Enuresis and more

We describe Pervasive Refusal Syndrome, an important but rare, debilitating condition that may present to paediatric services. Although previous reports have described improvement seen with care delivered in the mental health setting, we have demonstrated treatment predominately delivered in a paediatric ward environment associated with successful recovery.

Sensitivity of host-seeking nymphal lone star ticks (Acari: Ixodidae) to immersion in heated water

Host-seeking nymphal Amblyomma americanum (L.) (Acari: Ixodidae) were placed into heated water, and their survival or their torpidity was recorded as a function of exposure time. Exposures were determined that either kill the nymphs or affect their mobility. All nymphs died when exposed for a minute or more to a temperature > 51 degrees C. Nearly all nymphs remained motionless for a period of time when exposed for 3 min to a temperature > 44 degrees C.

The UK Standardisation of Breast Radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial

BACKGROUND

The international standard radiotherapy schedule for early breast cancer delivers 50 Gy in 25 fractions of 2.0 Gy over 5 weeks, but there is a long history of non-standard regimens delivering a lower total dose using fewer, larger fractions (hypofractionation). We aimed to test the benefits of radiotherapy schedules using fraction sizes larger than 2.0 Gy in terms of local-regional tumour control, normal tissue responses, quality of life, and economic consequences in women prescribed post-operative radiotherapy.

METHODS

Between 1999 and 2001, 2215 women with early breast cancer (pT1-3a pN0-1 M0) at 23 centres in the UK were randomly assigned after primary surgery to receive 50 Gy in 25 fractions of 2.0 Gy over 5 weeks or 40 Gy in 15 fractions of 2.67 Gy over 3 weeks. Women were eligible for the trial if they were aged over 18 years, did not have an immediate reconstruction, and were available for follow-up. Randomisation method was computer generated and was not blinded. The protocol-specified principal endpoints were local-regional tumour relapse, defined as reappearance of cancer at irradiated sites, late normal tissue effects, and quality of life. Analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN59368779.

FINDINGS

1105 women were assigned to the 50 Gy group and 1110 to the 40 Gy group. After a median follow up of 6.0 years (IQR 5.0-6.2) the rate of local-regional tumour relapse at 5 years was 2.2% (95% CI 1.3-3.1) in the 40 Gy group and 3.3% (95% CI 2.2 to 4.5) in the 50 Gy group, representing an absolute difference of -0.7% (95% CI -1.7% to 0.9%)--ie, the absolute difference in local-regional relapse could be up to 1.7% better and at most 1% worse after 40 Gy than after 50 Gy. Photographic and patient self-assessments indicated lower rates of late adverse effects after 40 Gy than after 50 Gy.

INTERPRETATION

A radiation schedule delivering 40 Gy in 15 fractions seems to offer rates of local-regional tumour relapse and late adverse effects at least as favourable as the standard schedule of 50 Gy in 25 fractions.

The UK Standardisation of Breast Radiotherapy (START) Trial A of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial

Background

The international standard radiotherapy schedule for breast cancer treatment delivers a high total dose in 25 small daily doses (fractions). However, a lower total dose delivered in fewer, larger fractions (hypofractionation) is hypothesised to be at least as safe and effective as the standard treatment. We tested two dose levels of a 13-fraction schedule against the standard regimen with the aim of measuring the sensitivity of normal and malignant tissues to fraction size.

Methods

Between 1998 and 2002, 2236 women with early breast cancer (pT1-3a pN0-1 M0) at 17 centres in the UK were randomly assigned after primary surgery to receive 50 Gy in 25 fractions of 2·0 Gy versus 41·6 Gy or 39 Gy in 13 fractions of 3·2 Gy or 3·0 Gy over 5 weeks. Women were eligible if they were aged over 18 years, did not have an immediate surgical reconstruction, and were available for follow-up. Randomisation method was computer generated and was not blinded. The protocol-specified principal endpoints were local-regional tumour relapse, defined as reappearance of cancer at irradiated sites, late normal tissue effects, and quality of life. Analysis was by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN59368779.

Findings

749 women were assigned to the 50 Gy group, 750 to the 41·6 Gy group, and 737 to the 39 Gy group. After a median follow up of 5·1 years (IQR 4·4–6·0) the rate of local-regional tumour relapse at 5 years was 3·6% (95% CI 2·2–5·1) after 50 Gy, 3·5% (95% CI 2·1–4·3) after 41·6 Gy, and 5·2% (95% CI 3·5–6·9) after 39 Gy. The estimated absolute differences in 5-year local-regional relapse rates compared with 50 Gy were 0·2% (95% CI −1·3% to 2·6%) after 41·6 Gy and 0·9% (95% CI −0·8% to 3·7%) after 39 Gy. Photographic and patient self-assessments suggested lower rates of late adverse effects after 39 Gy than with 50 Gy, with an HR for late change in breast appearance (photographic) of 0·69 (95% CI 0·52–0·91, p=0·01). From a planned meta-analysis with the pilot trial, the adjusted estimates of α/β value for tumour control was 4·6 Gy (95% CI 1·1–8·1) and for late change in breast appearance (photographic) was 3·4 Gy (95% CI 2·3–4·5).

