Vitamin D supplementation in cutaneous malignant melanoma outcome (ViDMe): a randomized controlled trial

BACKGROUND

Previous studies have investigated the protective effect of vitamin D serum levels, at diagnosis and during the follow-up period after treatment, on melanoma outcome. In the present study we assess whether vitamin D supplementation, in the follow-up period after diagnosis and surgical resection of the primary tumor, has a protective effect on relapse of cutaneous malignant melanoma and whether this protective effect correlates with vitamin D levels in serum and Vitamin D Receptor immunoreactivity in the primary tumor.

METHODS/DESIGN

This study is a multicenter randomized double blind placebo- controlled phase III trial. Patients between the age of 18 and 80 years diagnosed and treated surgically for a melanoma stage IB-III are eligible for randomization in a 1:1 ratio to active treatment or placebo. The study drug is taken each month and consists of either 100,000 International Unit cholecalciferol or arachidis oleum raffinatum used as a placebo. The primary endpoint is relapse free survival. The secondary endpoints are 25 hydroxyvitamin D3 serum levels at diagnosis and at 6 month intervals, melanoma subtype, melanoma site and stage of melanoma at diagnosis according to the 2009 American Joint Committee on Cancer melanoma staging and classification. At randomization a bloodsample is taken for DNA analysis. The study is approved by the local Ethics Committees.

DISCUSSION

If we can confirm our hypothesis that vitamin D supplementation after removal of the tumor has a protective effect on relapse of cutaneous malignant melanoma we may reduce the burden of CMM at several levels. Patients, diagnosed with melanoma may have a better clinical outcome and improved quality of life. There will be a decrease in health care costs related to treatment of metastatic disease and there will be a decrease in loss of professional years, which will markedly reduce the economic burden of the disease.

TRIAL REGISTRATION

Clinical Trial.gov, NCT01748448 , 05/12/2012.

Miscalibration and severe complications after diode laser cyclophotocoagulation: two case reports

Because two similar transscleral cyclophotocoagulation diode lasers with identical power & duration settings induced significantly different postoperative inflammation, we wanted to compare the real output of both lasers. Using a Power/Energy Meter (Fieldmaster) we compared the output of the two lasers (the Iridis [Quantel Medical] and the Iris Medical [OcuLight SLx]) at different energy levels. At a setting of 600, 1000, 1400, 1700, 2000 and 2500 mW, the measured output for the Iridis and Iris Medical diode laser were respectively 685 and 400 mW, 970 and 650 mW, 1470 and 875 mW, 1700 and 1000 mW, and 1990 compared to 1000 mW. On the average the output of the Iridis laser was correct and the output of the Iris Medical laser was 40% lower than the setting. Overtreatment and severe complications occurred with the Iridis laser because the manufacturer recommended using wrong power settings based on the Iris Medical laser, which was undercalibrated. The calibration of cyclophotocoagulation diode lasers should be performed prior to use when changing to a new device and whenever over- or undertreatment is observed.

High viral burden in the presence of major HIV-specific CD8(+) T cell expansions: evidence for impaired CTL effector function

To investigate the effect of HIV-specific CD8(+) T cells on viral plasma load and disease progression, we enumerated HLA-A2-, B8- and B57-restricted CD8(+) T cells directed against several HIV epitopes in a total of 54 patients by the use of tetrameric HLA-peptide complexes. In patients with high CD4(+) T cell numbers, HIV-specific tetramer(+) cells inversely correlated with viral load. Patients with CD4(+) T cell numbers below 400/microl blood, however, carried high viral load despite frequently having high tetramer(+) T cell numbers. This lack of correlation between viral load and tetramer(+) cells did not result from viral escape variants, as in only 4 of 13 patients, low frequencies of viruses with mutated epitopes were observed. In 15 patients we measured CD8(+) T cell antigen responsiveness to HIV peptide stimulation in vitro. FACS analyses showed differential IFN-gamma production of the tetramer(+) cells, and this proportion of IFN-gamma-producing tetramer(+) cells correlated with AIDS-free survival and with T cell maturation to the CD27(-) effector stage. These data show that most HIV-infected patients have sustained HIV-specific T cell expansions but many of these cells seem not to be functional, leaving the patient with high numbers of non-functional virus-specific CD8(+) T cells in the face of high viral burden.

