiological cultures including AFB. Radiological and cytological findings were recorded in each case. Radiological findings included: bony rarefaction and destruction (93.1%), narrowed disc space (89.7%), soft tissue calcification (65.5%) and para-vertebral abscess formation (51.7%). Cytological findings included: epithelioid cell granulomas (89.7%), granular necrotic background (82.8%) and lymphocytic infiltration (75.9%). Smears were positive for AFB in 51.7% of cases. A positive AFB culture was obtained in 82.8% of cases, including all cases with positive AFB on smear by Z-N stain. Radiologically guided FNAC with AFB culture is a simple, reliable and practical approach to diagnosing spinal TB lesions. With a high diagnostic yield, it allows immediate initiation of specific treatment, helps to avoid invasive diagnostic procedures, and decreases hospitalization time.

Fetal congenital malformations. Biophysical profile evaluation

OBJECTIVE

To study the association between various fetal congenital malformations and the biophysical profile (BPP), we tested the following hypotheses: (1) a specific organ system malformation is associated with the absence of one or more BPP parameters, and (2) four BPP parameters are not affected by the advancement of fetal maturation.

STUDY DESIGN

From 1985 to 1995, 316 fetuses with congenital malformations and 351 controls were identified in a high-risk population undergoing ultrasound examinations of anatomic structures and biophysical profile evaluations. For investigation of the influence of fetal maturity on biophysical profile evaluations, both the malformed fetuses and the controls were stratified into two gestational-age groups, 26-34 weeks and > 34 completed weeks. Four parameters of the BPP, including (1) fetal breathing, (2) gross fetal movements, (3) fetal muscle tone, and (4) quantitative amniotic fluid volume, were divided into low (0-6) and high (8) total score subgroups. Tests of significance were done using chi 2 analysis, Student's t test or Fisher's exact test, as appropriate. Level of significance was set at P < .05.

RESULTS

When comparing malformed fetuses to controls, the malformed group had a statistically significantly higher percentage of low BPP scores due to absent fluid, tone or breathing. Fetuses with a musculoskeletal anomaly were statistically significantly more likely to lose points for fetal movement (P < .02); fetuses with a genitourinary system anomaly lost points for fluid (P < .001), tone (P < .005) and breathing (P < .005); fetuses with a central nervous system anomaly lost points for tone (P < .02) and breathing (P < .001); and fetuses with a thoracic anomaly lost points for breathing (P < .002). There was no statistically significant difference in BPP scores between fetuses at 26-34 weeks' gestational age and fetuses > 34 completed weeks' gestational age.

CONCLUSION

The two hypotheses were confirmed by the study results.

Congenital complete heart block

Congenital complete heart block in utero has become diagnosed more frequently with the clinical use of fetal echocardiography. The fetus with complete heart block may remain asymptomatic or may develop congestive heart failure. Congenital complete heart block is more frequently seen in infants of mothers with systemic lupus erythematosus, both clinically manifested and subclinical systemic lupus erythematosus with positive antibodies (SS-A and SS-B antibodies). At birth, the neonate with complete heart block may remain asymptomatic and may not require a pacemaker to increase the heart rate. The indications for a pacemaker in neonates with complete heart block have been discussed. Both in-utero and neonatal management of congenital complete heart block are discussed to manage congestive heart failure in a fetus. Four patients with congenital complete heart block are presented covering a broad spectrum of clinical presentation, diagnosis, and management both in the fetal and neonatal period.

Prenatal diagnosis, clinical significance and management of fetal intracranial teratoma: a case report and literature review

We report the prenatal ultrasonographic diagnosis of a massive intracranial teratoma in a 32-week breech intrauterine pregnancy associated with polyhydramnios and enlarged fetal head circumference. Ultrasound appearance, clinical significance, and how the prenatal diagnosis affects management and prognosis for both mother and fetus are discussed.

Gonadotropin-releasing hormone agonist as a probe for the pathogenesis and diagnosis of ovarian hyperandrogenism

We have found that women with typical polycystic ovary syndrome have supranormal plasma 17-hydroxyprogesterone responses to a 100-micrograms test dose of the gonadotropin-releasing hormone agonist nafarelin without evidence of hindered estrogen secretion. To understand the basis of this response, we computed the apparent efficiency of the steps in steroid biosynthesis from the pattern of plasma steroids in response to nafarelin. The proximate cause appears to be excessive 17 alpha-hydroxylase activity and high, yet partially down-regulated, 17,20-lyase activity in the delta 4-pathway. These results suggest that this pattern of steroid secretion results from abnormal regulation (dysregulation) of these activities, possibly involving the enzyme cytochrome P450c17. To determine the usefulness of nafarelin testing for the diagnosis of ovarian hyperandrogenism, we then prospectively studied 40 hyperandrogenic women. The plasma 17-PROG response to nafarelin was supranormal in 58% of the women. The responses of 17-PROG to nafarelin and free testosterone to dexamethasone correlated well and were concordant in approximately 85% of cases. Baseline serum luteinizing hormone concentration was elevated in only 48% of cases. To understand ovarian structure-function relationships, we studied another 20 consecutive hyperandrogenic women. Among seven women with polycystic ovaries, five had an elevated LH level, and four of these five (80%) had an elevated 17-PROG response to nafarelin. Conversely, about half of patients with the PCOS-like disorder of ovarian function did not have polycystic ovaries. Ovarian stromal area, but not LH levels, correlated significantly (r = 0.45) with the 17-PROG response to nafarelin. Thus, both stromal hyperplasia and dysregulation of steroidogenesis seem to be manifestations of abnormal intraovarian regulation of cell growth and function. We conclude that a PCOS-like disorder of ovarian function in response to nafarelin testing is found in approximately half of hyperandrogenic women. The pathogenetic implication of our results is that abnormal intraovarian modulation of LH action seems to be a major factor in ovarian hyperandrogenism. The diagnostic implication of our data is that ovarian androgen excess will often be missed by use of common diagnostic criteria for PCOS.