Interpretation

The data are consistent with the hypothesis that breast cancer and the dose-limiting normal tissues respond similarly to change in radiotherapy fraction size. 41·6 Gy in 13 fractions was similar to the control regimen of 50 Gy in 25 fractions in terms of local-regional tumour control and late normal tissue effects, a result consistent with the result of START Trial B. A lower total dose in a smaller number of fractions could offer similar rates of tumour control and normal tissue damage as the international standard fractionation schedule of 50 Gy in 25 fractions.

Identification of the in vivo promoters of bacteriophages S13 and phi X174 and measurement of their relative activities

Regions of bacteriophages phi X174 and S13 that contain putative promoter sequences were amplified by the polymerase chain reaction (PCR) and cloned into the reporter vector pKO-1. Assays of galactokinase activity revealed in vivo promoter activity in those constructs containing the promoter sequences with transcription initiation (+1) sites at nucleotide positions 45, 982, 1823, and 5211. These were identical in location to sequences with in vitro promoter activity and to the three known promoters PA, PB, and PD. P5211 is the location of a new, fourth, promoter. A site with a +1 position at nucleotide 4876, previously shown to initiate RNA synthesis in an in vitro run-off transcription assay, had no in vivo promoter activity. To investigate whether flanking sequences had effects on promoter activity, restriction fragments of phi X174 and S13 that encompass the in vivo promoters were cloned into the reporter vector pKO-1. The PA and P5211 promoter constructs showed dramatic effects with increases in activity of up to 7 times that shown with the PCR-generated promoter constructs. The phi X174 PB promoter construct had a 50% decrease in activity compared with the PCR-generated PB clone. While the data showed that in most instances promoter activity is affected by the flanking sequences in which the promoter is embedded, no general pattern correlating flanking sequences and promoter activity could be discerned. Additional evidence that the promoter sequence regions were active in vivo promoters was obtained by S1 nuclease mapping experiments. Initiation of RNA synthesis was shown at positions 45, 982, and 5211.

Computer graphics of SEM images facilitate recognition of chromosome position in isolated human metaphase plates

There is general agreement that at the time of mitosis chromosomes occupy precise positions and that these positions likely affect subsequent nuclear function in interphase. However, before such ideas can be investigated in human cells, it is necessary to determine first the precise position of each chromosome with regard to its neighbors. It has occurred to us that stereo images, produced by scanning electron microscopy, of isolated metaphase plates could form the basis whereby these positions could be ascertained. In this paper we describe a computer graphic technique that permits us to keep track of individual chromosomes in a metaphase plate and to compare chromosome positions in different metaphase plates. Moreover, the computer graphics provide permanent, easily manipulated, rapid recall of stored chromosome profiles. These advantages are demonstrated by a comparison of the relative position of group A-specific and groups D- and G-specific chromosomes to the full complement of chromosomes in metaphase plates isolated from a nearly triploid human-derived cell (HeLa S3) to a hypo-diploid human fetal lung cell.

The efficacy and safety of the cytobrush during pregnancy

The safety and efficacy of abrasive cytology, using the cytobrush, were evaluated in 300 pregnant patients. When compared to conventional cytology obtained with a cotton-tipped applicator there was no difference in adverse pregnancy events. Smear adequacy (containing endocervical cells) was statistically (P less than 0.01) and clinically increased from 21 to 86%. The use of abrasive cervical cytology was associated with a twofold increase in the incidence of abnormal smears.

Split course interstitial brachytherapy with a source shift: the results of a new technique for salvage irradiation in recurrent inoperable cervical lymphadenopathy greater than or equal to 4 cm diameter in 23 patients

Between June 1981 and December 1986, 23 patients with prior irradiation of the neck for epithelial ENT tumors underwent salvage irradiation for isolated recurrent inoperable cervical lymphadenopathy greater than or equal to 4 cm. The initial irradiation had delivered 45-80 Gy to the cervical lymph nodes. Split course interstitial brachytherapy was used with a source shift in an attempt to decrease treatment complications. The first and second course of the split course implants delivered 35 Gy and 30 Gy at a 1 month interval. The active lines of the second implant were placed parallel to and in between the position of the lines of the first implant. Three patients did not receive the second implant (one death, one disease evolution, one necrosis). For the patient who died between the first and second implants the local control rate could not be determined. The immediate overall local control rate was 73% (16/22) with a later recurrence rate of 62% (10/16), but only in three cases was recurrence within the treated volume (19%-3/16). The local control rate was better (3/9) if the initial lymphadenopathy was greater than or equal to 4 cm less than or equal to 6 cm but worse (3/13) in those with initial lymphadenopathy greater than 6 cm. Survival of these patients overall was poor with 26% survival at 1 year and 13% at 2 years. Tolerance overall was acceptable with tissue necrosis occurring in 36.5% of cases including those with initial skin involvement. If these cases were excluded the necrosis rate was only 15.5%. In this patient population with inoperable recurrent cervical lymphadenopathy in whom a further dose of external irradiation is not possible interstitial brachytherapy should be considered. Our technique of implantation, split over two sessions with a source shift, is practicable with an acceptable toxicity. It may be used even after high dose external beam irradiation and in large volumes of disease, and it gives better results than classical brachytherapy.

