Is intrapartum fever associated with ST-waveform changes of the fetal electrocardiogram? A retrospective cohort study

OBJECTIVE

To investigate the association between maternal intrapartum fever and ST-waveform changes of the fetal electrocardiogram.

DESIGN

Retrospective cohort study.

SETTING

Three academic and six non-academic teaching hospitals in the Netherlands.

POPULATION

Labouring women with a high-risk singleton pregnancy in cephalic position beyond 36 weeks of gestation.

METHODS

We studied 142 women with fever (≥38.0°C) during labour and 141 women with normal temperature who had been included in two previous studies. In both groups, we counted the number and type of ST-events and classified them as significant (intervention needed) or not significant, based on STAN(®) clinical guidelines.

MAIN OUTCOME MEASURES

Number and type of ST-events.

RESULTS

Both univariable and multivariable regression analysis showed no association between the presence of maternal intrapartum fever and the number or type of ST-events.

CONCLUSIONS

Maternal intrapartum fever is not associated with ST-segment changes of the fetal electrocardiogram. Interpretation of ST-changes in labouring women with fever should therefore not differ from other situations.

Rehabilitation after surgery for flexor tendon injuries in the hand

BACKGROUND

Postoperative rehabilitation of the flexor tendons in the hand consists of a short period of immobilisation while pain and swelling diminish, followed by progressive mobilisation to maximize the range of motion of the affected fingers. By altering the time of immobilisation and the manner of subsequent mobilisation different rehabilitation regimes are created.

OBJECTIVES

To determine, with evidence from randomised controlled trials, the optimal rehabilitation strategy after surgery for flexor tendon injuries in the hand.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (November 2002), the Cochrane Central Register of Controlled Trials (The Cochrane Library, issue 4, 2002), MEDLINE (1966 to November 2002), EMBASE (1988 to November 2002), CINAHL (1982 to October 2002), CURRENT CONTENTS (1993 to October 2002), PEDro - The Physiotherapy Evidence Database (http://ptwww.cchs.usyd.edu.au/pedro/ accessed 30/10/2002) and reference lists of articles.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials of interventions for rehabilitation after surgery of flexor tendon injuries in the hand after surgery.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality, using a 10 item scale, and extracted data where possible. Additional information was sought from trialists when required. Due to the lack of extractable data and the variety of interventions used, pooling was not attempted. Where possible relative risks and 95 per cent confidence intervals were calculated for dichotomous outcomes, and mean differences and 95 per cent confidence intervals calculated for continuous outcomes.

MAIN RESULTS

Six trials, including three reported only in abstracts, with a total of 464 participants were included. Data were not pooled. One trial compared continuous passive motion (CPM) with controlled intermittent passive motion (CIPM) and found a significant difference in mean active motion favouring CPM (WMD 19.00 degrees, 95% CI 15.11 to 22.89). One trial compared a shortened passive flexion/active extension programme with a normal passive flexion/active extension mobilisation programme, and reported (without data) a significant reduction in absence from work of 2.1 weeks in favour of the shortened programme. Other trials compared active flexion with rubber band traction, early controlled active mobilisation with early controlled passive mobilisation and dynamic splintage versus static splintage. No trials found significant differences in overall functioning or complication rate.

REVIEWERS' CONCLUSIONS

Controlled mobilisation regimens are widely employed in rehabilitation after flexor tendon repair in the hand. This review found insufficient evidence from randomised controlled trials to define the best mobilisation strategy.

Contributions of bone density and geometry to the strength of the human second metatarsal

We investigated, at the whole bone level, the contribution of bone density and geometry to the fracture load of the second metatarsal, a bone that is prone to stress fracture. Dual-energy X-ray absorptiometry (DXA) was used to determine the areal bone mineral density (BMD), projected area of bone, and bone mineral content. Peripheral quantitative computed tomography (pQCT) was used to determine the volumetric cortical bone mineral density (vCtBMD) and cross-sectional moment of interia. Various metatarsal linear dimensions were also measured. The load at failure in cantilever bending was determined. The only linear dimension that had a significant correlation with load at failure was the height of the metatarsal base (r(2) = 0.30, p = 0.008). Utilizing all of the information provided by DXA gave no greater indication of whole bone strength than just BMD alone (adjusted r(2) = 0.40, p = 0.001). Using all of the information provided by pQCT gave no greater indication of whole bone strength than just vCtBMD alone (r(2) = 0. 46, p < 0.001). Volumetric cortical density and BMD were strongly correlated (r(2) = 0.81, p < 0.001). Our data suggest that, in the human second metatarsal, a variable such as material strength (as inferred from cortical density), and not geometry, may be the major factor in determining cantilever load to failure.

