Tight control: a new therapeutic strategy in the management of osteoporotic patients

BMD changes in patients under tight control (monitored at 3-month intervals with adjustment of therapy guided by bone turnover markers) and routine management (controlled once a year) were compared. After 1 year, the femoral neck BMD increased significantly in the tight control compared to the routine management group.

INTRODUCTION

We intended to ascertain whether tight control (i.e., follow-up visits and bone turnover markers/BTM/and parathyroid hormone/PTH/monitoring at 3-month intervals) strategy achieves a statistically greater increase in bone mineral density over the observation period than standard follow-up care (i.e., bone densitometry at 1-year intervals, without BTM monitoring).

METHODS

We studied involutional osteoporotic patients newly enrolled into chronic care. One hundred and eleven patients underwent tight control, while another 113 received routine treatment (with follow-up visits scheduled at > 1-year intervals). We compared the changes in bone mineral density reflected by the results of bone mineral density (BMD) measurements of the lumbar spine and of the left femoral neck. Statistical analyses were performed with version 22 of the SPSS software package.

RESULTS

In the group of patients under tight control, baseline and follow-up median BMD values were 0.842/0.881 g/cm² at the L_1-4 vertebrae and 0.745/0.749 g/cm² at the femoral neck. In the group under routine care, the corresponding values were 0.903/0.915 g/cm² and 0.742/0.72 g/cm², respectively. The relative changes of the bone mineral density of the femoral neck was significantly (p = 0.041) higher in patients under tight control than in those receiving routine care; however, BMD changes in the lumbar spine were not statistically different.

CONCLUSION

Our findings suggest that adopting tight control as a new therapeutic strategy might be justified in the osteoporosis management. In fact, a greater improvement of BMD can be achieved by treatment according to these principles.

Blockade of dopamine D3 receptors in the nucleus accumbens and central amygdala inhibits incubation of cocaine craving in rats

Cue-induced drug seeking progressively increases over time of withdrawal from drug self-administration in rats, a phenomenon called 'incubation of craving'. The underlying mechanisms have been linked to increased expression of brain-derived neurotrophic factor and GluR2-lacking AMPA receptors in the mesolimbic dopamine (DA) system and also to increased extracellular signal-regulated kinase activation in the central amygdala (CeA). However, it remains unclear whether any DA mechanism is also involved in incubation of craving. Recent research demonstrates that cue-induced cocaine seeking appears to parallel increased DA D3 , but not D1 or D2 , receptor expression in the nucleus accumbens (NAc) of rats over time of withdrawal, suggesting possible involvement of D3 receptors (D3 Rs) in incubation of cocaine craving. Here, we report that systemic or local administration of SB-277011A, a highly selective D3 R antagonist, into the NAc (core and shell) or the CeA, but not the dorsal striatum or basolateral amygdala, significantly inhibits expression of incubation of cocaine craving in rats after 2-30 days of withdrawal from previous cocaine self-administration but had no effect on sucrose-seeking behavior in rats after 10-30 days of withdrawal. These data suggest that DA D3 Rs in both the NAc and the CeA play an important role in incubation of cocaine craving in rats and support the potential utility of D3 R antagonists in the treatment of cocaine addiction.

YQA14: a novel dopamine D3 receptor antagonist that inhibits cocaine self-administration in rats and mice, but not in D3 receptor-knockout mice

The dopamine (DA) D3 receptor is posited to be importantly involved in drug reward and addiction, and D3 receptor antagonists have shown extraordinary promise as potential anti-addiction pharmacotherapeutic agents in animal models of drug addiction. SB-277011A is the best characterized D3 receptor antagonist in such models. However, the potential use of SB-277011A in humans is precluded by pharmacokinetic and toxicity problems. We here report a novel D3 receptor antagonist YQA14 that shows similar pharmacological properties as SB-277011A. In vitro receptor binding assays suggest that YQA14 has two binding sites on human cloned D3 receptors with K(i-High) (0.68 × 10(-4)  nM) and K(i-Low) (2.11 nM), and displays > 150-fold selectivity for D3 over D2 receptors and > 1000-fold selectivity for D3 over other DA receptors. Systemic administration of YQA14 (6.25-25 mg/kg) or SB-277011A (12.5-25 mg/kg) significantly and dose-dependently reduced intravenous cocaine self-administration under both low fixed-ratio and progressive-ratio reinforcement conditions in rats, while failing to alter oral sucrose self-administration and locomotor activity, suggesting a selective inhibition of drug reward. However, when the drug dose was increased to 50 mg/kg, YQA14 and SB-277011A significantly inhibited basal and cocaine-enhanced locomotion in rats. Finally, both D3 antagonists dose-dependently inhibited intravenous cocaine self-administration in wild-type mice, but not in D3 receptor-knockout mice, suggesting that their action is mediated by D3 receptor blockade. These findings suggest that YQA14 has a similar anti-addiction profile as SB-277011A, and deserves further study and development.