Evaluation of obstetric ultrasonography at the first prenatal visit

A prospective study was performed on 1000 consecutive patients to assess the value of ultrasonography at first prenatal visit. Significant ultrasonographic findings were noted in more than one third of the patients. A discrepancy between ultrasonography and menstrual dating was the most frequently noted abnormality, occurring in 27%; 59% of those would not have been discovered on initial physical examination. Other frequently noted abnormalities included missed abortion (5.7%) and twins (1.6%). The frequency of abnormalities on the initial laboratory studies recommended by the American College of Obstetricians and Gynecologists was evaluated and found to be significantly less than the frequency of clinically important ultrasonographic findings, ranging from 4.0% for positive urine cultures to 0.2% for positive serologic tests. Unexpected findings on physical examination, excluding assessment of pregnancy dating on the basis of uterine size, were even less frequent, occurring in 2.1% of the patients. It is concluded that obstetric ultrasonography at the time of the first prenatal visit is better than physical examination in evaluating the status of the pregnancy and should be considered for all patients.

Differential expression of c-myc and H-ras oncogenes in Barrett's epithelium. A study using colorimetric in situ hybridization

To determine the role of c-myc and H-ras in progressive, dysplastic Barrett's mucosa (BM), and the usefulness of these oncogenes as markers for dysplastic lesions at high risk for malignant transformation, sequential formaldehyde solution-fixed, paraffin-embedded biopsy specimens that were obtained from 12 patients with BM were evaluated by in situ hybridization with the use of biotinylated complimentary DNA probes. Nine of the patients were taken from a previous prospective study. Four of these nine patients had dysplasia, and adenocarcinoma had developed in two of them; five had nondysplastic BM only. Two additional patients had adenocarcinoma, but their initial biopsy specimens had revealed dysplasia. One additional patient had intermediate-grade dysplasia. The intensity of oncogene expression was quantified by computerized color-image analysis. Enhanced c-myc expression of approximately equal intensity was consistently observed in all grades of dysplasia and carcinoma. H-ras was also consistently expressed in higher grades of dysplasia and carcinoma but not in low-grade dysplasia. Neither c-myc nor H-ras expression was detected in nondysplastic BM. The expression of H-ras in dysplastic BM appears to be a helpful marker for identifying which dysplastic lesions will progress to carcinoma.

Funic reduction for the management of umbilical cord prolapse

The current management of umbilical cord prolapse centers on attempts to alleviate the pressure of the presenting part on the cord while preparation for cesarean section is being made. A 10-year experience in which there were vigorous attempts to accomplish safe vaginal delivery after the diagnosis of umbilical cord prolapse is presented. Eight cases of umbilical cord prolapse occurred, a frequency of 1 in 277 deliveries (0.37%), all of which had a normal immediate neonatal outcome. Vaginal delivery was accomplished in seven patients (87.5%); diagnosis was made in two of them when delivery was imminent. Five patients were more remote from delivery and had successful funic reduction (manual replacement of the prolapsed cord). Funic reduction is proposed as a potentially beneficial initial step in the management of umbilical cord prolapse.

Continuous or interrupted fascial closure: a prospective evaluation of No. 1 Maxon suture in 402 gynecologic procedures

During a 14-month period of using a long-term absorbable suture (No. 1 Maxon), 402 patients were entered into a prospective, randomized trial of fascial closure. Patients were randomized between a continuous closure (201 patients) and an interrupted en bloc (201 patients) technique. Each patient was subjected to a preoperative and intraoperative protocol for wound management. There were no acute wound failures. Wound infection rates and risk of hernia were not apparently affected by closure technique.

Single-dose antibiotic prophylaxis for patients undergoing extended pelvic surgery for gynecologic malignancy

The comparative efficacy of single-dose antibiotic prophylaxis was retrospectively evaluated in 116 patients undergoing extended pelvic surgical procedures with curative intent. During the 24-month period, other important variables such as surgeon's experience, duration of preoperative hospitalization, preoperative preparation, method of hair removal, suture type, suture size, use of drains, use of cautery, and abdominal closure were controlled. The overall surgical site infection rate was 4.3% after radical hysterectomy with lymphadenectomy and 4.5% after total hysterectomy with lymphadenectomy. In this clinical situation the use of a single dose of antibiotic prophylaxis theoretically decreases cost and patient exposure and appears to be as efficacious as a multiple-dose regimen.