Bilateral cataract and high myopia in a child with trichothiodystrophy: a case report

Trichothiodystrophy refers to a group of autosomal recessive disorders that have in common brittle sulphur-deficient hair (7). The abnormalities are usually obvious at birth and the clinical expression is variable. Ocular abnormalities are common with bilateral cataract being the most frequent one. We report on a four year old boy with trichothiodystrophy (complementation group TTD-A) who presented to us with strabismus, high myopia and bilateral cataract.

A comparison of methods for preoperative discrimination between malignant and benign adnexal masses: the development of a new logistic regression model

OBJECTIVE

The aim of this study was to assess the complementary use of ultrasonographic end points with the level of circulating CA 125 antigen by multivariate logistic regression analysis algorithms to distinguish malignant from benign adnexal masses before operation.

STUDY DESIGN

One hundred ninety-one patients aged 18 to 93 years with overt adnexal masses were examined by transvaginal ultrasonography with color Doppler imaging and 31 variables were recorded. The end points were the histologic classification of the tumor and the areas under the receiver-operator characteristic curves of alternative algorithms.

RESULTS

One hundred forty patients had benign tumors and 51 (26.7%) had malignant tumors: 31 primary invasive tumors (37% International Federation of Gynecology and Obstetrics stage I), 5 tumors of borderline malignancy (100% International Federation of Gynecology and Obstetrics stage I), and 15 tumors were metastatic and invasive. The most useful variables for the logistic regression analysis were the menopausal status, the serum CA 125 level, the presence of >/=1 papillary growth (>3 mm in length), and a color score indicative of tumor vascularity and blood flow. The optimized procedure had a sensitivity of 95.9% and a specificity of 87.1%. The area under the receiver-operator characteristic curve was significantly higher (P <.01) than the corresponding values from the independent use of serum CA 125 levels or indexes of tumor form or vascularity.

CONCLUSION

Regression analysis of a few complementary variables can be used to accurately discriminate between malignant and benign adnexal masses before operation.

Regulation of glycogen breakdown by glycogen level in contracting rat muscle

The interaction of glycogen concentration, insulin and beta-adrenergic stimulation in the regulation of glycogen breakdown was studied in perfused rat muscles. Rats were pre-conditioned to obtain two groups with either normal (N) or 'supercompensated' (SC) muscle glycogen. The next day their hindlimbs were perfused with a medium containing insulin (0, 40 and 100 microU mL(-1)) and/or isoproterenol (0 and 1.5 nmol L(-1)). Contractions were induced by electrical stimulation of the sciatic nerve. Compared with N, glycogen breakdown in white gastrocnemius during contractions was greater in SC at any hormonal combination (P < 0.05). Conversely, in red gastrocnemius (RG) the higher glycogenolytic rate in SC, compared with N, faded as the insulin concentration was raised from 0 to 100 microU mL(-1). However, isoproterenol restored the higher glycogenolytic rate in SC. In any condition, RG glycogen synthase fractional activity was lower (P < 0.05) during contractions in SC than in N. Furthermore, the percentage of phosphorylase a was higher in SC except when muscles were exposed to insulin alone. In conclusion, high initial glycogen concentration in fast-glycolytic muscle causes high glycogenolytic rate during contractions, irrespective of hormonal stimulation. In contrast, due to down-regulation of phosphorylase activity, such a relationship does not exist in insulin-stimulated fast-oxidative muscle.

Shortening of muscle relaxation time after creatine loading

The effect of creatine (Cr) supplementation on muscle isometric torque generation and relaxation was investigated in healthy male volunteers. Maximal torque (Tmax), contraction time (CT) from 0.25 to 0.75 of Tmax, and relaxation time (RT) from 0.75 to 0.25 of Tmax were measured during 12 maximal isometric 3-s elbow flexions interspersed by 10-s rest intervals. Between the pretest and the posttest, subjects ingested Cr monohydrate (4 x 5 g/day; n = 8) or placebo (n = 8) for 5 days. Pretest Tmax, CT, and RT were similar in Cr and placebo groups. Also in the posttest, Tmax and CT were similar between groups. However, posttest RT was decreased consistently by approximately 20% (P < 0.05) in the Cr group from the first to the last of the 12 contractions. In addition, the mean decrease in RT after Cr loading was positively correlated with pretest RT (r = 0.82). It is concluded that Cr loading facilitates the rate of muscle relaxation during brief isometric muscle contractions without affecting torque production.