The selective dopamine D3 receptor antagonists SB-277011A and NGB 2904 and the putative partial D3 receptor agonist BP-897 attenuate methamphetamine-enhanced brain stimulation reward in rats

RATIONALE

We have previously reported that selective antagonism of brain D3 receptors by SB-277011A or NGB 2904 significantly attenuates cocaine- or nicotine-enhanced brain stimulation reward (BSR).

OBJECTIVE

In the present study, we investigated whether the selective D3 receptor antagonists SB-277011A and NGB 2904 and the putative partial D3 agonist BP-897 similarly reduce methamphetamine (METH)-enhanced BSR.

MATERIALS AND METHODS

Rats were trained to respond for rewarding electrical self-stimulation of the medial forebrain bundle. To assess the degree of drug-induced changes in BSR, a rate-frequency curve shift paradigm was used to measure brain-reward threshold (theta 0).

RESULTS

METH (0.1-0.65 mg/kg, i.p.) dose-dependently lowered ( approximately 10-50%) BSR thresholds, producing an enhancement of BSR. Pretreatment with SB-277011A (12 mg/kg, but not 24 mg/kg, i.p.) significantly attenuated METH-enhanced BSR. NGB 2904 (0.1-1.0 mg/kg, but not 10 mg/kg) also attenuated METH-enhanced BSR. SB-277011A or NGB 2904 alone, at the doses tested, had no effect on BSR. Pretreatment with BP-897 (0.1-5 mg/kg) dose-dependently attenuated METH-enhanced BSR. However, when the dose was increased to 10 mg/kg, BP-897 shifted the stimulation-response curve to the right (inhibited BSR itself) in the presence or absence of METH.

CONCLUSIONS

Selective antagonism of D3 receptors by SB-277011A or NGB 2904 attenuates METH-enhanced BSR in rats, while the METH-enhanced BSR attenuation produced by BP-897 may involve both D3 and non-D3 receptors. These findings support a potential use of selective D3 receptor antagonists for the treatment of METH addiction.

A comparison of drug-seeking behavior maintained by D-amphetamine, L-deprenyl (selegiline), and D-deprenyl under a second-order schedule in squirrel monkeys

L-Deprenyl (selegiline) is used in the treatment of Parkinson's disease and has been proposed as an aid for cigarette smoking cessation and a treatment for psychostimulant abuse. L-Deprenyl is metabolized in the body to L-methamphetamine and L-amphetamine, suggesting that it may have abuse potential. The current study assessed whether L-deprenyl or its isomer would maintain drug-seeking behavior on a second-order schedule and whether L-deprenyl would alter drug-seeking behavior maintained by D-amphetamine if given as a pretreatment. Squirrel monkeys learned to respond on a second-order schedule of reinforcement, where every tenth response was followed by a brief light flash, and the first brief light flash after 30 min was paired with intravenous (i.v.) injection of D-amphetamine (0.56 mg/kg), administered over a 2-min period at the end of the session. When responding was stable, saline or different i.v. doses of D-amphetamine (0.3-1.0 mg/kg), L-deprenyl (0.1-10.0 mg/kg), and D-deprenyl (0.1-3.0 mg/kg) were substituted for 10 days each. Subsequently, monkeys were pretreated with 0.3 or 1.0 mg/kg L-deprenyl intramuscularly 30 min prior to D-amphetamine baseline sessions. D-Amphetamine maintained high rates of drug-seeking behavior on the second-order schedule. D-Deprenyl maintained high rates of drug-seeking behavior similar to D-amphetamine. L-Deprenyl maintained lower rates of responding that were not significantly above saline substitution levels. Pretreatment with L-deprenyl failed to alter drug-seeking behavior maintained by D-amphetamine. These results indicate that D-deprenyl, but not L-deprenyl, may have abuse potential. Under conditions where drug-seeking and drug-taking behaviors are actively maintained by D-amphetamine, L-deprenyl, at doses that specifically inhibit type B monoamine oxidase, may not be effective as a treatment.