Immunocytochemical study of ras and myc proto-oncogene polypeptide expression in the human menstrual cycle

The human endometrium is a unique and dynamic tissue model system characterized by cyclic processes of cellular proliferation, differentiation, and menstrual desquamation. Both the glandular epithelial and stromal mesenchymal components work in synchronous response to the mitogenetic effect of estradiol and the antimitogenetic effect of progesterone. Mechanisms whereby estradiol and progesterone exert their effects are not completely understood. This study was undertaken to evaluate the expression and localization of the polypeptide products of the ras and myc proto-oncogenes sequentially during the menstrual cycle. Sixteen endometrial biopsy specimens were evaluated. Immunocytochemical quantitation of ras and myc expression was done by use of color image analysis (CoreScan). There was no cyclic variation in the ras polypeptide product, but the expression of myc polypeptide was low in the secretory phase and high in the proliferative phase.

Immunocytochemical study of transforming growth factor expression in benign and malignant gliomas

Immunocytochemical studies using polyclonal antibodies to epidermal growth factor (EGF) and transforming growth factor (TGF) alpha and beta were performed on 20 cases of human gliomas. EGF immunoreactive material was detected in both benign and malignant glial tumors. In addition, EGF immunoreactive material was detected in normal brain. TGF-beta was detected in both benign and malignant tumors, but was not detected in normal brain. In contrast, TGF-alpha was highly conserved in its expression, occurring predominantly in malignant compared with benign or normal brain tissue (P less than 0.0001). In malignant gliomas, glioblastomas contained 76% TGF-alpha reactivity (immunoreactive product), and anaplastic types contained 85% reactivity. Benign gliomas contained only 13% TGF-alpha reactivity. These findings support the role of TGF-alpha as an oncoprotein marker in brain neoplasms.

Single-center study results of cefotetan and cefoxitin prophylaxis for abdominal or vaginal hysterectomy

A prospective randomized study of 90 patients undergoing hysterectomy who received a single 1 gm dose of cefotetan and multiple 2 gm doses of cefoxitin was completed. An overall infection rate of 1.2% was recorded. Bacteriologic and clinical success rates were not different between antibiotics.

Pharmacokinetics and tissue kinetics of 1 gm cefotetan prophylaxis in abdominal or vaginal hysterectomy

Plasma and tissue levels of cefotetan after a single-gram intravenous preoperative dose were measured. Levels were high in some tissues (parametrium, fascia) but quite low in others (subcutaneous fat). The implications as to the prophylactic effectiveness of this drug are addressed.

Rat urinary kallikrein localization in kidney: effects of fixation

The influence of fixation on the immunocytochemical localization of tissue kallikrein in the kidney has been evaluated using both monoclonal and polyclonal antibodies. These studies have provided several results relevant to kallikrein localization in kidney: (1) the intensity and distribution of immunostaining with both polyclonal and monoclonal anti-kallikrein antibodies is fixation-dependent; (2) the most intense and consistent localizations of kallikrein are in the connecting tubule and the cortical collecting duct of the nephron; (3) kallikrein-like immunoreactivity is seen in proximal tubules with polyclonal but not with non-cross-reactive monoclonal antibodies; and (4) fixatives which disrupt membranes reveal a kallikrein-like antigen in straight tubules of the outer medulla. However, immunostaining with monoclonal antibodies indicates that much of the observed immunostaining at this site probably represents cross-reactivity with another member of the kallikrein family of enzymes.

Plasma 6-keto prostaglandin F1 alpha and thromboxane B2 in sick preterm neonates

To determine if vascular abnormalities in preterm neonates might be related to vasoactive prostaglandins, stable prostacyclin (6-KPGF1 alpha) and thromboxane A2 (T X B2) metabolites in arterial blood were measured at less than or equal to 6 hours after birth and at 24, 48, and 72 hours using a radioimmunoassay. Neonates of less than 32 weeks gestation (N = 26) were diagnosed as having either the idiopathic respiratory distress syndrome (IRDS, N = 15) or pulmonary edema (PE, N = 11), and were also grouped according to the presence or absence of intracranial hemorrhage (ICH, N = 11) or patent ductus arteriosus (PDA, N = 10). Initial plasma 6-KPGF1 alpha was greater in neonates with ICH (0.23 +/- 0.04 ng/ml, mean +/- SE) than without ICH (0.11 +/- 0.04, p less than 0.05). Neonates with both ICH and IRDS (N = 8) had significantly elevated T X B2 at all sampling times compared to neonates with IRDS and no ICH (N = 7). Both T X B2 and 6-KPGF1 alpha increased with time in those with major ICH. Among neonates without ICH, 7 with IRDS had higher initial 6-KPGF1 alpha (0.19 +/- 0.07 ng/ml) and lower T X B2 (0.15 +/- 0.04 ng/ml) than 8 with PE (0.04 +/- 0.01 and 0.37 +/- 0.09 ng/ml, respectively). The initial 6-KPGF1 alpha (0.024 + 0.003 ng/ml), measured in neonates with PE and without PDA or ICH (N = 6), was significantly less than the corresponding value in the other neonates (0.201 +/- 0.036 ng/ml) (N = 20).

