Persistent Pulmonary Hypertension and Histologic Chorioamnionitis in Preterm Infants: Controlled Study

Persistent pulmonary hypertension (PPHN) of the newborn is one of the most challenging acute disorders of postnatal transition with substantial morbidity and mortality. The aim of the study was to find if there is an association between persistent pulmonary hypertension and histologic chorioamnionitis in preterm infants. 27 preterm infants with echocardiographic evidence of PPHN within the first 3 days of life were eligible for the study. A matched control group of 27 patients was chosen according to gestational age, date of birth, and gender. Data collection included the need for respiratory support, use of nitric oxide oxygen supplementation, duration of rupture of membranes, blood culture, blood count, and C-reactive protein levels at birth and 12 h. Maternal clinical and laboratory data suggesting clinical chorioamnionitis Placentas of both groups were examined. Differences between groups were analyzed using two-tail t test, Kolmogorov-Smirnov test, Chi-square test. No statistically differences were found in all parameters compared between groups, except for a higher number of patients in the PPHN group who were treated by oxygen supplementation. An association was not found between the incidence of HCA and echocardiographic PPHN in preterm infants in the first 3 days of life.

Value of laboratory studies in assessment of dehydration in children

Background: Due to the lack of a reliable way of clinically measuring dehydration, laboratory tests are usually used to improve the accuracy of clinical assessment of dehydration in children. The purpose of this study was to compare the relationship between clinical and laboratory parameters in the assessment of dehydration and to evaluate the improvement of those parameters over time.

Methods: We conducted a retrospective study to assess the relationship between clinical assessment of dehydration and laboratory findings.

Results: Three hundred children were eligible for the study. Twenty-six per cent of those with mild dehydration had serum urea concentrations greater than 14.3 mmol/L, compared with 38% and 5% of those with moderate or no dehydration, respectively. Urea concentration showed a good specificity, 95%. Creatinine concentrations and mean pH were similar whether or not dehydration was present. Bicarbonate and base excess concentrations decreased with the increasing severity of dehydration and were significantly greater in subjects with moderate dehydration than in those without. The sensitivity (71%) and specificity (74%) of both tests were rather poor. All groups had an abnormal anion gap, which was significantly greater in those with mild or moderate dehydration.

Conclusion: This study confirms that there is a discrepancy between clinical assessment and laboratory parameters of dehydration. Urea showed good specificity, and anion gap was the most sensitive laboratory parameter for assessment of dehydration. These findings need further validation.

Time required to determine performance variables and production efficiency of lactating dairy cows

Thirty-five lactating dairy cows throughout weeks of lactation (WOL) 16 to 30 were used to determine optimal time needed for reliable measurement of performance variables, and to classify the cows into high-, medium-, and low-efficiency groups. Individual performance variables [body weight (BW), dry matter intake (DMI), and milk production] were measured daily with a computerized monitoring system. Body condition was visually scored weekly and used to calculate retained or depleted body energy as a result of fat content change (REF). Milk composition was analyzed weekly. Body weight, DMI, and total recovered energy (RE), which represents energy in milk production plus REF, were summarized weekly. Efficiency was calculated as RE/DMI and as residual feed intake (RFI; i.e., the difference between actual and expected DMI), which was calculated from multiple linear regression of DMI dependence on BW(0.75) and RE. Unexpectedly, it was found that BW did not affect DMI and RE/DMI. Changes and relative changes in phenotypic coefficient of variation and correlations among data from shortened tests ranging from 1 wk (WOL 16) to a sequence of 15-wk tests were used to determine optimal test period durations for 5 traits: BW, DMI, RE, RE/DMI, and RFI. Traits were fitted into a mixed model with repeated measures. For each week, the traits were summarized as a sequence of cumulative data, starting from WOL 16 and cumulated over periods that increased in 1-wk steps up to WOL 16 to 29. Weekly cumulations were compared with those for entire test period (WOL 16 to 30). Consistency of each cow's efficiency classification as high, medium, or low was tested by the total-agreement procedure; the kappa index P-value was used. Throughout WOL 16 to 30, the effects of increasing test period duration on between-animal coefficient of variation differed with respect to the various performance variables and RE/DMI: it tended to change with respect to BW, did not change with respect to DMI, and decreased with respect to RE and RE/DMI. In conclusion, compared with a 15-wk study, a 2-wk study can classify RFI and RE/DMI to 3 efficiency levels, with an individual correlation coefficient of 0.6. When the study was carried out over 3 wk or more, the lowest significant index of the classification was P<0.004, the lowest individual correlation coefficient was 0.65, and its lowest significance was P<0.01. The current study indicated that the insignificant effect of the BW of dairy lactating cows on their DMI should be validated in more studies.

Hypotension during gradual blood loss: waveform variables response and absence of tachycardia

BACKGROUND

Variation in arterial pressure and plethysmographic waveforms has been shown to be predictors of cardiac output response to fluid challenge. The objective of this study was to evaluate the ability of arterial and plethysmographic waveform variables to predict hypotension during blood loss.

METHODS

Patients undergoing autologous haemodilution were studied. After anaesthesia induction, blood was withdrawn in steps of 2% of estimated circulating blood volume (ECBV). Arterial and plethysmographic waveforms were recorded and analysed offline at each step of blood withdrawal.

RESULTS

Thirty-four (29%) out of 118 studied patients tolerated 20% ECBV withdrawal without hypotension. Patients who tolerated 20% ECBV withdrawal were younger than those who did not [mean (sd): 53.8 (11.1) vs 62.7 (10.7); P<0.0001]. Patients with hypertension developed hypotension earlier than healthier patients did. There were no differences at the baseline in arterial and plethysmographic waveform variables between those who did and those who did not tolerate 20% of ECBV withdrawal. All values of variables increased significantly from the baseline after the withdrawal of 4% of ECBV (P<0.005). There were no changes in heart rate (HR), 73 (12) at the baseline and 76 (13) after 20% of ECBV withdrawal (P=0.4).

CONCLUSIONS

Arterial and plethysmographic waveform variables were augmented with increasing blood loss in all patients. Older patients, patients who received anti-hypertensive drugs, or both developed hypotension earlier than others. Baseline values were weak predictors of hypotension during stepwise blood withdrawal. No clinically significant increase in HR was observed, regardless of tolerance of arterial pressure to blood withdrawal.

Prenatal diagnosis of a pulmonary arteriovenous malformation

Pulmonary arteriovenous malformations (PAVMs) are caused by abnormal communications between pulmonary arteries and pulmonary veins. They are most often congenital, and may occur as isolated lesions or part of complex congenital syndromes. We describe a case of PAVM in a 16-week-old fetus. To the best of our knowledge this is the first case to be described in the literature of diagnosis, at such an early gestational age, of PAVM with the shunt found between the main pulmonary artery and pulmonary vein.

Dimensions of the fetal facial profile in normal pregnancy

OBJECTIVE

To determine sonographic dimensions of the fetal facial profile in normal pregnancy.

METHODS

This was a prospective, cross-sectional study of 397 normal healthy fetuses at 14-33 weeks of gestation. After exclusion of the small numbers of patients at the upper GAs, 379 patients between 14.0 and 26.9 weeks of gestation were included in the analyses. The sagittal plane of the fetal facial profile was evaluated using transvaginal and transabdominal ultrasound. Distances from the tip of the nose to the mouth (the line between the lips), from the mouth to the gnathion (lower chin), from the upper philtrum to the mouth, and from the mouth to the upper concavity of the chin were measured and are presented according to gestational age (GA).

RESULTS

There was a significant linear correlation between GA and the distance from the tip of the nose to the mouth (r = 0.943; P < 0.00001; y = -37.98 + 7.54 x GA), from the mouth to the gnathion (r = 0.946; P < 0.00001; y = -46.34 + 7.95 x GA), from the upper level of the philtrum to the mouth (r = 0.71; P < 0.00001; y = 0.22 + 3.33 x GA) and from the mouth to the upper concavity of the chin (r = 0.665; P < 0.00001; y = 1.65 + 2.95 x GA). The ratio between the distance from the tip of the nose to the mouth and that from the mouth to the gnathion was also almost constant throughout gestation, as was the ratio between the distance from the upper philtrum to the mouth and that from the mouth to the upper concavity of the chin.

CONCLUSIONS

We provide normative data of the fetal facial profile across GA. Our data offer a potential tool for the prenatal diagnosis of abnormal fetal facial profile.