99m Tc-HMPAO labelled leukocyte scintigraphy in patients with rheumatoid arthritis: a comparison with disease activity

The aim of this study was to test the applicability of 99mTc-hexamethylpropylene amine oxime (99mTc-HMPAO) labelled leukocyte joint scintigraphy in the assessment of disease activity in 21 patients with rheumatoid arthritis, and to compare leukocyte scintigraphy with the Disease Activity Score (DAS), a validated activity index developed by the European League Against Rheumatism (EULAR). Twenty-one patients with rheumatoid arthritis were investigated by using 99mTc-HMPAO labelled leukocyte joint scintigraphy. The clinical and laboratory data were recorded, and the DAS was calculated and compared with the scintigraphic results in each case. A relatively high DAS score (4.71+/-1.07) was found in the majority of patients. The degree of accumulation of 99mTc-HMPAO leukocytes showed no correlation with a patient's age, gender, duration of disease, use of disease modifying anti-rheumatic drugs (DMARDs), visual analogue scale (VAS), Richie index, DAS, or any laboratory parameters. In contrast, a significant correlation was found between the global regional accumulation of the labelled leukocytes of the hands and feet, and the swollen-joint count. It is concluded that radiolabelled leukocyte scintigraphy could become one of the promising methods in the assessment of disease activity in patients with rheumatoid arthritis.

Transdermal formulations of deprenyl: guinea pig and pig models

The efficacy of many drugs relies on their presence at the site of action over a period of time. The retardation or programmed release capability of the conventional dosage forms like oral and parenteral are limited and toxic and undesired side-effects may occur after their applications. These problems may be solved using transdermal delivery systems. Transdermal systems are aimed for local, or systemic action. In the letter case controlling the rate of delivery or modulating the distribution in the organism. The selection of an adequate biological method of evaluating a new transdermal formulation is a critical point of the development. The in vitro methods can help in the characterization of the different formulas, but without an in vivo disposition study they cannot give relevant information about the expectable therapeutic behavior. We adapted and improved an in vivo test system for the evaluation of new transdermal particulate systems (patches) and liposomes containing deprenyl selegiline as active ingredient. The in vivo evaluation system consists of two steps: 1. Full biodisposition study on guinea pig, using isotope labeled selegiline. 2. Biodisposition studies on domestic pigs including dose, area, surface dependence and comparative bioavailability with traditional dosage forms and application moods. Specific examples of these studies and experimental technology are presented.

A comparative study of vertical and horizontal deliveries in the presence and with the assistance of the woman's partner

The authors are the first in Hungary to have applied the method of vertical delivery with the husband's or partner's presence in the delivery room. This is part of the authors' family-centered delivery program at the Maternity Ward of Borsod-Abauj-Zemplén County Hospital, Miskolc. A comparison of 321 births was carried out, which included 158 vertical deliveries and 163 horizontal deliveries. During both vertical and horizontal deliveries, the husband or partner was present in the delivery room. The comparison included the mother's biometrics and social characteristics, as well as the circumstances of the delivery and the clinical parameters of the newborns. Certain stages of delivery in the vertical position took a shorter period of time compared to horizontal delivery, but the differences were not significant. Episiotomies were carried out in fewer cases of vertical deliveries, and significant injuries due to the lack of an episiotomy in the case of vertical deliveries were not detected. The parameters characterizing the clinical state of the newborns were the same in both groups. The answers given to questionnaires supported the favorable psychological effects of a vertical delivery. The authors hope that vertical delivery, as a possible alternative, will find its place in obstetric practice in Hungary.