Phosphocreatine resynthesis is not affected by creatine loading

PURPOSE

Oral creatine supplementation has been shown to improve power output during high intensity intermittent muscle contractions. Facilitated muscle phosphocreatine (PCr) resynthesis, by virtue of elevated intracellular PCr concentration, might contribute to this ergogenic action. Therefore, the effect of creatine loading (C: 25 g X d(-1) for 5 d) on muscle PCr breakdown and resynthesis and muscle performance during high intensity intermittent muscle contractions was investigated.

METHODS

A double-blind randomized cross-over study was performed in young healthy male volunteers (N = 9). 31P-NMR spectroscopy of the m. gastrocnemius and isokinetic dynamometry of knee-extension torque were performed before and after 2 and 5 d of either placebo (P) or C administration.

RESULTS

Compared with P, 2 and 5 d of C increased (P < 0.05) resting muscle PCr concentration by 11% and 16%, respectively. Furthermore, torque production during maximal intermittent knee extensions, including the first bout of contractions, was increased (P < 0.05) by 5-13% by either 2 or 5 d of C. However, compared with P, the rate of PCr breakdown and resynthesis during intermittent isometric contractions of the calf was not significantly affected by C.

CONCLUSION

Creatine loading raises muscle PCr concentration and improves performance during rapid and dynamic intermittent muscle contractions. Creatine loading does not facilitate muscle PCr resynthesis during intermittent isometric muscle contractions.

Experience with fetoscopic cord ligation

OBJECTIVE

In the case of a monochorionic multiple pregnancy with one non-viable fetus who compromises its co-twin, fetoscopic cord ligation may be performed. We describe our fetoscopic cord ligation technique and discuss the efficacy of cord ligation for salvaging the co-twin, based on available data.

STUDY DESIGN

Descriptive case series of four cases and review of the cases published up to 1996.

RESULTS

We performed four successful ligations. Of the 23 reported cases, which include the present series, two ligations failed. Four fetuses died in utero, and 17 were born alive at a mean of 8 weeks following the procedure. Two babies died in the perinatal period, a third after 60 days. Preterm uterine contractions do not seem to be a clinical problem. Preterm prelabour rupture of the membranes (PPROM) complicates about 40% of cases, the majority occurring prior to 32 weeks.

CONCLUSION

Fetoscopic cord ligation is a feasible procedure with a 71% survival rate and a high risk for PPROM.

Tracheoscopic endoluminal plugging using an inflatable device in the fetal lamb model

OBJECTIVE

Intra-uterine tracheal occlusion has been proposed to reverse pulmonary hypoplasia, an important prognostic factor in congenital diaphragmatic hernia. We aimed to evaluate the feasibility and pulmonary effects of tracheoscopic tracheal obstruction with a detachable balloon.

STUDY DESIGN

Fourteen mid-trimester fetuses out of 24 in 13 ewes underwent tracheoscopic balloon obstruction. Ten non-operated fetuses served as controls. Plugging was performed under fiber-tracheoscopy using a detachable balloon. Outcome measures consisted of: total operating time, tracheoscopy time, fetal survival, efficiency of plugging, and pulmonary effects. The Mann-Whitney test and linear regression were used for statistical analysis.

RESULTS

Mean operating time and tracheoscopy time were 65+/-12 and 6.6+/-3.9 min, respectively. One intra-operative death occurred in each group. The post-operative mortality was 2/13 for cases and 2/9 for controls. In all 14 fetuses, the trachea was successfully obstructed. In the 11 treated animals born alive, the lung-to-body-weight ratio was 0.060+/-0.01, while in controls it was 0.031+/-0.01 (P = 0.0001). In a subset of six fetuses obstructed for 14-18 days, mean-terminal-bronchial density was 0.95+/-0.59, compared to 2.06+/-0.80 for controls (P = 0.046).