Osteogenic ability of free periosteal autografts in tibial fractures with severe soft tissue damage: an experimental study

OBJECTIVE

The present study was undertaken to assess whether free nonvascularized autologous periosteum transplants enhance bone healing in a rabbit fracture model designed to resemble a tibial fracture with severe soft tissue damage.

DESIGN

Transplantation of free autologous periosteal grafts on the anteromedial site of the tibia (experimental group) was compared with nontransplantation on the contralateral tibia (control group). We produced a standardized transverse osteotomy of both tibial diaphyses in white male adult New Zealand rabbits. The endomedullary cavity was reamed and nailed, and then a one-centimeter segment of periosteum was excised from either side of the osteotomy. To prevent periosteal and extraosseous ingrowth at the osteotomy site, a silastic sheet was wrapped around two-thirds of the circumference of the tibia. In the first group, on the silastic-free bone window, we then spanned the osteotomy with a free, nonvascularized, longitudinally oriented autologous periosteum and sewed it to the adjacent periosteum both proximally and distally. In the second group, the periosteum was placed transversely, leaving a gap between it and the adjacent periosteum proximally and distally. Revascularization of the graft was determined with the colored microsphere technique.

MAIN OUTCOME MEASUREMENTS

Histomorphometric analysis of the periosteal callus was done on a transparent grid superimposed on enlarged photographs of the histologic sections.

RESULTS

Free, nonvascularized, longitudinally placed autologous periosteum in contact with intact periosteum produced significantly more periosteal callus than was seen in the control group, in which no periosteal graft was used. However, when transversely placed periosteal grafts were set in the silastic-free bone window and there was no contact with surrounding remnants of intact periosteum, no significant difference in callus production was noted when compared with the control. Revascularization of these grafts was seen within one week after transplantation. Bone healing occurred mainly through endochondral ossification.

CONCLUSION

Our data suggest that orthotopically placed autologous nonvascularized periosteum retains its osteogenic potential in a poorly vascularized environment such as a tibial fracture with severe soft tissue damage. The effect is enhanced if the graft is in contact with intact periosteum. Histologically, callus formation after periosteal grafting resembles endochondral and intramembranous ossification.

Noma (Cancrum Oris) associated with Kwashiorkor: a case report and review of the literature

Noma (Cancrum Oris/Ulcerogingivostomstitis) is a rare devastating grangrenous orofacial disease. It may lead to severe facial mutilation and deformities with dysfunctional effects. This disease primarily affects malnourished children from underdeveloped countries. It has recently been associated with AIDS in North America and Western Europe. We will be reporting and discussing the pathogenesis, bacteriological complications and treatments according to the literature.

A complication of mesenteric lymphangioma: case report and brief review of literature

Mesenteric lymphangioma (ML) has only rarely been reported in the literature. These cases are rare enough to arouse interest when encountered. Usually, the cases are asymptomatic but may present with acute or chronic intestinal obstruction. We report an additional case of ML associated with intermittent intestinal volvulus in a 5 years old boy.

Altered membrane fluidity in rat hepatocytes during endotoxic shock

Steady-state fluorescence anisotropy measurements of the fluorescent hydrocarbon probe 1,6-diphenyl-1,3,4-hexatriene (DPH) were carried out in isolated hepatocytes of saline control and Salmonella enteritidis endotoxin (20 mg/kg) injected rats. Statistically significant differences were observed in the fluorescent anisotropy (rs) and membrane microviscosity (eta) values of control (rs = 0.107 +/- 0.004 (SEM), eta = 0.98 +/- 0.08, n +/- 6) versus endotoxin injected rat hepatocytes (rs = 0.134 +/- 0.005, eta = 1.43 +/- 0.08, n = 6, p < 0.001) at 37 degrees C. Fluidity was similarly lower in the isolated plasma membrane preparations from endotoxin-injected rat livers relative to control livers. When endotoxin-injected rats were treated with the calcium channel-blocker diltiazem, the anisotropy and microviscosity values were comparable to those obtained from control rats (rs = 0.152 +/- 0.003, eta = 1.00 +/- 0.003, n = 6). These measurements were made in animals five hours after endotoxin had been injected, and thus represent the in vivo effects of bacterial endotoxins. Temperature scan studies of DPH from 5-40 degrees C revealed that the membrane fluidity of endotoxin-injected rat hepatocytes was significantly lower than control hepatocytes at all temperatures investigated. The data suggest that endotoxin alters the membrane fluidity of hepatocytes, and that calcium-channel blockers can prevent the alteration. Our previous studies have shown that calcium channel blocker prevented endotoxin induced alterations in hepatic cellular regulation of Ca2+. Thus, cellular calcium homeostasis may be important in the maintenance of membrane fluidity and other membrane-associated transport functions.