Physiological and morphological responses of the rat kidney to reduced dietary protein

Renal physiological and morphological adjustments to a reduced protein diet were studied in young Munich-Wistar rats. Two groups of animals were used for the correlative physiological-morphological studies: normal protein (NP, 24% dietary protein) rats and reduced protein (LP, 8% dietary protein) rats. Both groups were fed their respective diets for 4-5 wk and had free access to drinking water. Physiological measurements of GFR and urea clearance were made on five animals from each group. These data showed that the changes in renal function specifically and almost exclusively affected the handling of urea. There was no difference in GFR between the NP and LP rats. Urea clearance was substantially reduced in LP rats. Morphological analyses were made on perfusion-fixed kidneys of five animals from each group. Selected slices were examined and photographed by light and electron microscopy. These data showed no difference in size and number of elements within the vascular bundles but showed significantly smaller lumina of the thin limbs of the short-looped nephrons and a significant thinning of the wall of the thin descending limbs of the long-looped nephrons. These morphological changes may in part be responsible for the observed physiological adjustments to a reduced protein diet. An additional group of rats (6 NP and 5 LP, all dehydrated) were analyzed for distribution of solutes within the inner medulla. The data showed that the concentration of urea, but not that of Na+, was reduced at the papillary tip in LP rats.

Fetal heart rate responses to meperidine alone and in combination with propiomazine

A study was performed to evaluate the effects of three regimens of intrapartum analgesia upon fetal heart rate characteristics. Either meperidine 50 mg (M50), meperidine 50 mg plus propiomazine 20 mg (M50/P20), or meperidine 25 mg plus propiomazine 10 mg (M25/P10) was given intravenously for intrapartum analgesia to 204 patients in the first stage of labor, and the effects were evaluated upon fetal heart rate variability (FHRV) and fetal heart rate reactivity (FHRR). M25/P10 was found to cause a decrease in FHRV in fewer patients than M50/P20 (13.6% vs 36.5%, P less than .005), while still providing adequate analgesia for most patients. Although M50 also caused a decrease in FHRV in fewer patients than M50/P20 (19.1% vs 36.5%, P less than .05), it produced emesis in 20% of patients. When FHRV was minimal or moderate before the analgesic was given, FHRV became absent in only eight of 222 doses (3.6%). FHRR was lost in fewer patients given M50 than in those given M50/P20 (45% vs 71%, P less than .01); there was no significant difference between M50 and M25/P10. We conclude that the effects of meperidine upon fetal heart rate characteristics are both potentiated by propiomazine, and, when meperidine is given with propiomazine, dose-related. We also conclude that absent FHRV is rarely caused by meperidine; when FHRV becomes absent after meperidine administration, the patient should be fully evaluated for the possibility of fetal distress before the absence of variability is attributed to analgesia.

The effect of type of delivery on neonatal outcome in singleton infants of birth weight of 1,000 g or less

To evaluate the relationship between management of delivery and neonatal outcome in singleton neonates with birth weights between 501 and 1,000 g, a retrospective analysis was performed. In the 54-month period ending June 30, 1981, a total of 109 singleton neonates were born at Vanderbilt University Hospital, Nashville, Tenn, with birth weights between 501 and 1,000 g, 31 weighing 501 through 750 g, and 78 weighing 751 through 1,000 g. The overall neonatal survival rate was 60%, 39% in the group weighing 501 through 750 g and 69% in the group weighing 751 through 1,000 g. In terms of morbidity and mortality, there was no difference between neonates delivered by cesarean section compared with those delivered vaginally. The only significant factor found relating to neonatal mortality was the occurrence of labor. In the 17 newborns delivered without occurrence of labor, the frequency of neonatal death was significantly decreased, although this difference may be caused by differing risk factors in the infants delivered without occurrence of labor. When labor was present and the fetus had a cephalic presentation, cesarean section was not found to be superior to vaginal delivery in terms of neonatal morbidity or mortality for neonates of 1,000 g or less.