CONCLUSIONS

Using fetal tracheoscopy, the trachea can successfully be obstructed with an inflatable balloon. Pulmonary hyperplasia is achieved when the obstruction lasts 2 weeks.

Effect of creatine loading on endurance capacity and sprint power in cyclists

The effect of creatine loading on endurance capacity and sprint performance was investigated in elite cyclists according to a double-blind cross-over study design. Subjects (n = 12) underwent on 3 occasions and separated by 5 week wash-out periods, a 2 h 30 min standardized endurance protocol on their own race bicycle, which was mounted on an electromagnetically braked roller-system, whereupon they cycled to exhaustion at their predetermined 4 mmol lactate threshold. Immediately thereafter they performed 5 maximal 10 second sprints, separated by 2 min recovery intervals, on a Monark bicycle ergometer at 6 kg resistance on the flywheel. Before the exercise test, subjects were either creatine loaded (C: 25 g creatine monohydrate/day, 5 days) or were creatine loaded plus ingested creatine during the exercise test (CC: 5 g/h), or received placebo (P). Compared with P, C but not CC increased (p<0.05) peak and mean sprint power output by 8-9% for all 5 sprints. Endurance time to exhaustion was not affected by either C or CC. It is concluded that creatine loading improves intermittent sprint capacity at the end of endurance exercise to fatigue. This ergogenic action is counteracted by high dose creatine intake during exercise.

Fetal cardiac tamponade due to an intrapericardial teratoma

A case of an intrapericardial tumor diagnosed in utero at 26 weeks of gestation is presented. The prenatal echocardiographic follow-up of an incipient hydrops fetalis determined the management and the emergency surgical treatment. Histologically, the tumor appeared to be a benign teratoma, grade I. In the postoperative period an unexpected mediastinal tumor was found and removed later. This tumor also appeared to be a benign teratoma, grade 0. Both teratomas were independent and therefore primary.

Fetal membrane closure techniques after hysteroamniotomy in the midgestational rabbit model

OBJECTIVE

We studied closure techniques for amniotic access in midgestational rabbits.

STUDY DESIGN

Twenty-eight rabbits with a total of 313 amniotic sacs were used for this study. In each animal a 1 cm hysteroamniotomy was made in two amniotic sacs at 22 days' gestation (term = 32). For 12 amniotic sacs (group 1) only the myometrium was closed by microsurgical suturing. In group 2 (n = 12), sutures included myometrium and membranes. In group 3 (n = 8), a collagen plug was placed, and in group 4 (n = 12) fibrin glue was used. Twelve sacs were left unclosed (positive controls) and the unmanipulated 257 sacs were negative controls. Eight days later (gestational age 30 days) amniotic sacs were evaluated for the presence of amniotic fluid, membrane integrity, and fetal weight and survival. Statistics were done with two-tailed Fisher's exact test and one-way analysis of variance.

RESULTS

Membrane integrity (p = 0.0036) and amniotic fluid (p = 0.047) were best restored after myometrial closure. Fetal weight and survival rate were not affected by different closure techniques.

CONCLUSION

In this model primary closure of the myometrium only yielded best results.

Alternative technique for Nd: YAG laser coagulation in twin-to-twin transfusion syndrome with anterior placenta