Curriculum at the Scholl College. Toward mainstream medical education

The Dr. William M. Scholl College of Podiatric Medicine in Chicago recently affiliated with a teaching hospital, the Illinois Masonic Medical Center, and used this alliance as a catalyst to effect a change in the clinical curriculum. The affiliation set up a joint venture to operate two clinics, one on Scholl College's traditional campus and one at the teaching hospital. At the hospital site, Scholl College students rotate through clinical externships in areas such as internal medicine, emergency medicine, and podiatric elective; podiatric and general medical residents assist in the tutelage of the students. At the Scholl College campus, beginning clinical students learn basic skills in a teaching clinic, then refine and further their skills in a comprehensive clinic under the guidance of faculty members. The faculty and administration at Scholl College have embraced the concept of mainstream medical education, and are striving to prepare podiatric physicians to practice 21st century medicine.

Juvenile gastrointestinal polyposis or the infantile Cronkhite-Canada syndrome

This is a report of a case of juvenile gastrointestinal polyposis consisting of widespread juvenile polyps encountered from the stomach into the rectum. Only few cases have been reported, and extra intestinal manifestations include clubbing of fingers, macrocephaly, hypotonia, hepatosplenomegaly, anemia, and protein-losing enteropathy. The outcome is usually dismal, the children barely becoming older than 2 years. Modern fibreoptic endoscopy with polypectomies performed via the upper and lower gastrointestinal intestinal tracts and via a midbowel ileostomy may offer a viable form of management.

Inhibition of Na+ flux in Chinese hamster ovary cells and Swiss 3T3 cells by a potent new derivative of amiloride, methylisopropyl-amiloride

Amiloride inhibits the mitogen-stimulated Na+ influx of cultured fibroblasts with very low affinity. We have therefore analyzed eight new derivatives of amiloride for their efficacies of inhibiting the Na+ flux in Chinese hamster ovary cells (CHO-K1). Four of these analogs demonstrate markedly enhanced potencies relative to amiloride. One of the derivatives, methylisopropyl-amiloride (MIA), is approximately 900-fold more potent (ID50 = 42 nM) than amiloride in inhibiting Na+ uptake of these cells. Inasmuch as external Na+ ions antagonize amiloride inhibition of Na+ influx competitively, we investigated the ability of MIA to inhibit Na+ flux in the absence of external Na+ ions. The ID50 value determined for MIA inhibition of CHO-K1 cell Na+ efflux from Na+-loaded cells into Na+-free media is 15 nM. We also examined the efficacy of MIA for Na+ efflux inhibition in a nontransformed fibroblast cell line, Swiss 3T3. The ID50 value for inhibition of Na+ efflux from 3T3 cells is comparable to that for CHO-K1 cells. Thus, we have identified a highly potent derivative of amiloride, MIA, that inhibits Na+ flux at nanomolar concentrations in both a transformed and a nontransformed cell line. It is possible that MIA may serve as a useful tool for biochemical characterization of the mitogen-stimulated Na+ transporter and for assessment of the role of this transporter in mitogenesis.

Localization of parathyroid adenomas by digital subtraction angiography. A report of 4 cases

Intravenous digital subtraction angiography provides an accurate but not specific method for localization of small vascular tumours. It is carried out on outpatients as an intravenous procedure and takes only 40 minutes. It appears to be eminently suited to the demonstration of parathyroid adenomas and shows that a hyperplastic parathyroid gland can produce a significant enough vascular blush to create a visible image.

Pharyngeal injuries. A report on 2 cases

Two patients incurred barotrauma to the pharynx by the explosion of soft-drink bottles into their mouths. The resultant effects on the pharynx (and in one case on the right lung) are described and guidelines are laid down for the approach to and treatment of these injuries. Both patients recovered, with an acceptable cosmetic and functional result.