Metabolism of (-)-deprenyl and PF-(-)-deprenyl in brain after central and peripheral administration

We examined the cerebral metabolism of L-deprenyl and its fluoro-derivative pF-deprenyl, assaying the parent compounds, their metabolites desmethyl deprenyl, L-amphetamine, and L-methamphetamine, and the fluoro analogs of these metabolites. We compared the levels of the metabolites after subcutaneous injection with those after intracerebral administration (via microdialysis) of the parent compounds. The assay of the parent compounds and their metabolites was by GC-MS measurement of the components of brain microdialysate samples. After their subcutaneous administration, deprenyl and F-deprenyl rapidly entered the brain and then their concentration decreased, with an approximate half-life of 4.5 h. After the intracerebral administration the diffusion from the site of administration was minor. A small fraction (a few percent) of the intracerebrally administered deprenyl was metabolized in situ in the brain possibly by a nonenzymatic process. Metabolism of pF-deprenyl was somewhat more rapid. The higher cerebral levels of metabolites after the subcutaneous administration indicate their exogenous origin-metabolism of parent compounds in the periphery and penetration of the brain by the metabolites.

Myocardial gallium-67 citrate scintigraphy in patients with systemic sclerosis

OBJECTIVE

To detect myocardial involvement in 16 patients with systemic sclerosis using radiogallium scintigraphy

METHODS

Sixteen patients with systemic sclerosis were investigated by myocardial gallium-67 citrate scintigraphy. Echocardiographic studies and (in the positive cases) magnetic resonance imaging were also performed.

RESULTS

Increased myocardial gallium uptake was found in five of the 16 patients. None of these positive cases exhibited any 'classical' clinical, electrocardiographic or laboratory signs characteristic of myocarditis. The mean age of the positive cases was 60.8 (SD 5.0) years compared with 44.6 (10.7) years for the negative cases; no difference was detected in the mean disease duration between these two groups. Two of the affected cases belonged to the limited scleroderma subgroup.

CONCLUSIONS

In spite of the low number of patients investigated, it is tempting to speculate that elderly patients with a disease onset around 60 years tend to be the candidates in whom a positive gallium-67 scintigraphy test may best indicate a silent myocardial interstitial inflammation.

The distribution of orally administered (-)-deprenyl-propynyl-14C and (-)-deprenyl-phenyl-3H in rat brain

Using alternatively labelled (-)-deprenyl (3H label in the ring and 14C in the propargyl group) the distribution of the compound was studied in 15 brain regions and the plasma of rats over a period of 96 h, after oral administration of 1.5 mg/kg of (-)-deprenyl. The compound is rapidly absorbed (within 15-30 min) from the gastrointestinal tract, as indicated by its high plasma level. It penetrates to the central nervous system, where it reaches a peak level within 45-60 min. During the first 2 h in the plasma the 14C label, whilst in cerebral tissues during the whole period of the experiment the 3H tracer dominates. The difference in the ratio of 3H to 14C radioactivity (compared to the 0 time relation) develops as early as in the first 15 min, which indicates the operation of a rapid "first pass" biotransformation of the compound. Our data represent the tissue molar concentration -time curves of (-)-deprenyl calculated from both the 3H and 14C radiolabels. A ratio of 1 of the concentrations of the two tracers would indicate that the molecule remained unchanged. The changes in the ratio, therefore, suggest the formation of considerable quantities of metabolites (methylamphetamine and amphetamine) and their presence in the brain. The difference between the area under the curves (AUC0-t for 3H and AUC0-t for 14C) represents the amount of metabolites expected to be formed during the experiment. The concentration of the metabolites should be taken into account while evaluating the pharmacological effect of (-)-deprenyl. We proved earlier that a dose of 1.5 mg/kg of (-)-deprenyl completely blocks MAO-B activity in the central nervous system. The fast metabolism of the inhibitor indicates that a minor part of the orally administered (-)-deprenyl is sufficient to produce a high level of selective MAO-B inhibition in the brain.

Amphetamine-metabolites of deprenyl involved in protection against neurotoxicity induced by MPTP and 2'-methyl-MPTP

The ability of 1-deprenyl to protect against the parkinsonian effects of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) has been attributed to the inhibition of conversion of MPTP to MPP+ (1-methyl-4-phenylpyridinium) catalyzed by MAO-B. We report here that deprenyl-treatment in mice has an additional neuroprotective element associated with the rapid metabolization of 1-deprenyl to 1-methamphetamine and 1-amphetamine. 1-Methamphetamine and 1-amphetamine inhibit MPP(+)-uptake into striatal synaptosomes prepared from rats. Post-treatment by 1-deprenyl, 1-methamphetamine, 1-amphetamine (at times when MPTP is no longer present in the striatum of mice) protects against neurotoxicity in C57BL mice by blocking the uptake of MPP+ into dopaminergic neurons, and even against the neurotoxicity induced by 2'CH3-MPTP, which is partly bioactivated by MAO-A. These findings may have clinical implications since deprenyl has recently been found to delay the progression of Parkinson's disease.