Nd: YAG laser coagulation is used to treat severe twin-to-twin transfusion syndrome (TTS). Success of the technique depends on visualization of the placenta, the fetal membranes and the targeted vessels, as well as obtaining an optimal inclination angle for laser coagulation. In the rare case of an extensive anterior placenta, it may be difficult to achieve these conditions using the percutaneous approach. Here, we propose an alternative to the percutaneous procedure. Modifications involve an open access and the use of a flexible cannula and bent scope. An extraplacental area, usually at the fundus, is identified by B-mode and color Doppler imaging. A mini-laparotomy is made under general anesthesia. The viscera are retracted and the cannula is inserted under direct view and ultrasound control by the Seldinger technique. The curved fiberscope is passed through the flexible cannula, allowing adequate inspection of the placenta, and target vessels can be coagulated at an angle close to 90 degrees. After the procedure, the uterus is closed primarily to prevent postoperative leakage of amniotic fluid or hemorrhage. This technique has been successfully used in six patients with TTS and a completely anterior placenta, with a gestational age between 18.5 and 22.0 weeks. In all patients, the amniotic cavity was accessed without hemorrhage. The outcomes are similar to those published previously for laser coagulation. The mean interval from intervention until delivery was 10.5 weeks. All 12 fetuses were live born but four died from complications of extreme prematurity. No maternal complications occurred.

Polyhydramnios as a prenatal symptom of the digeorge/velo-cardio-facial syndrome

Prenatal diagnosis of the DiGeorge/velo-cardio-facial syndrome has become possible since it was recognized that this syndrome is caused by a submicroscopic deletion in chromosome 22q11. In a sporadic patient presenting a conotruncal heart defect and polyhydramnios, the del 22q11 was made prenatally by fluorescence in situ hybridization (FISH) after amniocentesis. Seven additional patients with a del 22q11 were identified, who presented during pregnancy with polyhydramnios. In one of them, unilateral hydronephrosis was present. These findings further add to a growing list of clinical presentations of a del 22q11 and suggest that in patients with polyhydramnios and a conotruncal heart defect or uropathy, fetal karyotyping should be complemented by FISH for a del 22q11.

Prenatal diagnosis of a terminal short arm deletion of chromosome 8 in a fetus with an atrioventricular septal defect

We report the prenatal diagnosis at 30 weeks of gestation of a del(8)(p21.3-->pter) in a growth-retarded fetus with an unbalanced atrioventricular septal defect (AVSD) and a hypoplastic right ventricle. This observation further confirms the association of AVSD with terminal deletions of chromosome 8p. Terminal deletions of chromosome 8p are more frequent than previously thought, but small terminal deletions can easily be overlooked. This observation illustrates that when an AVSD is diagnosed prenatally, special attention should be paid to distal chromosome 8p.

Long-term creatine intake is beneficial to muscle performance during resistance training

The effects of oral creatine supplementation on muscle phosphocreatine (PCr) concentration, muscle strength, and body composition were investigated in young female volunteers (n = 19) during 10 wk of resistance training (3 h/wk). Compared with placebo, 4 days of high-dose creatine intake (20 g/day) increased (P < 0.05) muscle PCr concentration by 6%. Thereafter, this increase was maintained during 10 wk of training associated with low-dose creatine intake (5 g/day). Compared with placebo, maximal strength of the muscle groups trained, maximal intermittent exercise capacity of the arm flexors, and fat-free mass were increased 20-25, 10-25, and 60% more (P < 0. 05), respectively, during creatine supplementation. Muscle PCr and strength, intermittent exercise capacity, and fat-free mass subsequently remained at a higher level in the creatine group than in the placebo group during 10 wk of detraining while low-dose creatine was continued. Finally, on cessation of creatine intake, muscle PCr in the creatine group returned to normal within 4 wk. It is concluded that long-term creatine supplementation enhances the progress of muscle strength during resistance training in sedentary females.

Intrauterine tracheal obstruction, a new treatment for congenital diaphragmatic hernia, decreases amniotic fluid sodium and chloride concentrations in the fetal lamb

OBJECTIVE

To evaluate the effect of fetal tracheal occlusion on sodium and chloride concentrations in amniotic and tracheal fluid.

SUMMARY BACKGROUND DATA

Intrauterine tracheal occlusion has been proposed to reverse pulmonary hypoplasia, an important prognostic factor in congenital diaphragmatic hernia. In early human trials, technical failure of the obstructive device has been reported.

METHODS

Eight fetal lambs (gestational age = 95 days) were subjected to fetal tracheoscopy, and amniotic and tracheal fluid samples were taken. In multiple pregnancies (n = 6), amniotic fluid was also sampled from the contralateral amniotic sac and used as a control. Subsequently, endotracheal obstruction, using a detachable balloon, was performed. After 14 days, all fetuses were delivered, and sodium and chloride concentrations in amniotic and tracheal fluid were measured again. Statistical analysis was done using a two-tailed Student's t test, paired or unpaired as appropriate.