The effect of harmaline on unidirectional potassium fluxes and ouabain binding in renal cell cultures

Harmaline inhibits K+ influx into primary cell cultures of ground squirrel kidneys to a greater extent than either ouabain or furosemide. A concentration of 200 microM harmaline was required to inhibit half of the total K+ influx; this effect was also seen at low temperature (5 degrees C), and in another species (hamster). Although kinetic analysis of K+ influx indicates that harmaline does not compete with extracellular K+, harmaline did reduce the binding of [3H]ouabain to the cells. K+ efflux was also reduced. Therefore, harmaline may inhibit the furosemide-sensitive Na+/K+ cotransport system as well as the ouabain-sensitive Na+/K+ pump.

Effect of the tumor promoter 12-O-tetradecanoylphorbol-13-acetate on alpha-aminoisobutyrate uptake in friend Erythroleukemic cells

In Friend erythroleukemic cells, the tumor promoter 12-O-tetradecanoylphorbol-13-acetate (TPA) increases the rate of influx as well as the steady-state accumulation of the amino acid transport probe alpha-aminoisobutyric acid (AIB). This nonmetabolizable analog is concentrated in these cells by utilizing the energy of the Na+ electrochemical gradient. The effect of TPA is to increase the ouabain-sensitive component of uptake of AIB (and of the K+ analog 86Rb+). Transport changes are not observed until 30 min after application of the promoter and reach a maximum in about 6 hr. The effects are blocked by cycloheximide. The flux results are consistent with a model in which the membrane potential is increased and, with it, the driving force on the coupled Na+-AIB movement. The effect is possibly mediated by a change in electrogenicity of the Na:K pump. TPA raises the steady-state accumulation levels of AIB. By altering external K+ in the presence of valinomycin, the membrane potential may be adjusted and, with it, the accumulation of AIB. Over a wide range of membrane potentials, TPA-treated cells accumulate more AIB than do controls, suggesting a possible change in the internal Na+ activity.

Properties of Na-K pump in primary cultures of kidney cells

Activities related to Na-K transport were measured in cell cultures of ground squirrel kidney cortex in order to compare these cells with those of intact kidney and of continuous cell lines. A microsomal preparation containing plasma membrane Na,K-ATPase from fresh kidney showed twice the activity of a similar preparation from 72-hour cultured cells. Na,K-ATPase of homogenates of 72-hour cells showed one-third to one-fourth the specific activity of that from 6-hour cultured cells. The associated K-dependent phosphatase activity also declined as a function of time in culture. The ouabain-sensitive influx of K into 6-hour cultured cells was twice as great as the K influx into 72-hour cells. The number of sites binding 3H-ouabain in intact cultured cells declined 81% on a cell protein basis between 6 and 72 hours in culture. This decline in ouabain binding sites was relatively greater than that of K influx, so that the K turnover number increased over this same time period. The decline in ouabain-sensitive K influx during culture was complementary to an increase in furosemide-sensitive K influx. Measurements of unidirectional and net K fluxes showed that there were three components of K influx into 3-day cultured cells: ouabain-sensitive Na:K exchange, furosemide-sensitive K:K exchange, and K diffusion. In the 6-hour cultures, however, there was no furosemide-sensitive K:K exchange. Thus, after three days in culture ground squirrel kidney cells lose a feature characteristic of the original parent cells (high Na,K-ATPase activity), and gain a feature common to many undifferentiated cultured cells (furosemide-sensitive K:K exchange).

Na-K pump and Na-K-ATPase: disparity of their temperature sensitivity

As previously observed in red blood cells, ouabain-sensitive K influx of kidney cells grown in culture for 3 days was much less inhibited by cooling that Na-K-ATPase of the same cells. (At 5 degrees C K influx was 9.7% of that at 38 degrees C, Na-K-ATPase, 1--2%.) Resealed ghosts of erythrocytes of ground squirrels were made containing 24Na and ATP, and the Na efflux and ATP hydrolysis were measured simultaneously. Under these conditions there was no difference in the reduction of activity with cooling, and the amount of reduction was close to that of active K transport in intact cells. The high sensitivity to temperature, characteristic of broken membranes, could not be induced in intact cells or resealed ghosts by eliminating either the Na/K gradient or the ATP gradient nor by chelation of cellular and extracellular Ca. It could not be eliminated in broken membranes by protection with ATP or Mg. Structural reorganization of membrane during lysis may cause the increase in temperature sensitivity of Na-K-ATPase.