In vitro fertilisation and use of ovulation enhancers may both influence childhood height in very low birthweight infants

CONTEXT

Term-born children conceived by in vitro fertilisation (IVF) are reportedly taller than naturally conceived (NC) children. High levels of growth promoting hormones and epigenetic imprinting have been suggested as pathogenetic mechanisms.

HYPOTHESIS

Tall stature in prematurely born IVF-conceived (IVF-C) children suggests pre- or early implantation imprinting rather than a postnatal effect.

METHODS

We studied 334 very low birthweight (VLBW: birth weight <1500 g) children born prematurely during 1995-1999 and obtained their anthropometric measures at 6-10 years of age. Perinatal and neonatal data were obtained from the Israeli VLBW database. We compared IVF-C, ovulating agents conceived (OA-C) and naturally conceived (NC) groups of children with respect to their and their parents' anthropometry and their perinatal/neonatal variables.

RESULTS

Childhood height standard deviation scores (SDSs) were greatest in IVF-C (-0.12 (SD 1.25); p<0.022) and insignificantly greater in OA-C (-0.37 (SD 1.02)) as compared to NC (-0.58 (SD 1.36)) children. The IVF-C and NC groups were significantly different regarding 17 parental and perinatal variables; however, multiple regression analysis including these variables showed that, as compared with NC, IVF-C children had significantly older mothers at birth with earlier follow-up during pregnancy and more multi-fetal pregnancies.

CONCLUSIONS

IVF-C and to a lesser extent OA-C prematurely born children are taller than otherwise NC children. After ruling out postnatal and parental causes, we speculate that pre- or early implantation factors might have contributed to the taller stature of IVF-C children.

Three-dimensional power Doppler in the evaluation of painful leiomyomas and focal uterine thickening in pregnancy

OBJECTIVE

To determine the usefulness of 3-dimensional (3D) power Doppler ultrasound in distinguishing painful leiomyomas from focal myometrial contractions or nonpainful leiomyomas in pregnancy.

METHODS

A 2D section of the area of interest in the uterine wall was first obtained in 29 patients to determine whether the pain originated from a myoma or a uterine contraction. Then, volume acquisition was activated and Doppler indices (vascularization index, flow index, and vascularization-flow index) were calculated for thickened and normal uterine wall.

RESULTS

Of 15 patients found to have uterine myomas, 11 had multiple tumors and 4 had single tumors. In the remaining 14 patients the painful uterine thickening proved to be a focal contraction. Painful segments of uterine thickening were associated with lower Doppler indices. Painful myomas were found to have significantly lower indices than normal uterine wall (P=0.008, 0.03, and 0.01 for VI, FI, and VFI, respectively, vs. 0.001, 0.003, and 0.01). However, the differences in indices between nonpainful myomas and uterine wall on the one hand, and nonpainful myomas and focal uterine contractions on the other, were not statistically significant.

CONCLUSION

Three-dimensional power Doppler ultrasound may be a sensitive and reliable tool for distinguishing painful uterine myomas from focal myometrial contractions and nonpainful myomas.

Cardiac troponin I serum concentrations in newborns: A study and review of the literature

BACKGROUND

Serum cardiac troponin I (cTnI) is a specific marker of cardiac injury. The use of cTnI in neonates, especially in relation to perinatal asphyxia has not been extensively examined. We defined the range of normal values of cTnI in newborns, and study factors that may influence these concentrations.

METHODS

Serum cTnI concentrations were measured on the third day of life in 179 normal newborns: 157 were term (after 37 weeks, mean: 39.7+/-1.1, range: 37-42) and 22 were premature infants (mean: 32.6+/-2.9, range: 27-36 weeks).

RESULTS

Mean cTnI for the term infants was 0.63+/-0.58 ng/ml (median: 0.50, range: 0.00-4.30). The concentration of 1.80 ng/ml, can serve as the upper limit of normal values. There was a borderline significant trend for higher cTnI in preterm infants. The number of newborns with cTnI>1.80 ng/ml was significantly higher after delivery by caesarean section, compared to vaginal delivery (14.6% vs. 2.9%, p<0.02). No other significant associations were found between cTnI and perinatal or neonatal parameters.

CONCLUSIONS

Normal reference values for cTnI in healthy term newborns were defined, but need to be addressed with caution due to the wide range of normal values.

A prospective randomized trial of itraconazole vs fluconazole for the prevention of fungal infections in patients with acute leukemia and hematopoietic stem cell transplant recipients

Fluconazole antifungal prophylaxis is standard care in allogeneic hematopoietic stem cell transplant (HSCT) recipients, but this drug lacks anti-Aspergillus activity, the primary cause of invasive fungal infection (IFI) in many transplantation centers. We performed a randomized trial to compare itraconazole vs fluconazole, for prevention of IFIs in patients with acute leukemia (AL) and HSCT recipients. One hundred and ninety-five patients were randomly assigned to either fluconazole or itraconazole antifungal prophylaxis, after stratification into high-risk and low-risk groups. Antifungal prophylaxis was started at the beginning of chemotherapy and continued until resolution of neutropenia, or until amphotericin B treatment was started. IFI occurred in 11 (11%) of itraconazole, and in 12 (12%) fluconazole recipients. Invasive candidiasis (IC) developed in two (2%) itraconazole and one (1%) fluconazole recipients, while invasive aspergillosis (IA) developed in nine (9%) itraconazole and 11(11%) fluconazole recipients. There was no difference in the incidence of total IFI, IC and IA between the two study arms. However, there was a nonsignificant trend towards reduced mortality among patients who developed IA while receiving itraconazole prophylaxis (3/9=33% vs 8/11=73%, P=0.095).

Changes in creatine phosphokinase (CK) concentrations after minor and major surgeries in children

BACKGROUND

During surgery, damage occurs to muscles in the area of the operation. The few studies that have examined creatine phosphokinase (CK) values after surgery have been in adults. The only study in children was after cardiac surgery. Understanding the normal enzyme pattern of change may help to differentiate malignant hyperthermia, anaesthesia-induced rhabdomyolysis and elevated CK values resulting from inherited muscle disease in cases in which these are suspected. The aim of this study was to delineate the normal rise of CK after minor and major surgery in children.

METHODS

A total of 71 patients aged 1 month-17 yr were studied. From the cohort of 71 patients, 46 underwent elective surgery (14 major, 32 minor) and in 25 the surgery was designated as an emergency surgery (21 major, 4 minor). The anaesthesia protocol was similar for both groups with halothane induction and isoflurane maintenance. Owing to its possible effect on CK, succinylcholine was avoided during the study.

RESULTS

The mean values of CK concentration before and after surgery were 63.1 iu litre(-1) and 151.5 iu litre(-1), respectively. The median CK elevation (range) for the major and minor surgery groups was 43 iu litre(-1) (4-647) and 10 iu litre(-1) (-28 to 122), respectively (P<0.0001).

CONCLUSIONS

CK concentrations in the major surgery group were significantly higher than the minor surgery group. This profile can contribute to the evaluation of patients who present with the possibility of malignant hyperthermia, anaesthesia-induced rhabdomyolysis and underlying muscle disease. Any rise of CK concentration above what is expected should prompt further investigation.

Interferon-alpha2a is sufficient for promoting dendritic cell immunogenicity

Type I interferons (IFNs) are widely used therapeutically. IFN-alpha2a in particular is used as an antiviral agent, but its immunomodulatory properties are poorly understood. Dendritic cells (DCs) are the only antigen-presenting cells able to prime naive T cells and therefore play a crucial role in initiating the adaptive phase of the immune response. We studied the effects of IFN-alpha2a on DC maturation and its role in determining Th1/Th2 equilibrium. We found that IFN-alpha2a induced phenotypic maturation of DCs and increased their allostimulatory capacity. When dendritic cells were stimulated simultaneously by CD40 ligation and IFN-alpha2a, the production of interleukin (IL)-10 and IL-12 was increased. In contrast, lipopolysaccharide (LPS) stimulation in the presence of IFN-alpha2a mainly induced IL-10 release. The production of IFN-gamma and IL-5 by the responder naive T cells was also amplified in response to IFN-alpha2a-treated DCs. Furthermore, IL-12 production by IFN-alpha2a-treated DCs was enhanced further in the presence of anti-IL-10 antibody. Different results were obtained when DCs were treated simultaneously with IFN-alpha2a and other maturation factors, in particular LPS, and then stimulated by CD40 ligation 36 h later. Under these circumstances, IFN-alpha2a did not modify the DC phenotype, and the production of IL-10/IL-12 and IFN-gamma/IL-5 by DCs and by DC-stimulated naive T cells, respectively, was inhibited compared to the effects on DCs treated with maturation factors alone. Altogether, this work suggests that IFN-alpha2a in isolation is sufficient to promote DC activation, however, other concomitant events, such as exposure to LPS during a bacterial infection, can inhibit its effects. These results clarify some of the in vivo findings obtained with IFN-alpha2a and have direct implications for the design of IFN-alpha-based vaccines for immunotherapy.