Suicide inhibition of monoamine oxidases A and B by (-)-deprenyl. A computer-aided solution for determining inhibition specificity

An analytical solution to the differential equations describing the kinetics of the suicide inhibition of a two-enzyme system has been derived and the modelling of suicide inhibition of the monoamine oxidases A and B (MAO A and B, EC 1.4.3.4) by a quasi-selective agent, (-)-deprenyl, is presented as an example. A new parameter, the specificity index is defined and used in a model which describes the specific and non-specific binding of (-)-deprenyl to MAO B and MAO A, respectively. This type of analysis may be of therapeutic value by indicating optimal dosage of quasi-selective MAO B inhibitors for the treatment of Parkinson's disease.

[Family-centered obstetrics]

Family centralised delivery model program in the Department of Obstetrics of Borsod County Hospital in Miskolc is reviewed. This program has been started since 1986. Significance and positive emotional effects are emphasized. Preparation for the birth, the presence of the husband in the labour ward, the alternative delivery position and the rooming-in system are discussed in detail. The natural birth's behaviour, which is very important in the life of the family, would be realized with this program.

[Representation of the increase of fetal biparietal and thoracic diameter on a new (14-zone) ultrasonic diagnostic table]

From the somatic development of the fetus one may conclude to its functional maturity and if birth is near to its life prospects too. Thus the ultrasonographic examination of the biparietal and thorax transversal diameter reflecting the somatic development is of prognostic significance too. The authors composed a new table to increase the information value of the ultrasonographic finding, for the uniform designation of the given BPD and THD (biparietal and thorax diameter) sizes and for the better recognition of the tendencies of BPD and THD changes. A new system of symbols and representation method were elaborated for the description of standard positions. According to the gestation weeks 14-14 BPD and THD size-ranges were separated. The so called "UFD" Ultrasonographic index of the Fetal Development gives information besides the gestation time also on the BPD and THD standard position of the fetus and demonstrates illustratively the direction and rate of deviation of the standard positions from the average. The system provides the possibility of a better information to the obstetrician or consulting physician who evaluates the US finding, a uniform interpretation of the findings and serves better the clinical diagnostics.

[Incidence over 10% of premature deliveries in Hungary (based on the experience in Borsod-Abaúj-Zemplń County)]

The incidence over 10% of premature delivery in Hungary was studied. The cause which motivated this work was the fact that despite of several preventive and therapeutic measures the incidence e.g. in BAZ county surpassed even the average of the country. Professors of clinics in different countries of Europe as well as medical societies dealing with this question have been consulted about the matter of whether it was sufficient to consider a neonate a premature infant and the delivery a premature one solely on the basis of birth weight (under 2.500 g). Data of BAZ county proved that this determination was misleading and proposals are made concerning the modification on the basis of the examinations of the authors.

Effect of MAO inhibitors on the uptake and metabolism of dopamine in rat and human brain

Complex pharmacological effect of l-deprenyl cannot be explained by its MAO-B inhibitory action only. In contrast to other parent MAO inhibitors (J-512, J-516, LK-63, U-1424) l-, and d-deprenyl inhibit the hypothalamic noradrenaline and striatal dopamine (DA) reuptake without influencing the uptake of serotonin, both in rat and in human brain. Long-term treatment 19 x 0.25 mg/kg or 0.5 mg/kg, sc with l-deprenyl elicits 37 +/- 2.8 and 43 +/- 3.2% inhibition, respectively, of DA reuptake capacity in the rat striatal cell-free homogenate. To compare the potencies of deprenyl isomers on DA and DOPAC levels of rat striatum drugs were given 0.25, 2 and 8 mg/kg ip and their effects measured 4 and 48 h after treatment. DA content was increased only by 8 mg/kg d-deprenyl 4 h after its injection, but DOPAC level was decreased by both isomers. After 48 h, actions of d-deprenyl terminated but the effect of l-deprenyl was still present.