Detection of functional ovarian hyperandrogenism in women with androgen excess

BACKGROUND

Distinguishing between ovarian and adrenal causes of androgen excess may be difficult. We have found that women with the polycystic ovary syndrome have supranormal plasma 17-hydroxyprogesterone responses to the gonadotropin-releasing hormone agonist nafarelin. We determined the usefulness of testing with nafarelin to distinguish ovarian causes of hyperandrogenism in women.

METHODS

We studied 40 consecutive women with hyperandrogenism who had oligomenorrhea, hirsutism, or acne. All 40 underwent testing with nafarelin, dexamethasone, and corticotropin with measurement of circulating concentrations of gonadotropins and steroid hormones, and 19 underwent ovarian ultrasonography.

RESULTS

The plasma 17-hydroxyprogesterone response to nafarelin was supranormal in 23 of the 40 women (58 percent), and the plasma androgen response to corticotropin was elevated in 23; 13 women had both abnormalities. Only one woman had conclusive evidence of a steroidogenic block; she had nonclassic adrenal 21-hydroxylase deficiency. Of the 23 women with abnormal responses to nafarelin, only 11 (48 percent) had elevated base-line serum luteinizing hormone concentrations. Of the 13 women with abnormal responses to nafarelin who underwent ultrasonography, 7 (54 percent) had polycystic ovaries. Peak plasma 17-hydroxyprogesterone concentrations after nafarelin administration correlated closely with plasma free testosterone concentrations after dexamethasone administration (r = 0.75, P less than 0.001).

CONCLUSIONS

Approximately half of women with oligomenorrhea, hirsutism, or acne have an abnormal response to the gonadotropin-releasing hormone agonist nafarelin, suggesting an ovarian cause of their androgen excess.

The association between oligohydramnios and intrauterine growth retardation

Among 147 cases of suspected intrauterine growth retardation (IUGR) identified based upon ultrasonic abdominal circumference below the tenth percentile, 56 were confirmed IUGR infants at birth and 91 were non-IUGR infants. Eight of 316 control fetuses with abdominal circumference above the tenth percentile turned out to be IUGR infants at birth. The incidence of oligohydramnios was strikingly different among the three groups: 29% for the IUGR group, 9% for the non-IUGR group, and 0.6% for the controls (P less than .001). When the criteria of abdominal circumference below the tenth percentile and presence of oligohydramnios were used together, the positive predictive value doubled (from 38.1 to 66.7%; P less than .01). Oligohydramnios developed some time after the somatic evidence of fetal growth retardation in all cases in this study. Finally, there were no significant differences between fetal growth retardation with or without oligohydramnios with respect to maternal risk factors or fetal outcome. We conclude that in fetal growth retardation, the occurrence of oligohydramnios during the third trimester of pregnancy is not associated with worse fetal outcome.

Cystic hygroma and 45,X/46,XY mosaicism

We report a case of fetal cystic hygroma with 45,X/46,XY mosaicism.

Fetal urinary tract obstruction and trisomy 18 mosaicism. A case report

Routine ultrasound examination has led increasingly to antepartum detection of fetal anomalies. Management decisions remain difficult, however, because information on the presence of other anomalies is frequently unobtainable. A case of fetal urinary tract obstruction, although apparently an isolated defect, proved to be associated with a lethal chromosome abnormality, trisomy 18 mosaicism.

Predictive value, sensitivity, and specificity of ultrasonic targeted imaging for fetal anomalies in gravid women at high risk for birth defects

In this report the predictive value of ultrasonic targeted imaging for fetal anomalies (TIFFA) is defined. Six hundred fifteen pregnant women at high risk for birth defects were scanned from January, 1980, to December, 1983. Follow-up evaluation was available on 569 fetuses. The pregnancies were classified into five groups according to the indications used for ultrasonic targeted imaging studies. The largest number of women were placed in group 1 and were referred because of a variety of abnormalities in previous or ongoing pregnancies. The women classified in the other four groups were examined because of maternal or fetal reasons related to specific craniospinal (29%), urinary (7.9%), gastrointestinal (6.7%), and skeletal (3.7%) defects. In our series the predictive values of abnormal and normal ultrasonic targeted imaging studies were 95% and 99%, respectively. A detailed breakdown of the accuracy of ultrasonic targeted imaging in relation to each anatomic category is presented; these data are useful in counseling gravid women with anomalous fetuses.