Outcome and early complications of ERCP: a prospective single center study

BACKGROUND/AIMS

ERCP has been used since 1968 both as a diagnostic and as a therapeutic procedure. In the last ten years several less invasive imaging methods have developed which allow visualization of bile ducts and pancreatic ducts; therefore ERCP has become mainly a therapeutic tool. The aim of the study was to prospectively evaluate the early outcome of ERCP when used essentially as a therapeutic tool.

METHODOLOGY

All patients referred to our unit between April 1 1998 and March 31 2000 were included in the study. The indication for the procedure, number of cannulations, duration of procedure, performance of endoscopic sphinterotomy or pre-cut, insertion of stent and the final outcome were recorded. All patients were visited (in-patients) or contacted by phone (outpatients) 24 hours and one week after the procedure. If a complication occurred the patient was followed until it was resolved.

RESULTS

722 ERCP procedures were performed on 534 patients (59% females), mean age 63.4 years (range 3 to 98 years). The procedure was performed with a therapeutic intention in 95% of cases because of suspicion of: cholelithiasis (58%), tumor of pancreas/bile ducts (30%), post-cholecystectomy bile leak or bile duct stenosis (6%) or treatment of chronic pancreatitis (1%). The overall success rate of selective duct cannulation was 92%. Endoscopic sphincterotomy was performed in 375 procedures (52%), pre-cut in 152 (21%) and stent inserted in 180 (25%). Among the 701 procedures with complete information 76 complications occurred in 73 patients (10.8%): pancreatitis 4.3%, perforation 1.3%, sepsis 3.7%, bleeding 1.4%. Most of the complications (63/701, 9%) were mild to moderate. Procedure-related mortality was 0.6% due to perforation (1 patient), and sepsis (3 patients). The main factors influencing the complication rate were the difficulty of the examination, performance of an invasive procedure or the operator.

CONCLUSIONS

In the era of therapeutic ERCP, the risk of severe complication from the procedure is low--1.8% (including a mortality rate of 0.6%) when using the appropriate technique in experienced and skilled hands.

Alpha-fetoprotein in the early neonatal period—a large study and review of the literature

BACKGROUND

Alpha-fetoprotein (AFP) is a glycoprotein molecule, which has similarity to albumin and is produced by the fetal liver. Its biological role is unclear and factors that may influence its concentrations in neonates are only partially identified. However, it has an important role as a diagnostic marker, especially in certain tumors and liver diseases of childhood. Its normal reference values in newborns have not been well defined.

METHODS

Serum AFP concentrations were measured and characterized in 260 term and near-term newborns [gestational age (GA)> or =34 weeks, birthweight (BW)> or =1700 g] at birth [umbilical cord (UC) blood] and upon discharge from the nursery at 60+/-24 h of life (venous sample).

RESULTS

Due to the nonnormal distribution of AFP levels, it is useful to relate to reference interval for AFP concentrations at birth that was 15.7-146.5 microg/ml, based on 95% confidence interval (CI). The median value of 48.3 microg/ml is also a useful reference. However, mean AFP concentrations at birth that were 61.6+/-44.8 microg/ml are less informative due to the large standard deviation (S.D.). Upon discharge, AFP concentrations dropped to 9.7-111.9 microg/ml (95% CI) with a median of 34.2 microg/ml. A significant negative correlation was found between AFP serum levels and gestational age and to a lesser extent with birthweight. No significant differences were found between males and females.

CONCLUSIONS

Normal reference intervals for AFP in term and near-term newborns have been defined, but need to be addressed with caution due to the wide range of normal values. AFP levels at birth decrease as gestation advances and the newborn weighs more.

Sonographic imaging of cervical scars after Cesarean section

OBJECTIVE

To investigate whether uterine contractions at the time of a Cesarean section have an impact on future presence and location of a cervical Cesarean scar.

METHODS

A targeted transvaginal ultrasound examination of the fetus, uterus and cervix was done in 2973 consecutive women at 14-16 weeks' gestation. The sonographer was blinded to the women's previous obstetric histories. The presence and location of a sonographic cervical hypoechogenic line, which probably represented a Cesarean scar, was recorded.

RESULTS

There were 180 women with a previous Cesarean section performed before the start of uterine contractions and 173 with a Cesarean section performed during contractions in labor. The cervical hypoechogenic line was more common in sections performed during contractions (75.7% vs. 52.7%; P < 0.001) and was more distally located from the internal os (17.9 +/- 9.4 vs. 14.6 +/- 9.1 mm; P = 0.01). A hypoechogenic line was observed in 21/2620 women without a previous Cesarean section, representing a false-positive rate of 0.8%.

CONCLUSION

Cesarean sections, especially those done during uterine contractions, are actually performed through cervical tissue. This finding is in agreement with the physiological process of cervical effacement during contractions.

The role of umbilical cord alpha fetoprotein as a screening tool for neonatal hyperbilirubinemia

Our aim was to test whether alpha fetoprotein (AFP) might serve as a marker of hepatic immaturity sufficient to predict an increased risk for neonatal hyperbilirubinemia (NHB) in term babies. We checked umbilical cord AFP (UC AFP) levels in 174 healthy full-term infants (male/female ratio 1.26:1) at birth. Bilirubin levels were measured upon discharge from the nursery on day 3 of life (mean, 57 +/- 10 hours of life). Mean UC AFP was 60.2 +/- 45.9 mg/L. UC AFP levels were linearly correlated with subsequent bilirubin levels, and significantly higher bilirubin levels were found in neonates whose UC AFP levels were 100 mg/L or more. Although statistically significant correlation between UC AFP and subsequent NHB exists, UC AFP cannot currently be recommended for use in clinical practice because of its inability to serve as a screening tool for significant NHB in the individual newborn.

Bone quantitative ultrasound and nutritional status in severely handicapped institutionalized children and adolescents

BACKGROUND & AIMS

Children with cerebral palsy (CP) have a high prevalence of pathologic fractures. Bone quantitative ultrasonography (QUS) has emerged as a radiation-free method for the assessment of bone quality and fracture risk. In this study, we applied QUS technique in order to investigate bone status in handicapped institutionalized children and adolescents.

METHODS

This cross-sectional study included 87 handicapped institutionalized patients. Measurements of the velocity of ultrasound wave, speed of sound (SOS), at distal radius and midshaft tibia, were performed using Omnisense 7000S analyser (Sunlight Ltd., Tel Aviv, Israel). In addition, all the participants had a thorough evaluation of nutritional status, demographic and clinical characteristics.

RESULTS

Forty-five of patients had either radius or tibia bone SOS lower than -1 SD, and 21% had either radius or tibia bone SOS lower than -2.5 SD. Using step-wise regression analysis, female gender (P=0.003) and stature (P=0.008) were correlated with radius SOS. Age (P=0.03) and fracture history (P=0.04) were negatively correlated with tibia SOS.

CONCLUSION

In this group of children and adolescents with CP one-fifth had poor bone status as suggested by low tibia/radius SOS assessed by QUS. Female gender, stature, age and fracture history were significantly correlated with poor bone status.

Neonatal lenticulostriate vasculopathy: further characterisation

BACKGROUND

Lenticulostriate vasculopathy (LSV) is sometimes detected on routine brain ultrasonography in neonates, and is often associated with various perinatal and neonatal abnormalities. However, most reports on LSV are retrospective with no controls.

OBJECTIVES

To compare the perinatal and neonatal clinical characteristics of neonates with LSV with matched controls and to summarise all published reports of LSV.

DESIGN

A prospective study that summarises the clinical, laboratory, and neurosonographic data of neonates with LSV.