Detailed analysis of heterogeneity of [3H]naloxone binding sites in rat brain synaptosomes

The experiments reported in this paper address the question of heterogeneity of [3H]naloxone binding sites in rat brainstem synaptosomal preparations at 23 degrees C in the presence of 100 mM sodium chloride. Kinetic analysis in the presence of 0.4, 4 and 10 nM [3H]naloxone gave pseudo-first order association rate of 0.9 +/- 0.04, 1.23 +/- 0.08 and 1.06 +/- 0.08 min-1, respectively. The dissociation of a 1 nM [3H]naloxone receptor complex was biphasic with dissociation rate constants of 1.8 and 0.4 min-1. On the other hand, dissociation of 10 nM [3H]naloxone was monophasic with a kd of 1.1 min-1. Two subpopulations of binding sites were also observed by steady state binding studies, with Kd values of 0.5 and 3.4 nM and a ratio of high to low affinity sites of 1:9. Heterogeneity of [3H]naloxone binding sites could be seen by displacement studies performed with opioid peptides and alkaloids. We suggest that our data best fits a model with two independent naloxone binding sites wherein either one or both undergo a multi-step interaction with ligand.

Displacement analysis of binding inhomogeneities in crude extracts of receptors

Guidelines are given to distinguish different kinds of binding inhomogeneities of non-radiolabeled ligands in crude extracts of receptors if an appropriate 'binding analogue' of the displacers is available in radiolabeled form. Three minimal models for the simplest types of binding inhomogeneities are analysed theoretically. These models include a cooperative system (with two interacting sites on the same receptor molecule) and two non-cooperative systems (one of them with a single-site receptor having two conformational states in equilibrium and the other with two single-site receptors independent of each other). In certain cases one can distinguish these systems experimentally. Furthermore, if a group of displacers is already classified according to the above models, then dissociation constants can be determined. The quantitative comparison of these displacers on the basis of their dissociation constants is more appropriate (e.g. in Quantitative Structure Activity Relationship studies) than on the basis of their ID50 and Ki values or Hill coefficients, which is often done.

Change in the reactivity of the active-site serine OH of butyrylcholinesterase caused by a new reversible inhibitor

The 2-chloro-12-(2-piperidinoethyl)-dibenzo[d,g] (1,3,6)-dioxazocine . HCl (EGYT-2347), a new specific inhibitor of butyrylcholinesterase inhibits reversibly and non-competitively the enzymatic hydrolysis of butyrylthiocholine iodide (Ki = 0.15 microM, at 37 degrees C in 0.1 M Tris/HCl, pH 7.5). The theoretical progress curve of product accumulation has been developed for the case when a non-competitive reversible inhibitor (EGYT-2347) and an active-site-directed irreversible inhibitor (diisopropylfluorophosphate) act simultaneously. By the aid of this approach it was concluded that the butyrylcholinesterase--EGYT-2347 binary complex does not react with diisopropylfluorophosphate either because of a structural change caused by binding or by the direct steric hindrance of EGYT-2347.

Hepatic nuclear protein kinases in young rats pretreated with 3-methylcholanthrene

The activities of rat liver nucleolar and nucleoplasmic protein kinases were investigated after administration of a single intraperitoneal (i.p.) dose of 100 mg/kg body weight 3-methylcholanthrene (3-MC). A significant increase was observed in the activities of both the nucleolar and nucleoplasmic protein kinases in the hepatic cells from young rats. The maximum stimulation was evident 24 h after pretreatment with 3-MC. The extent of the maximum activation was distinctly greater in the nucleolar (186%) than in the nucleoplasmic fraction (133% compared with the controls). A second activation of the extranucleolar protein kinase fractions was demonstrated 96 h after 3-MC pretreatment. It is suggested that both kinds of enzymes are involved in the mechanism of the cytochrome P-448-inducing action of 3-MC via stimulating nuclear RNA polymerases.

Fetal arrhythmia during pregnancy and labour

The significance of fetal arrhythmia presenting during pregnancy and labour has been examined in 68 patients. The different types of rhythm disorders diagnosed included 61 extrasystoles, 6 atrioventricular blocks and 1 auricular fibrillation. Extrasystoles were not associated with acidosis or organic cardiac disease. Atrioventricular block, though not associated with fetal hypoxia, was occasionally associated with congenital cardiac failure.