Sonographic placental localization in the determination of the site of uterine incision for placenta previa

The presence of a placenta previa is associated with increased maternal and fetal morbidity. Hemorrhage is considered the primary underlying factor contributing to this increased morbidity. Patients who have a placenta previa are often hypovolemic and are therefore at high risk for hemorrhagic shock if intraoperative blood loss during cesarean section is not minimized. The authors reviewed sonographic localization of the placenta prior to cesarean section for placenta previa, in order to facilitate proper selection of uterine incision based on placental site and so reduce intraoperative blood loss. Nineteen cases of placenta previa were reviewed. Seventeen patients underwent a conventional low cervical or classic incision, whereas two underwent paramedian uterine incision. Data from these cases suggest that in patients who wish to be sterilized and in whom the site of placental implantation is directly beneath the lower uterine segment, as well as extending to an area in which a traditional classic cesarean section would be made, a paramedian incisional technique is of value.

Comparison of aggressive and conservative management of premature rupture of fetal membranes

A 3-year prospective study was undertaken to compare two types of management of rupture of the fetal membranes between 26 and 34 weeks. Patients in whom amniotic fluid, obtained by amniocentesis, was shown to have no evidence of infection, and who had less than mature lecithin/sphingomyelin (L/S) ratios, were given steroids and, if needed, treated with tocolytic agents. Patients in whom no amniotic fluid could be obtained were not given steroids, but were managed expectantly. Only patients with rupture of membranes greater than or equal to 24 hours were included in the collection of data. Despite the aggressive treatment protocol of the steroid group, no significant difference was found between the two groups in the prevalence of respiratory distress, hyperbilirubinemia, patent ductus arteriosus, episodes of apnea and bradycardia, or necrotizing enterocolitis. Perinatal mortality rates were similar in the two groups, and no difference in the incidence of maternal or neonatal infectious complications was found.

Pregnancy-related rupture of arterial aneurysms

Over 50 per cent of ruptured arterial aneurysms in women under the age of 40 are pregnancy-related. The hemodynamic and endocrine changes of pregnancy appear to be the cause of arterial alterations which may lead to new aneurysm formation and/or weakening of preexisting aneurysms. The most commonly reported arteries to have aneurysms rupture during pregnancy are the aorta, cerebral arteries, splenic artery, renal artery, coronary artery, and ovarian artery. In many instances, the rupture of an arterial aneurysm will initially simulate other less serious disease processes, thus delaying the correct diagnosis until a catastrophic event occurs. Early diagnosis and treatment of a ruptured arterial aneurysm are imperative in order to give optimal chances of survival to the mother and fetus.

The effect of type of delivery upon neonatal outcome in premature twins

A retrospective study from January 1, 1976, through July 31, 1981, was performed to evaluate the relationship between type of delivery and perinatal morbidity and mortality in twins of birth weight less than 2,000 gm. Vaginally delivered second twins who weighed 601 to 999 gm had increased risk of neonatal mortality when compared to their siblings. Among twins who weighed 1,000 to 1,499 gm, vaginally delivered second twins had significantly lower Apgar score and increased risks of neonatal morbidity in comparison to their siblings, whereas second twins who were delivered by cesarean section had no difference in Apgar score or neonatal morbidity from those of their siblings. In twins who weighed 1,500 to 1,999 gm, a significant increase in neonatal complications in vaginally delivered second twins was not found, although the majority of neonatal complications did occur in vaginally delivered second twins. Cesarean section is proposed as the optimal route of delivery for all twins expected to have a birth weight less than 1,500 gm.

Induced abortion: a risk factor for placenta previa

A threefold increase in the incidence of placenta previa, from one in 318 deliveries (0.3%) in 1972-1974 to one in 109 deliveries (0.9%) in the twelve-month period ending June 30, 1980, was noted at Vanderbilt University Hospital. Two large groups of patients not present in 1972-1974 were found to be responsible for this increased incidence of placenta previa: one-way maternal transports and women who had had induced first trimester abortions. The frequency of maternal transports having placenta previa was 3.3% (p less than 0.0001), and the frequency of placenta previa in women after an induced first trimester abortion was 3.8% (p less than 0.0001). When correction for maternal transports was made, the endogenous induced first trimester abortion population had a frequency of placenta previa of 2.1% (p less than 0.004), whereas the remainder of the endogenous population had an incidence of placenta previa similar to that found in the years 1972-1974. Induced first trimester abortion is seen as a significant factor predisposing to placenta previa.

Hydrops fetalis: sonographic evaluation and clinical implications

A systematic sonographic evaluation of hydropic fetus is presented, based on 21 cases and a literature review. The clinical implications of fetal ascites with or without anasarca, maternal hydramnios, maternal oligohydramnios, or an abnormally thick placenta are discussed as they relate to fetal outcome. It is concluded that sonography could play a major role in determining the optimal approach to perinatal management of the fetus in hydrops fetalis, and thus contribute to a reduction in the perinatal mortality and morbidity associated with this disorder.