METHODS

Of 1184 neonates admitted to the neonatal intensive care unit (NICU) during a three year period, 857 had a routine head ultrasound examination. Twenty one had LSV, and were compared with 42 matched controls with regard to gestational, perinatal, neonatal, laboratory, and neurosonographic characteristics.

RESULTS

LSV was detected in 21 of the 857 (2.45%) neonates. It was bilateral in 10 of the 21 cases and located in the thalamus (n = 14) and basal ganglia (n = 7). Infants with LSV were not significantly different from matched controls in most tested variables. However, compared with the control group, the LSV group included significantly more multiple births and more disturbances in amniotic fluid volume, but less meconial amniotic fluid. In addition, the patients with LSV required fewer blood transfusions and less phototherapy.

CONCLUSIONS

Except for more multiple births, neonates with LSV did not display more adverse findings than their matched controls.

Insulin in human milk: postpartum changes and effect of gestational age

OBJECTIVE

To determine if human milk insulin (HMI) concentrations are affected by gestational age and postnatal age.

DESIGN AND SETTING

An observational study carried out in a level III neonatal intensive care unit. Insulin concentrations were determined in human milk of 90 parturient mothers who delivered between 30 and 41 weeks gestation. Samples were collected on days 3 and 10 after delivery.

RESULTS

HMI concentrations for mothers of preterm infants were not significantly different from those of full term infants, on either day 3 or 10 post partum. When results for all 90 mothers were pooled, regardless of gestational age, HMI concentration fell significantly from day 3 to day 10 (50.1 (34.6) v 41.1 (28.5) microU/ml; p = 0.01; mean (SD)). However, this decrease was only significant for mothers delivering at term (37-41 weeks).

CONCLUSIONS

HMI concentrations were not influenced by gestational age at delivery. They decreased post partum, mainly in mothers of term infants. The postnatal changes in HMI concentrations and the effects of oral insulin on the immature intestinal mucosa warrant further investigation.

Modulation of polymorphonuclear leukocytes function by incubation with human serum from oxidant-challenged individuals

Polymorphonuclear leukocytes (PMN) from healthy donors were tested for stimulated release of superoxide anions after being incubated with serum of welders and of a group of unexposed individuals. These two groups were further subdivided either according to age or to smoking habits. The experiments showed that stimulated superoxide production from PMN was inhibited (P < 0.05) by serum from young smokers as compared to that of young nonsmokers, both from the unexposed group. Incubation of PMN with serum from elderly nonsmoking individuals decreased superoxide production as compared to incubation with serum from young nonsmoking individuals, both from the unexposed group. A decrease in superoxide production by incubation with serum of welders as compared to that of unexposed individuals was significant only when the comparison was carried out between the young, non-smoking subgroups. These findings suggest that age, smoking, and exposure to oxidants induce appearance in serum of factors that affect the PMN function

Total skin electron irradiation in mycosis fungoides: comparison between a modified Christie Hospital translational technique and the Stanford technique

Seventy-one patients with mycosis fungoides (MF) were treated by Total skin electron irradiation (TSEI) using either a modified Christie Hospital translational technique (44 pts) or a six dual-field Stanford technique (27 pts). There was no statistical difference in response rate, disease-free survival and overall survival between the two irradiation techniques. However, the Stanford technique was significantly less toxic than the modified Christie Hospital technique.

Obstetricians' opinions regarding patient choice in cesarean delivery

OBJECTIVE

To survey the opinions of Israeli obstetricians regarding their position on patient choice cesarean delivery.

METHODS

Short anonymous questionnaires were sent by mail. The questionnaire included basic demographic data followed by three short case presentations of patients requesting cesarean delivery without a medical indication; the respondents were asked if they would consent to the patients' request. Respondents were then asked about their personal preferences on the mode of delivery, their attitude towards women's right to choose cesarean delivery, and whether obstetricians should inform their patients of this right.

RESULTS

Of the 650 questionnaires sent, 257 were returned. Most of the respondents were specialists, aged 35 years or older, and worked in hospitals. Seventy-five percent were male, and 27% had a teaching academic degree. The consent rate for patient choice cesarean delivery in the three case presentations ranged from 40% to 79%. Only 9% of the respondents said they would prefer cesarean delivery for themselves (if female) or for their partners. Forty-five percent supported women's right to choose cesarean delivery, and half of them stated that obstetricians should inform their patients of this right.

CONCLUSION

Although the vast majority (91%) of the Israeli respondents personally prefer vaginal delivery, almost half of them support women's autonomy to choose cesarean delivery. Consequently, approximately 50% of the respondents were willing to perform cesarean delivery on request because of their support of women's autonomy, despite the fact that they believe that vaginal delivery is a better option.

Cerebellar growth in normal fetuses of multiple gestations

OBJECTIVE

The purpose of this study was to compare the cerebellar growth in twin and triplet gestations with cerebellar growth in singleton pregnancies.

METHODOLOGY

An ultrasound study was conducted in a population of normal pregnant women with singleton, twin and triplet gestations. Routine ultrasound examinations were performed in healthy pregnant women: 951 women with singleton pregnancies; 151 with twin gestations; and 28 with triplet gestations. Although multiple biometric parameters were measured throughout the course of pregnancy, in this study a single measurement (the last measurement before delivery) of the transverse cerebellar diameter (TCD) was used from each patient for statistical analysis. Growth of the TCD was determined in the multiple gestations and compared with growth in singleton pregnancies.

RESULTS

A statistically significant relationship was found between TCD and gestational age in all three groups (singleton, twin A and B, and triplets) respectively: R2 = 0.963; R2 = 0.980; R2 = 0.977. No statistical difference was found between the three sets of normative measurements.

CONCLUSIONS

There was no significant difference observed in cerebellar growth among singleton and multiple gestations. Therefore, nomograms previously established for singleton pregnancies may be useful to assess growth in multifetal pregnancies.

Protective effect of faecal occult blood test screening for colorectal cancer: worse prognosis for screening refusers

BACKGROUND AND AIMS

Screening for colorectal cancer (CRC) by faecal occult blood testing (FOBT) decreases CRC mortality by 15-33%. Compliance remains an obstacle to maximising the benefit of FOBT screening. We tested the hypothesis that individuals offered FOBT screening but refused would have an increased incidence and worse prognosis for CRC compared with those tested and with controls.

METHODS

Annual screening was offered to 3548 average risk individuals, > or = 40 years of age, from a highly stable population. A total of 2538 agreed to testing (group 1) and 1010 (28%) refused (group 2). Another 1376 individuals were never offered the test and served as controls (group 3). The groups were followed for 11 years: a three year screening period (1985-1987) and an eight year follow up period at the end of the screening programme (1988-1995). Incidence, stage, and mortality were compared. Characterisation of refusers was completed in 188 and 130 subjects of groups 1 and 2, respectively.

RESULTS

In the screening phase, mortality from CRC was significantly lower in group 1 than in groups 2 and 3. The cumulative incidence of CRC in the eight year follow up period was 21 (0.88%), 23 (2.28%), and 13 (0.94%) in groups 1, 2, and 3, respectively. This shows a reduction of 61.4% in group 1 compared with group 2 (relative risk 0.28 (95% confidence interval (CI) 0.19-0.32)) (p<0.001) and 6.4% compared with group 3 (relative risk 0.93 (95% CI 0.93-1.00)) (NS). During follow up, group 1 subjects also demonstrated a decrease in advanced Dukes' stage and mortality rate by 80% and 64%, and 79% and 62%, compared with groups 2 and 3, respectively. Refusers were more likely to be male, of Asian-African descent, and more likely to smoke, consume more coffee, and less tea or dairy foods.

CONCLUSIONS

When accepted, FOBT may protect against CRC for prolonged periods. Individuals who refuse FOBT have a significantly higher CRC incidence and mortality rates than those who accept testing.

Trends in medical specialty choice among Israeli medical graduates, 1980-1995

BACKGROUND

Which medical specialties do Israeli medical graduates choose? Answers to this question can serve as an essential means of evaluating both Israeli medical education and the healthcare system.

OBJECTIVES

To determine the distribution of medical specialty choice, its change over time and the possible influence of the medical school on the choice; to study the graduates' gender, gender variability in specialty choice and time trends in both; and to assess the choice of family medicine as a career among the graduates as a group, by medical school, gender, and time trends.