RESULTS

In controls, between 95 and 109 days gestational age, no significant changes occurred in sodium or chloride concentrations in amniotic or tracheal fluid. After 2 weeks of tracheal obstruction, however, chloride and sodium concentrations in amniotic fluid decreased (chloride = 76.7 mEq/L vs. 107.6 mEq/L, p = 0.0003; sodium = 109.6 mEq/L vs. 125.9 +/- 5.2 mEq/L, p = 0.019). A concomitant increase in chloride and sodium concentration was observed in tracheal fluid (chloride = 145.4 mEq/L vs. 130.0 mEq/L, p = 0.047; sodium = 153.1 mEq/L vs. 142.9 mEq/L, p = 0.051). When comparing groups at 109 days, chloride and sodium concentrations in amniotic fluid were markedly lower in the treated group versus controls (p = 0.0004 and p = 0.05 for chloride and sodium, respectively).

CONCLUSION

Complete tracheal occlusion in ovine fetuses results in a significant decrease of amniotic fluid sodium and chloride concentrations.

Operative fetoscopy: new perspective in fetal therapy?

In a limited number of conditions in utero surgery may be life-saving, such as some cases of congenital diaphragmatic hernia, cystic adenomatoid malformation of the lung, sacrococcygeal teratoma and lower urinary tract obstruction. Postoperative premature labour and its extreme invasiveness have been major drawbacks for open fetal surgery. More recently the merger of fetoscopy and advanced video-endoscopic surgery has been the basis of the concept of endoscopic fetal surgery. In order to evaluate the opportunities of 'fetendo' surgery, animal models have been developed to test the safety of the endoscopic approach, and the feasibility of surgical manipulations on the fetus. In the non-human primate, a lesser invasiveness of endoscopy over open surgical approach was demonstrated, by a significant decrease in uterine activity in comparison with hysterotomy. The main application of fetoscopy today is the surgical treatment of complicated or abnormal monochorionic twin gestations. Fetoscopic laser coagulation of chorionic plate vessels is suggested as a causal therapy for severe feto-fetal transfusion syndrome. Survival rates are around 55 per cent with an incidence of five per cent of neurological morbidity. Fetoscopic cord ligation is associated with a 66 per cent survival rate, but unfortunately also with a risk of 30 per cent for PPROM prior to 32 weeks. Although still in its early experimental phase, endoscopy seems to offer new hope for surgical fetal therapy. Though conceptually very tempting, the development of endoscopic fetal surgery should follow the formal guidelines, as earlier formulated for open surgery by the International Fetal Medicine and Surgery Society. The prospective registration of worldwide experience is advocated and a randomized trial of laser therapy versus amniodrainage is announced.

Tracheoscopic endotracheal occlusion in the ovine model: technique and pulmonary effects

BACKGROUND/PURPOSE

The purpose of this study was to assess the tracheoscopic placement of a detachable balloon to obstruct the trachea in the fetal lamb model and to study the pulmonary effects 2 weeks later.

METHODS

Thirteen pregnant ewes carrying 27 fetuses were used in this trial. Thirteen fetuses underwent endotracheal plugging at a mean gestational age of 95 (90 to 100) days (term, 145). Fourteen nonoperated fetuses served as controls. The intended duration of obstruction was 15 days. Study parameters consisted of operating time, fetal survival, performance of the balloon, and pulmonary changes.

RESULTS

Hysterotomy time was 41 +/- 25 minutes and tracheoscopy time was 7.2 +/- 3.4 minutes. There were no intraoperative deaths in this series. Postoperative fatalities occurred in 2 of 13 plugged fetuses and 1 of 14 controls. At completion of the experiment, the balloon was recovered intact in the trachea of 12 of 13 (92.3%) fetuses. The lung weight/body weight ratio was 76 +/- 16 mg/kg for plugged animals, while in controls it was 34 +/- 8 mg/kg (P = .0001). The lung volume/body weight ratio was 101 +/- 17 mL/kg in plugged fetuses, compared with 47 +/- 4 mL/kg for controls (P = .0002). Mean-terminal-bronchial-density was 0.937 +/- 0.303 for plugged animals, compared with 1.911 +/- 0.441 for controls (P = .0002). Mean linear intercept was 60.9 +/- 5.2 microm in treated fetuses, and 46.3 +/- 5.8 microm for controls (P = .0004).