The nonstress test: an evaluation of 1,000 patients

In November, 1978, the fetal heart rate nonstress test (NST) was instituted as the primary screening procedure for the evaluation of fetal well-being at Vanderbilt University Hospital. The results of the first 1,000 patients tested are presented. The stillborn rate within 8 days of a reactive NST was 6.4 per 1,000, with the stillbiths occurring either in patients with diabetes mellitus or with intrauterine growth retardation (IUGR). A review of other series in which both the total indications for nonstressed testing and the risk groups in which stillbirths occurred within 7 days of an NST reveals that patients with diabetes mellitus (p less than 0.025) and patients with IUGR (p less than 0.01) are at greater risk for stillbirth within 7 days of an NST. Weekly nonstress testing, effective in preventing stillbirths in most risk groups, is not adequate in patients with diabetes mellitus or IUGR.

The effect of electronic fetal monitoring on the incidence of cesarean section

In an attempt to elucidate the effect of electronic fetal monitoring on cesarean section rates, a review was made of the experience before and that during the 7 years after the initiation of fetal monitoring at Vanderbilt University Hospital. When a comparison was made of the cesarean section rates in the 3 years prior to fetal monitoring with those over the subsequent 2 years, no change was observed, thus indicating that, in experienced hands, a liberal use of fetal monitoring in low-risk and high-risk patients does not necessarily cause a rise in the overall incidence of cesarean sections. During this time, the neonatal mortality rate fell approximately fourfold. On the basis of this study, the belief is that a liberal attitude toward delivery by cesarean section for patients with breech presentations and other high-risk conditions contributed more to the rise in cesarean sections at Vanderbilt University Hospital than did electronic fetal monitoring. With proper education of the clinician and correct interpretation of the findings, electronic fetal monitoring need not increase cesarean section rates, but rather should allow for a more accurate description of intrapartum life.

Acute effect of cigarette smoking on the fetal heart nonstress test

A major limitation in the use of the nonstress test (NST) has been the high frequency of nonreactive NSTs in the absence of fetal distress. Exogenous factors causing loss of fetal heart rate reactivity (FHRR) have not been fully evaluated, although it has previously been shown that chronic smokers have an increased incidence of nonreactive NSTs in the absence of fetal distress. A group of chronically smoking high-risk pregnant women at 31 to 44 weeks' gestation was studied to determine if the acute effects of smoking caused the NST to become nonreactive. After a reactive NST was obtained, each patient smoked 1 cigarette and the effects of the fetus were observed. Twenty-six studies were performed on 25 patients. A transient mild elevation of baseline fetal heart rate was noted after smoking in several studies; however, no significant change was found in FHRR, indicating that the acute effects of smoking a single cigarette are not responsible for the increased incidence of nonreactive NSTs in smokers.

Association of portal hypertension and ruptured splenic artery aneurysm in pregnancy

Spontaneous rupture of a splenic artery aneurysm is a rare, usually catastrophic event complicating pregnancy. Among risk factors for splenic artery aneurysm in nonpregnant patients is portal hypertension. The third case of rupture of splenic artery aneurysm in a patient with portal hypertension is reported, and previous reports are reviewed. In each of these cases the portal hypertension was due to hepatic cirrhosis. A previously unreported association between portal hypertension in pregnancy and rupture of a splenic artery aneurysm is presented.

Bleomycin, vinblastine, and cis-platinum in the treatment of advanced endodermal sinus tumor

The endodermal sinus tumor has traditionally been associated with an exceedingly poor prognosis. Three women with advanced pure endodermal sinus tumors were treated with a combination of bleomycin, vinblastine, and cis-platinum (VBC). Serum alpha-fetoprotein levels were monitored for all patients during and after therapy, and in each case the alpha-fetoprotein returned to normal range, correlating with complete clinical remission. Second-look laparotomy was negative for tumor in each case. Two patients have had no overt sign of recurrence 12 months after cessation of therapy. The third patient had post-treatment elevation of alpha-fetoprotein levels, and eventually was found to have recurrent tumor 6 months after chemotherapy was stopped. The VBC combination, previously found effective in testicular germ cell tumors, is also effective in ovarian germ cell tumors.

Documentation of recent fetal demise with simultaneous maternal and fetal heart rate monitoring

A case of recent fetal demise with maternal-fetal electrocardiogram (ECG) signal conduction is presented. Diagnosis and graphic documentation of fetal demise were made by comparison of heart tracings obtained from the maternal precordium and from the fetal scalp. Combined monitoring is suggested as a diagnostic procedure and as a method of graphic documentation.