METHODS

The study population comprised all graduates of the four medical schools in Israel during 16 years: 1980-1995 inclusive. Data were obtained from the four medical schools, the Israel Medical Association's Scientific Council, and the Ministry of Health. Data allowed for correct identification of two-thirds of the graduates.

RESULTS

A total of 4,578 physicians graduated during this period. There was a significant growth trend in the proportion of women graduates from 22.6% in 1980 (lowest: 20.0% in 1981) to 35.3 in 1995 (highest: 41.5% in 1991). Overall, 3,063 physicians (66.8%) started residency and 1,714 (37.4%) became specialists. The four most popular residencies were internal medicine, pediatrics, obstetrics and gynecology, and family medicine. Ten percent of Israeli graduates choose family medicine.

CONCLUSIONS

The overall class size in Israel was stable at a time of considerable population change. Women's place in Israeli medicine is undergoing significant change. Family medicine is one of the four most popular residencies. A monitoring system for MSC in Israel is imperative.

Gastric emptying time and gastric motility in patients with Parkinson's disease

Gastrointestinal symptoms such as nausea, abdominal pain, and bloating are frequent complaints of patients with Parkinson's disease (PD). It has been postulated that impaired gastrointestinal function may contribute to the development of motor fluctuations such as delay on and no on in patients with PD. Gastrointestinal impaired function and symptoms may be associated with the disease itself or secondary to levodopa treatment. Thus, we assessed gastric emptying (GE) and gastric motility in PD patients to examine the association between clinical status and gastric function. GE and antral contraction (frequency and amplitude) were evaluated by scintigraphy in 29 patients with mild PD (Hoehn and Yahr [H&Y] stage 1.0-2.0); 22 patients with moderate PD (H&Y stage 2.5-3.0); and 22 healthy volunteers, following the ingestion of a labeled standard meal. Gastric emptying (mean +/- SD of T(1/2)) and antral contraction were not significantly different between patients with mild PD (63.4 +/- 28.8 minutes) and moderate PD (54.7 +/- 25.5 minutes). In the control group, GE was 43.4 +/- 10.8 minutes (range 29.0 - 61.0 minutes). The prevalence of delayed emptying (>61 minutes) was not significantly different in patients with mild disease (48.3%) as compared with patients with moderate disease (36.4%). Antral contraction, both frequency and amplitude, were not significantly different between patients with mild and moderate PD throughout the entire 100 minutes of the study. Untreated patients (n = 28) had mean GE T(1/2) of 59 +/- 30.6 minutes. Patients with smooth response to levodopa showed slower GE (n = 10; 73.6 +/- 25.3 minutes), while treated patients with motor response fluctuations when tested at the on state (n = 13), had much faster GE (49.3 +/- 16.2 minutes). This shortened GE in the on state was similar to the GE of normal volunteers. We conclude that gastric emptying time in patients with PD was delayed compared with control volunteers. It was even slower in patients treated with levodopa. This effect of levodopa treatment was reversed to pseudonormalization (normal GE) at the advanced stages of the disease, when patients developed motor response fluctuation. Other clinical features of PD were not associated with delayed gastric emptying.

Phenotypic characteristics of colo-rectal cancer in I1307K APC germline mutation carriers compared with sporadic cases

The I1307K APC germline mutation is associated with an increased risk to colo-rectal cancer (CRC). Whether and to what extent the phenotype of CRC in mutation carriers differs from sporadic cases, remains unknown. To gain insight into this issue, we analysed 307 unselected Israeli patients with CRC, who were treated in a single medical centre, for harbouring the I1307K mutation. Twenty-eight mutation carriers (9.1%) were detected. Two of 28 mutation carriers (7.1%) and 93/277 (33.6%) of non-carriers, were of non-Ashkenazi origin (P < 0.01). In 74/278 (26.6%) of the sporadic cases, and only 1/28 (3.6%) of mutation carriers (3.6%) the tumour was located in the right colon (P < 0.01). Mutation carriers had a more advanced disease stage (14/28 - 50% Dukes C), as compared with 60 (19.5%) of non-carriers (P = 0.02). The mean age at diagnosis was similar: 65 (+/- 9.7) years and 66.3 (+/- 11.6) years, for mutation carriers and non-carriers, respectively. No statistical differences were noted between the two groups in sex distribution, tumour grade, and family history of cancer. We conclude that early age at diagnosis and family history of cancer cannot be used to predict who is likely to harbour the I1307K APC germline mutation carriers. However, the tumours in patients with this mutation appear different than those without, are less likely to be proximal and more likely to be advanced than tumours in non-carriers.

Early hyperbaric oxygen therapy for retinal artery occlusion

PURPOSE

To assess whether early hyperbaric oxygenation (HBO) treatment has a beneficial effect on visual results after retinal artery occlusion (RAO).

METHODS

A comparative retrospective study in which medical records of all HBO-treated RAO patients in our department were reviewed and compared with matched RAO patients not treated by HBO (from a different medical center). Mean visual acuity (VA) at completion of treatment, the presence or absence of improvement in VA between admission and discharge, and the mean change in VA between admission and discharge were noted. All patients treated by HBO had treatment no later than 8 hours after the beginning of visual symptoms.

RESULTS

Mean VA at discharge was 0.2981 (6/20) in the treated group and 0.1308 (6/46) in the control group (p < 0.03). In the treated group, 82.9% had an improvement in VA between admission and discharge, compared with 29.7% of the control group (p < 0.00001). Mean improvement in VA was 0.1957 in the treated group and 0.0457 in the control group (p < 0.01). Differences in outcome measures between treatment and control groups were found to reflect the difference between treated and untreated hypertensive patients. No difference was found between treated and untreated non-hypertensive patients.

CONCLUSIONS

Early HBO therapy appears to have a beneficial effect on visual outcome in patients with RAO. Further large-scale prospective controlled studies are needed to confirm this.

Superoxide anion release by peripheral polymorphonuclear leukocytes in welders

OBJECTIVES

To investigate peripheral blood neutrophil [polymorphonuclear leukocyte (PMN)] function in a group of 23 welders compared with that in an age- and smoking habit-matched non-exposed control group.

METHODS

Stimulated release of superoxide anions from PMN isolated from peripheral blood of welders and of a matched group was carried out.

RESULTS

The stimulated release of superoxide anions in PMNs from welders was significantly lower (P = 0.021) than that of a control group. Smokers and older workers had a lower function of PMNs than non-smokers and younger workers.

CONCLUSIONS

PMN function of welders is lower than that of controls. This effect might indicate reduced immunological defences in oxidant-exposed individuals. It is possible that PMN function might serve as a biological marker of exposure in the periodic health surveillance of welders.

The role of high-dose oral iron supplementation during erythropoietin therapy for anemia of prematurity

OBJECTIVE

To assess whether a high intake of oral iron would increase the effect of recombinant human erythropoietin (rHuEPO) on hemoglobin synthesis.

METHODS

We studied 30 preterm infants (gestational age 29+/-1.8 weeks, birth weight 1161+/-200 g, at age of 28+/-10 days) who were randomly assigned to receive either 8 mg/kg per day (n=15) or 16 mg/kg per day of oral iron during a course of rHuEPO therapy (900 microg/kg per week) for a duration of 4 weeks. Both groups were comparable in regard to clinical and laboratory data at the time of enrollment.

RESULTS

rHuEPO caused a significant increase in reticulocyte count in the low- and high-dose iron groups, 17.1+/-5.3 to 34.7+/-9.2 and 16.3+/-3.3 to 42.5+/-5.6 (10(9)/l), respectively (p<0.05). However, in both groups, hematocrit values remained stable at the end of the study as compared to baseline (0.35+/-0.03% vs. 0.30+/-0.03%, 0.35+/-0.05% vs. 0.30+/-0.03%, NS) and in both groups there was a comparable and significant decrease in ferritin level (259+/-109 to 101+/-40 and 168+/-54 to 69+/-38 microg/l, respectively; p<0.01). The rates of bloody stools without any evidence of necrotizing enterocolitis were not significantly different between the two treatment groups (1/15 vs. 4/15, NS).

CONCLUSION

We conclude that a higher dose (16 mg/kg per day) of oral iron is not more beneficial when compared to a lower dose (8 mg/kg per day) during rHuEPO therapy for anemia of prematurity. Further studies will define the optimal dosage and route of administration of iron supplementation during rHuEPO therapy.