CONCLUSIONS

Fetal endotracheal occlusion, using a tracheoscopically placed detachable balloon, is reliable, and results in pulmonary hyperplasia after 2 weeks of obstruction. This technique may be beneficial in treating the pulmonary hypoplasia seen in congenital diaphragmatic hernia. Further studies using this balloon device are now required to corroborate these findings.

Access techniques in endoscopic fetal surgery

Endoscopic surgery may in the future become an attractive alternative to open fetal surgery. Herein, we present our evolving experience with minimal access techniques in sheep and nonhuman primate models. Fifty-two pregnant sheep (term = 145 d) were used. All underwent laparotomy. Cannulas were 5 mm diameter with balloon fixation device. In group I (95-105 d, n = 22, and 70-74 d, n = 19), a total of 119 cannulas were placed by open hysterotomy and pursestring suture through myometrium and membranes. In group II (n = 11), access was obtained by Seldinger guidewire technique. Eight cannulas were introduced over a dilator and 7 were radially expanding endoscopic cannulas. Fifteen cannulas were also placed in 5 pregnant Rhesus monkeys using Seldinger and radially expanding techniques. Cannula removal was followed by insertion of a collagen sponge plug and oversewing of the myometrium. Mini-hysterotomies with purse-stringing provided excellent access to the amniotic cavity, without dissection of the membranes. Classic Seldinger technique with forward dilatation was equally effective, but caused stretching of membranes. In sheep and in primates, Seldinger technique with radial dilatation allowed safe access without membrane separation. Leak-proof removal of the cannulas was achieved in all primates. Open hysterotomy with purse-string and balloon-tipped cannula provides efficient and safe access to the gravid sheep uterus. Seldinger technique allows equally secure access, and alleviates the need for hysterotomies. Radial dilatation of the porthole eliminates forward dissection of the membranes, both in sheep and primate models. This method, and collagen plug insertion upon completion of the endoscopic procedure, may provide a truly minimally invasive approach to in-utero surgery.

Diagnostic echographic findings in cryptophthalmos syndrome (Fraser syndrome)

We report two male siblings with cryptophthalmos syndrome (Fraser syndrome), an autosomal recessive multiple malformation syndrome with cryptophthalmos, abnormal genitalia, and syndactyly of the fingers and toes as major clinical symptoms. Renal anomalies (uni- or bilateral agenesis) occur in 85 per cent. In the second trimester of both pregnancies (at 23.5 and 18.5 weeks, respectively), echographic examination revealed multiple anomalies: oligoamnios sequence and fetal hydrops with nuchal oedema. Contrasting with the oligohydramnios, the lungs were voluminous and hyperechogenic. Fetopathological examination revealed that the oligoamnios sequence was due to major renal abnormalities (bilateral renal agenesis in the first, and unilateral renal agenesis and contralateral multicystic renal dysplasia in the second sibling). Laryngeal substenosis had resulted in another malformation sequence consisting of overdistended lungs, and non-immune fetal hydrops. The present experience shows that in the presence of an oligoamnios sequence with contrastingly voluminous, hyperechogenic lungs, the diagnosis of cryptophthalmos syndrome should seriously be considered in the differential diagnosis.

Chromosome 22q11 deletion presenting as the Potter sequence

A female fetus with the Potter sequence, caused by unilateral renal agenesis and contralateral multicystic renal dysplasia, was found to have a submicroscopic deletion in chromosome 22q11. The only associated anomaly was agenesis of the uterus and oviducts (Von Mayer-Rokitansky-Küster anomaly). The deletion was inherited from the father, who presented the typical velocardiofacial syndrome phenotype, but no urological anomalies. This observation further extends the clinical spectrum associated with a deletion in 22q11.