The ultrastructural localization of membrane ATPase in rat thin limbs of the loop of Henle

The cytochemical distribution of nonspecific membrane ATPase activity in the epithelial membranes of the thin limbs of the loops of Henle of rat nephrons was studied at the ultrastructural level. Membrane ATPase activity was localized in the luminal, lateral, and (to a lesser extent) basal membranes of only the outer medullary segment of the thin descending limbs of long nephrons (Type II epithelium). The reaction product was lacking in the thin limb of short nephrons (Type I epithelium) as well as in the inner medullary descending (Type III epithelium) and ascending (Type IV epithelium) segments of the thin limbs of long nephrons. These data reinforce the concept of thin limb heterogeneity and may indicate a specialized role for the outer medullary segment of thin descending limbs of long nephrons in the concentrating mechanism.

The structural organization of the kidney of the desert rodent Psammomys obesus

The architecture of the desert rodent Psammomys obesus has been studied by means of standard histologic procedures and by single nephron injections. As other rodent kidneys (rat, mouse), the Psammomys kidney consists of two types of nephrons, 66% short looped and 34% long looped nephrons. The cortex is composed of 4 to 5 layers of glomeruli, which lie closely put together, the glomeruli often touch each other. The superficial and the midcortical glomeruli give rise to short looped neophrons, the juxtamedullary to long looped nephrons. In the strongly developed medulla the inner stripe shows the most striking pattern. It consists of two distinct compartments, that of the giant vascular bundles and that of the interbundle regions. The giant vascular bundles consist of about 8 to 14% arterial vasa recta and 39 to 47% venous vasa recta; furthermore they include the thin descending limbs of the short loops of Henle which amount to 44 to 51% of the bundle structures. The tubules of the interbundle regions surround the bundles in a regular pattern. The inner zone is almost completely surrounded by the renal pelvis; the long broad papilla protrudes into the ureter. The thin descending limbs of short looped nephrons traverse the inner stripe inside the giant vascular bundles. Leaving the bundles they turn back within the inner stripe; their ascending limbs lie in the interbundle region. Both limbs of the long loops of Henle run in the interbundle region, together with the ascending limbs of the short loops and the collecting ducts. The long loops penetrate deeply the inner zone. Many bends are found near the tip of the papilla. The renal pelvis has a very specialized form. It penetrates the inner stripe with many complexely shaped extensions, which surround the giant vascular bundles. Large parts of the bundles with their thin walled structures are thus separated from the pelvic urine only by a single layer of cuboidal epithelium. The possible functional importance of the described specializations of the Psammomys kidney (giant vascular bundles, large inner zone, special shape of the renal pelvis) for the urine concentrating and urea recyclng mechanisms is discussed.

The ultrastructure of the thin loop limbs of the mouse kidney

The thin limbs of the loops of Henle in the mouse kidney have been investigated by conventional electron microscopy. Resulting from light microscopic investigations, a distinction in the epithelia of short and long loops can be demonstrated. Ultrastructurally, the thin limbs (descending) of short loops are composed of a uniformly thin and simple epithelium. In contrast, long loops (thin descending and ascending) are composed of three different epithelial types which are representative of a distinctly more complex epithelial system. Two epithelial types were observed in the thin descending limbs of long loops and the third type was observed in the ascending thin limbs. Based upon these findings it is suggested that the thin descending limbs of short and long loops of Henle in the mouse kidney cannot perform the same functions in the renal concentrating mechanism.

Microbodies of the rat renal proximal tubule: ultrastructural and cytochemical investigations

The present study was undertaken to provide a detailed morphological and cytochemical characterization of the microbodies of the rat renal proximal tubule following perfusion fixation. The following observations were made: 1) Two basic types of microbodies (Mb-I and Mb-II) can be identified. Mb-I have both circular and tubular profiles which are located peripherally within the granular matrix of these microbodies. Mb-II have marginal plates and crystalloid inclusion in addition to circular and tubular profiles. 2) Circular and tubular profiles, 100 nm in diameter, described by previous investigators as being infrequent in occurrence, are the most consistent morphological characteristic of rat renal microbodies after perfusion fixation. These profiles have a homogeneous center surrounded by a double or single ring of granules. The uniform size and spacing of these granules within profiles establish a basic 100 A periodicity found in both types of microbodies. 3) Evidence is presented which suggests that both "nucleoids" and "tubular protrusion rods" as described by other investigators of the rat renal microbodies may result from poor fixation and/or osmotic stress. 4) The density of the matrix of Mb-I is, in contrast to previous reports, greater than the density of adjacent mitochondria. 5) Marginal plates or crystalloid inclusions were demonstrated in some microbodies (Mb-II) of all the rats studied; periodicities of 100, 200, and 300 A were identified within these structures. 6) Both types of microbodies were positive for catalase activity, but were negative for acid phosphatase activity. On the basis of both morphological and cytochemical criteria, it seems plausible that these two populations of renal microbodies (Mb-I and Mb-II) represent a morphological and functional continuum.