The Catz-Itzkovich SCIM: a revised version of the Spinal Cord Independence Measure

PURPOSE

To examine the suitability of the revised Spinal Cord Independence Measure, the Catz-ltzkovich SCIM, for evaluation of patients with spinal cord lesions, as compared to the original SCIM and to the Functional Independence Measure (FIM).

METHOD

The revised SCIM was applied by paired independent teams of occupational therapists, physiotherapists and nurses and the FIM by a single nurse. The examiners assigned scores to the functional capabilities of 28 patients with spinal cord lesions. The scores by the revised SCIM were analysed for reproducibility as between the two teams of examiners (interrater reliability) and for their correlation with the FIM scores.

RESULTS

The frequency of identical scoring by two independent examiners (total agreement) was 80% or higher for 13/18 individual functions listed in the revised SCIM. In the self-care category it was 80-99%, as compared to 75-87% before revision. In neither bowel management nor bed mobility was there an increase over the original SCIM in the frequency of identical scores, despite rephrasing and restructuring of the scoring criteria. A high correlation was noted between the paired scores for all functions listed as well as for those comprising each of the four functional categories (r = 0.90-0.96, p <0.001). The total revised-SCIM scores were significantly correlated with those derived by the FIM (r = 0.835, p < 0.001).

CONCLUSIONS

The findings indicate that the newly revised SCIM (Catz-Itzkovich) is a valid and highly reproducible measure of daily function in patients with spinal cord lesions, and is superior to the original SCIM. We recommend that it supersede the original SCIM.

Spinal pain independence measure--a new scale for assessment of primary ADL dysfunction related to LBP

PURPOSE/METHOD

SPIM Spinal Pain Independence Measure. a new disability scale designed for patients with chronic low back pain disability, has been developed and studied at the Spinal Department of Loewenstein Rehabilitation Hospital. The SPIM differs from other existing scales for evaluation of chronic back disability, in that it is designated particularly for patients with deficits in primary ADL and evaluates function by observation.

RESULTS/CONCLUSIONS

This study shows the SPIM to be reliable: it supports the validity of the scale and points out a possible advantage of the SPIM over existing scales in sensitivity to functional change of patients with prominent disability. Further elaboration and examination of the SPIM is still needed.

Congenital subependymal pseudocysts: own data and meta-analysis of the literature

BACKGROUND

Congenital subependymal pseudocysts are incidental findings that are found in 0.5-5.2% of neonates during postmortem examination or head ultrasonography. In our institution we detected 10 neonates with CSEPC.

OBJECTIVE

To investigate associated etiological factors, morphologic characteristics and outcome of CSEPC.

METHODS

We performed a meta-analysis of the literature on CSEPC (1967-98), including our 10 cases.

RESULTS

A total of 256 cases of CSEPC were analyzed. Ultrasound diagnosed 77.6% of CSEPC; 48.8% were bilateral and 53.4% were located in the caudothalamic groove or head of caudate nucleus. Altogether, 93.5% resolved during 1-12 months of ultrasonographic follow-up. Compared to the general neonatal population, the following features were more prevalent in the CSEPC population: prematurity, maternal vaginal bleeding, preeclamptic toxemia, intrauterine growth restriction, asphyxia, fetal cytomegalovirus and rubella infections, congenital malformations, chromosomal aberrations, infant mortality, and neurodevelopmental handicap. The risk for neurodevelopmental handicap was significantly higher when CSEPC were associated with fetal infections, IUGR, malformations and chromosomal aberrations, or persistence of CSEPC during follow-up. CSEPC infants without any of these four conditions had a low risk for neurodevelopmental handicap.

CONCLUSIONS

CSEPC are morphologic features of various underlying conditions encountered in the fetus. Association of CSEPC with IUGR, fetal infections, malformations and chromosomal aberrations or persistence of CSEPC indicates a higher risk for future neurodevelopmental handicaps, probably because of the deleterious effects on the fetal brain that are inherent in these conditions. A favorable outcome is expected in the absence of these risk factors.

Save a child's heart: we can and we should

BACKGROUND

Congenital heart disease (CHD) causes the death of thousands of children in developing countries. At the Wolfson Medical Center (WMC), a prototype program has been developed to address this issue.

METHODS

Since 1996, indigent children have been referred to the program, with the cooperation of partners in developing countries. The project's aims are to (a) train their medical personnel at WMC, (b) travel to participating countries to teach, evaluate patients, operate, and promote the development of local centers, and (c) treat children with CHD, at WMC, who lack a local option for care either due to prohibitive costs or unavailability. The project's personnel are state employees who volunteer to treat additional patients within the framework of their salaries, and community volunteers.

RESULTS

The program has seven partner sites in six countries, including two provinces in China (Hebei and Gansu), Ethiopia, Moldova, Nigeria, the Palestinian Authority, and Tanzania. Five physicians and 10 nurses have been trained from five participating countries. Over the past 4 years, 11 teaching trips have been made abroad, and operations have been performed at four partner sites. A total of 386 patients have been operated on-360 at WMC and 26 at other sites. There have been 17 (4.3%) acute deaths. Follow-up is 92% complete with 3 late deaths reported.

CONCLUSIONS

Hospital-based regional centers can be created to promote the care of children with CHD in developing countries. Good results and follow-up care can be provided with appropriate planning.

The spinal cord independence measure (SCIM): sensitivity to functional changes in subgroups of spinal cord lesion patients

BACKGROUND

The spinal cord independence measure (SCIM) is a newly developed disability scale specific to patients with spinal cord lesions (SCL). Its sensitivity to functional changes in a whole cohort of SCL patients was found to be better than that of the functional independence measure (FIM).

OBJECTIVE

o compare the sensitivity to functional changes of the SCIM and the FIM in SCL subgroups.

DESIGN

A comparative self-controlled study.

SETTING

The Spinal Department, Loewenstein Rehabilitation Hospital, Raanana, Israel.

SUBJECTS

22 SCL inpatients.

INTERVENTIONS

Monthly SCIM and FIM assessments of the subgroups.

MAIN OUTCOME MEASURES

Functional change detection rate (FDR) and mean differences between consecutive scores (DCS).

RESULTS

The outcome measures of the SCIM were higher than those of the FIM for tetraplegia and paraplegia, complete and incomplete lesions (the FIM missed 25-27% of the functional changes detected by the SCIM; DSC 8.2-11.4 vs 5.2-9; P<0.05 in most comparisons). The SCIM did not exhibit this advantage, however, in the functional areas of self-care and mobility in the room and toilet. Further subgrouping yielded similar results.

CONCLUSIONS

The SCIM is more sensitive than the FIM to functional changes in the subgroups studied, and has the potential to serve as a universal tool for disability assessment of SCL patients.

The fetal superior cerebellar vermian width in normal, growth-restricted and macrosomic fetuses

OBJECTIVES

To obtain dimensions of the fetal superior cerebellar vermian width as a basis for further studies and for comparisons with deviation in growth.

STUDY DESIGN

The study group included 266 normal pregnant women from 20 to 37 weeks of gestation. Several biometric measurements were obtained throughout pregnancy, including the fetal superior cerebellar vermian width. Forty-three growth-restricted and 30 macrosomic fetuses were included in this study.

RESULTS

A linear growth function was observed between the superior cerebellar vermian width and gestational age (GA) (R = 0.859; p < 0.00001; y = -4.033 + 0.416 x GA), transverse cerebellar diameter (TCD) (R = 0.870; p < 0.00001; y = 0.404 + 0.223 x TCD), biparietal diameter (BPD) (R = 0.823; p < 0.00001; y = -3.086 + 0.155 x BPD), head circumference (HC) (R = 0.82; p < 0.00001; y = -3.21 + 0.434 x HC), femoral length (FL) (R = 0.843; p < 0.00001; y = -1.75 + 0.184 x FL) and humeral length (HL) (R = 0.824; p < 0.00001; y = -2.691 + 0.223 x HL). The ratio between the superior cerebellar vermian width and the transverse cerebellar diameter remained constant throughout gestation. In all 43 growth-restricted and the 30 macrosomic fetuses, the dimensions of the fetal superior cerebellar vermian width remained within the normal range for the indexed gestational age.

CONCLUSION

These results provide normative data for the fetal superior cerebellar vermian width in various dimensions and across gestational ages. In addition, growth of the superior cerebellar vermis remained normal in growth-restricted as well as macrosomic fetuses. Therefore, cerebellar vermian growth may be used adjunctively as a standard against which deviant fetal growth may be compared when precise gestational age determination is necessary.

Review of 49 neonates with acquired fungal sepsis: further characterization

BACKGROUND

Neonatal acquired fungal sepsis (AFS) is a risky condition that warrants every effort for early diagnosis and management.

METHODS

We retrospectively reviewed the medical charts of all 4445 neonatal intensive care unit (NICU) admissions in the past 10 years and detected 49 neonates with AFS. We then compared their data with those of 49 matched control neonates who did not have AFS. The following details were collected: gestational, perinatal and neonatal courses; bacterial sepsis; antibacterial therapy; laboratory and imaging investigations; and antifungal therapy and its complications.

RESULTS

The incidence of AFS was.4 to 2 cases per 1000 live-births and 3.8% to 12.9% of very low birth weight (VLBW) infants. Compared with 1989 through 1992, between 1993 and 1995 the rate of AFS in VLBW neonates significantly increased (3. 8%-5.6% --> 9.6%-12.9%), along with a significant increase of NICU admission rate (369-410 --> 496-510 admissions/year). Compared with controls, AFS neonates had significantly longer hospitalizations, higher rates of mechanical ventilation, umbilical vein catheterization, and previous treatment with broad-spectrum antibacterial agents (amikacin, vancomycin, ceftazidime, or imipenem). At the onset of AFS, 42.8% of patients had hyperthermia and 40.9% had normal white blood cell count. Causative fungi were as follows: Candida albicans-42.8% of cases, Candida parapsilosis-26.5%, and Candida tropicalis-20.4%. Fungal dissemination was rare, complications of antifungal therapy were infrequent, and no deaths occurred.

CONCLUSIONS

First, non-albicans Candida have become more frequent in neonatal AFS. Second, mechanical ventilation and antibacterial agents are significant risk factors for AFS. Third, hyperthermia is a frequent presenting sign of AFS. Fourth, a normal white blood cell count does not rule out AFS. Fifth, meningeal involvement in neonatal AFS should be ruled out before initiation of antifungal therapy. Sixth, the policy of empiric antifungal therapy for AFS should be considered on an individual NICU basis.newborn infant, fungal sepsis, clinical signs, risk factors.

The efficacy of intraoperative internal intercostal nerve block during video-assisted thoracic surgery on postoperative pain

BACKGROUND

Video-assisted thoracic surgery (VATS) is widely used for many thoracic surgical procedures. Post-operative pain is less after VATS than after conventional thoracic surgery, but is still significant. The objective of this study was to assess the efficacy of thoracoscopic, internal intercostal nerve block in alleviating immediate postoperative pain.

METHODS

Thirty-two patients underwent VATS bilateral sympathectomy for the treatment of hyperhidrosis. The patients were randomly divided into two groups with similar demographic and preoperative physiologic parameters. Group A (n = 16) was submitted to thoracoscopic, internal intercostal nerve blocks performed at T2, T3, and T4 intercostal levels using 3 cc of 0.5% bupivacain in each intercostal space. The injections were performed bilaterally, immediately after the sympathectomy, through the same port. Group B (n = 16) underwent bilateral thoracic sympathectomy without the block. During the immediate postoperative period, heart rate, blood pressure, respiratory rate, pain score, and analgesic requirements were monitored every 30 minutes.

RESULTS

No morbidity was recorded in association with the thoracoscopic, internal intercostal nerve block. The mean heart rates (77 +/- 6 vs 89 +/- 12 beats per minute, p < 0.001), respiratory rates (15 +/- 2 vs 18 +/- 3 respirations per minute, p < 0.01), pain score (1.9 +/- 0.6 vs 2.7 +/- 0.5, p < 0.01), and postoperative analgesic requirements (20 +/- 18 vs 50 +/- 21 mg pethidine HCL, p < 0.001) were significantly lower in group A. There was no significant difference in blood pressures.

CONCLUSIONS

Thoracoscopic, internal intercostal nerve block with bupivacain 0.5% during VATS is safe and effectively reduced the immediate postoperative pain and analgesic requirements.

Childhood epilepsy with occipital paroxysms: clinical variants in 134 patients

PURPOSE

In its recent proposal, the Commission on Classification and Terminology of the International League Against Epilepsy classified childhood epilepsy with occipital paroxysms (CEOP) into two syndromes with different predominant seizure types: early onset (Panayiotopoulos type) with eye deviation and ictal vomiting and late onset (Gastaut type) with initial ictal visual symptoms. We documented the clinical features of a large group of patients with CEOP to confirm whether the classification is justified.

METHODS

A file review of all patients with partial-onset seizure and interictal occipital spikes referred to our pediatric seizure unit between January 1975 and May 1997 yielded 134 who met the criteria for CEOP. Data were collected with a specially developed protocol and classified according to the two International League Against Epilepsy systems: (a) seizure classification, to test age-specific differences associated with the predominant seizure type, and (b) syndrome classification, to determine whether the clusters of signs and symptoms are sufficiently delineated.

RESULTS

Three groups were defined according to the predominant ictal manifestations. Group 1 (visual) consisted of 24 patients (17.9%) with ictal visual symptoms; 19 (14%) of these patients also had overlapping adversive manifestations, either as a separate seizure or as part of the same event (median age at first and last seizure, 7 years 11 months and 10 years). Group 2 (adversive) consisted of 72 patients (53.7%) with tonic eye deviation (median age at first and last seizure, 5 years 2 months and 7 years 2 months). Group 3 (nonvisual, nonadversive) consisted of 38 patients (28.4%) with various seizure spread patterns (median age at first and last seizure, 6 and 7 years 2 months). Two syndromes were identified. The Gastaut type included all 24 patients in the visual group (group 1); seizures were brief and frequent and were diurnal in 83%. The Panayiotopoulos type included all 72 patients in group 2; ictal eye deviation occurred in 100% of the patients and ictal vomiting in 44%; prolonged seizures were observed in 35% and were more frequent in patients who had ictal vomiting than in those who did not (46.8% versus 25%, respectively; p < 0.027). Seizures were infrequent; 24% of patients had a single seizure and 58% had nocturnal seizures. Onset was earlier than for the Gastaut type (p < 0.002). The 38 patients with nonoccipital manifestations did not satisfy the criteria for the complete form of either syndrome.

CONCLUSIONS

The most common type of CEOP, the Panayiotopoulos type, is characterized by a cluster of signs and symptoms sufficiently delineated to justify their separate classification from Gastaut-type CEOP, despite the absence of ictal vomiting in more than 50% of the patients.

Hepatitis C virus-related arthritis: characteristics and response to therapy with interferon alpha

OBJECTIVE

To characterize hepatitis C virus (HCV)-related arthropathy and to evaluate the response to treatment with interferon-alpha (INF-alpha).

METHODS

We studied 28 HCV-infected patients with arthritis. All patients underwent complete clinical, laboratory and radiological evaluation, including assessment and follow-up by a rheumatologist. Twenty-five patients were treated with INF-alpha for a median period of 12 months.

RESULTS

All patients were HCV-RNA positive (genotype 1b in 65%). The mean duration of arthropathy-related symptoms prior to the diagnosis of HCV infection was 12 months. 19 patients (68%) had symmetric polyarthritis and 19 (68%) had morning stiffness > or = 60 min. None of the patients had erosive disease or subcutaneous nodules. 12 (43%) had detectable cryoglobulin (mean cryocrit: 3.6 +/- 3.5%), 17 (61%) had rheumatoid factor (RF) (median titer: 1:80), and only 15 (54%) had elevated ESR. 14 patients (50%) had > or = 4 ACR (American College of Rheumatology) criteria for the diagnosis of rheumatoid arthritis (RA), 9 of whom were mistakenly diagnosed and previously treated as RA patients. Only 3 patients had a satisfactory response to previous treatment with anti-inflammatory or disease modifying drugs. Complete or partial response of arthritis-related symptoms in INF-alpha treated patients was observed in 44% and 32%, respectively. Cryoglobulin became undetectable in 9 of 12 patients. However, a complete biochemical and virological end-of-treatment response was achieved in only 8 (36%) and 5 patients (20%), respectively.

CONCLUSION

HCV arthropathy should be considered in the differential diagnosis of any patient with arthritis, even in the absence of liver disease. Treatment with interferon-alpha may lead to substantial clinical improvement of HCV-related arthritis even without a complete biochemical or virological response.

Peptide analogues as a strategy to induce tolerance in T cells with indirect allospecificity

BACKGROUND

It has been demonstrated that indirect recognition of allogeneic MHC molecules might play an important role in provoking graft rejection. Although direct recognition of allogeneic molecules on antigen presenting cells of the graft may induce a state of tolerance, the continuous presentation of processed alloantigens by specialized antigen presenting cells does not allow the same phenomenon to occur. Tolerance to interleukin-2 secreting T cells can be achieved in different ways, among these is the exposure to mutants of the wild type allopeptide. We have investigated whether peptide analogues of the allopeptide can induce tolerance in T cells with indirect allospecificity.

METHODS

T cell clones with indirect anti-HLA-A2-specificity generated from a HLA-A2-DRB1*1502+ patient who chronically rejected a HLA-A2-expressing kidney allograft were used for this study. Nine peptide analogues of HLA-A2 (residues: 103-120) were produced with single amino acid substitutions at the putative T cell receptor for antigen contact positions. Their effect on the proliferation of a panel of T cell clones was evaluated.

RESULTS

Peptide analogues and wild type peptide had similar capacity to bind to the restriction molecule HLA-DRB1*1502. Co-presentation of the peptide analogues 111R/A, H, K and 114H/K, with the wild type peptide inhibited T cell responses, indicative of antagonism. In addition, one analogue 112G/S induced unresponsiveness in the T cells to subsequent culture with the wild type peptide.

CONCLUSIONS

The data presented here suggest that using reagents such as altered peptides may represent a strategy to prevent the activation of T cells with indirect alloreactivity and allograft rejection in vivo.

Age-dependent alterations in the assembly of signal transduction complexes at the site of T cell/APC interaction

TCR interaction with peptide-MHC complexes triggers migration of protein kinases, actin-binding proteins, and other accessory molecules to the T cell/APC synapse. We used confocal immunofluorescence methods to show that the adapter protein LAT (linker for activation of T cells) and the guanine nucleotide exchange factor Vav also move to the APC interface in mouse CD4 T cells conjugated to anti-CD3 hybridoma cells, and in TCR-transgenic CD4 cells conjugated to APC bearing agonist (but not closely related nonagonist) peptides. The proportion of CD4+ T cells able to relocalize LAT or Vav, or to relocate cytoplasmic NT-AT (NF-ATc) from cytoplasm to nucleus, declines about 2-fold in aged mice. The decline in LAT relocalization is accompanied by a similar decline in tyrosine phosphorylation of LAT in CD4 cells stimulated by CD3/CD4 cross-linking. Two-color experiments show that LAT redistribution is strongly associated with relocalization of both NF-ATc and protein kinase C-theta among individual cells. LAT migration to the immunological synapse depends on actin polymerization as well as on activity of Src family kinases, but aging leads to only a small change in the percentage of CD4 cells that redistribute F-actin to the site of APC contact. These results suggest that defects in the ability of T cells from aged donors to move kinase substrates and coupling factors, including LAT and Vav, into the T cell/APC contact region may contribute to the decline with age in NF-ATc-dependent gene expression, and thus to defects in T cell clonal expansion.

Accuracy of the OMRON M4 automatic blood pressure measuring device

Despite widespread use of the automatic blood pressure (BP) measuring device OMRON M4, there is little formal validation on its accuracy. A study was conducted to assess the accuracy of the OMRON M4 compared with the true indirect BP measured by mercury sphygmomanometer (MS). A rapid method for the evaluation of automatic blood pressure measurement devices (READ) was applied for this study. The READ is based on numerous BP measurements at rest and during a standardised postural challenge in a small number of subjects who exhibit a wide range of BPs. Blood pressure measurements were done in supine position for 10 min followed by head-up tilt for 30 min and again supine for 10 min. The automatic device (AU) and the MS were connected to one arm-cuff by means of a T connector. A stethoscope with dual sets of ear-pieces was used for duplicate MS measurements (MS1 and MS2). The MS1, MS2 and AU measurements were taken simultaneously in a blinded manner. Three units of the automatic instrument were evaluated. An average of 111 measurements per unit were performed, every BP category being present in >/=15 MS measurements. The differences between MS1 and MS2 measurements (DeltaBP: MS1-MS2) were utilized to assess the consistency of true indirect BP and the differences between AU and MS measurements (DeltaBP:AU-MS2) were utilized to assess the accuracy of the AU. The following characteristics of the OMRON M4 were assessed: (1) grade of accuracy, (2) aberration pattern, (3) consistency of the aberration-pattern, and (4) correlation between levels of BP and DeltaBP: AU-MS. For MS paired readings, 92-100% of systolic and 99-100% of diastolic readings fell within 5 mm Hg difference range, that is consistent with a British Hypertension Society grade A of both. For AU compared to MS2, 29-64% of systolic and 73-94% of diastolic readings fell within 5 mm Hg and 49-86% of systolic and 86-99% of diastolic readings fell within 10 mm Hg and the devices qualified C, D and C, respectively. All devices exhibited irregular and inconsistent aberration patterns, making the design of correction formulas impractical. In conclusion, the OMRON M4 device did not meet the requirements of the British Hypertension Society and, therefore, cannot be recommended for clinical use.

Altered composition of the immunological synapse in an anergic, age-dependent memory T cell subset

In young mice, memory CD4 T lymphocytes with high P-glycoprotein activity (P-gp(high)) are unresponsive to TCR stimulation in vitro but can be activated by PMA plus ionomycin. The proportion of these hyporesponsive cells increases considerably with age. The earliest events in T cell activation were studied in P-gp(high) and P-gp(low) CD4 memory cells at the single-cell level using confocal immunofluorescence methods. Recruitment of both linker for activation of T cells (LAT) and protein kinase C-theta to the immunological synapse, i.e., the site of T cell interaction with stimulator cells, was greatly impaired in P-gp(high) cells from both young and old mice. Translocation of NF-AT to the nucleus, CD69 expression, and proliferative capacity were also diminished to a similar extent in P-gp(high) cells under the same activation conditions. In contrast, movement of c-Cbl to the synapse region occurred in a high proportion of CD4 memory T cells regardless of P-gp subset or age. Moreover, although P-gp(low) cells frequently recruited both c-Cbl and LAT to the APC synapse, cells in the less responsive P-gp(high) subset frequently relocated c-Cbl, but not LAT, to the interface region. In some systems, c-Cbl can act as a negative regulator of receptor-dependent tyrosine kinases, and alterations of c-Cbl to LAT ratios in the P-gp(high) subset may thus contribute to the hyporesponsiveness of this age-dependent, anergic memory cell population.

Stem cell factor inhibits erythroid differentiation by modulating the activity of G1-cyclin-dependent kinase complexes: a role for p27 in erythroid differentiation coupled G1 arrest

Terminal erythroid differentiation is accompanied by decreased expression of c-Kit and decreased proliferation of erythroid progenitor cells. Using a newly established erythroleukemia cell line HB60-5, which proliferates in response to erythropoietin (Epo) and stem cell factor (SCF) and differentiates when stimulated with Epo alone, we characterized several events associated with the cell cycle during erythroid differentiation. Forty-eight h after SCF withdrawal and Epo stimulation, there was strong inhibition of cyclin-dependent kinase (cdk) 4 and cdk6 activities, associated with an increase in the binding of p27 and p15 to cdk6. A significant increase in the binding of p27 to cyclin E- and cyclin A-associated cdk2 correlated with the inhibition of these kinases. In addition, the expression of c-Myc and its downstream transcriptional target Cdc25A were found to be down-regulated during Epo-induced terminal differentiation of HB60-5 cells. The loss of Cdc25A was associated with an increase in the phosphotyrosylation of cyclin E-associated cdk2, which may contribute to cell cycle arrest during differentiation. Although overexpression of p27 in HB60-5 cells caused G1 arrest, it did not promote terminal erythroid differentiation. Thus, the cell cycle arrest that involves p27 is part of a broader molecular program during HB60-5 erythroid differentiation. Moreover, we suggest that SCF stimulation of erythroblasts, in addition to inhibiting erythroid differentiation, activates parallel or sequential signals responsible for maintaining cyclin/cdk activity.