Amnioinfusion with Hartmann's solution: a safe distention medium for endoscopic fetal surgery in the ovine model

In this study, we have investigated the maternal effects of distending the uterine cavity with Hartmann's solution in 2nd trimester equivalent pregnant sheep. In 7 pregnant ewes, double endoscopic cannulation of the amniotic cavity was performed under general anesthesia, and 1 liter of Hartmann's solution at 38 degrees C, radiolabeled with 99mTc-red blood cells, was infused. Maternal central venous pressure, hematocrit, serum and amniotic fluid osmolarity, and amniotic fluid volume were measured at nine time points within a 2-hour period. Over this time interval, no significant fluid shift to the maternal compartment was observed. We detected no adsorption of radioactivity to the fetus or membranes, and no diffusion of radioactivity to maternal or fetal tissues was noticed. We conclude from these experiments that following double cannulation and intra-amniotic infusion of Hartmann's solution into the 2nd-trimester pregnant ovine uterus, no significant shift of fluid to the maternal compartment was observed over a 2-hour time period.

Prenatal diagnosis in Belgium

Prenatal diagnoses (PND) in Belgium are performed exclusively in licensed centres of medical genetics linked to university hospitals. These centres of genetics provide comprehensive genetic services which include, in addition to genetic tests, genetic counselling and moral support. These services are accessible to all residents in Belgium through coverage by the social security. PND has become a widely accepted procedure by the public and the health professionals, and has achieved significant prevention of birth defects, mainly chromosome abnormalities. The main problems involved in PND in Belgium are (1) the lack of regulations about indications for PND and (2) insufficient education in medical genetics in medical schools. It is hoped that the basic organisation of PND in Belgium will prevail in the future, with the proposed improvements.

Underwater Nd:YAG laser coagulation of blood vessels in a rat model

Endoscopic coagulation of placental and umbilical cord vessels has been suggested as a treatment for selected cases of twin-twin transfusion syndrome and of acardiac twin. The feasibility, safety and hemostatic effect of neodymium:yttrium-aluminium-garnet (Nd:YAG) laser in an underwater environment were experimentally studied in an in vivo model, mimicking the in utero situation and fetoplacental vessels. In 10 male Wistar rats, immersed in normal saline at 38 degrees C, femoral vessels, carotid artery, abdominal aorta and vena cava were coagulated under endoscopic control. A 100-Watt Nd:YAG laser was used in continuous mode with a 600-micron fiber. Outcome measurements were vascular diameter, total energy (joules) used to obtain visual coagulation and subsequent vascular obliteration. Overall failure rate was 32% and perforation of the vessel occurred in 7.7% of cases.

Endoscopic In Utero Tracheal Plugging in the Fetal Lamb to Treat Congenital Diaphragmatic Hernia

A case control surgical trial was performed in 13 time-dated pregnant ewes to evaluate the feasibility and pulmonary effects of intratracheal obstruction by an endoscopically positioned balloon. Fifteen fetuses were subjected to tracheoscopic balloon obstruction for progressively longer periods (range 2-18 days). In case of multiple pregnancies, 10 other fetuses were used as negative controls. A 1.2-mm miniscope with a double-lumen sheath and a detachable balloon were used. Feasibility of the technique was assessed in all animals based on operating time, intraoperative complications, and tracheal obstruction. Pulmonary effects were assessed by lung-to-body weight ratio (LBWR) and morphometric terminal brachial density (MTBD). In 14 animals the trachea was successfully obstructed until delivery. Tracheoscopic manipulation time ranged from 3 to 14 minutes. One intraoperative death occurred, but the contralateral control fetus also died during the procedure. When obstruction lasted for more than 7 days, the mean LBWR was 0.060 &plusmn; 0.01 (range 0.051-0.075) and in controls 0.031 &plusmn; 0.01 (range 0.017-0.039, p <0.0005). The MTBD was 0.65 &plusmn; 0.59, compared with 1.30 &plusmn; 0.80 for controls. Using a simple and fast technique of fetoscopic tracheoscopy, the trachea can be obstructed, leading to pulmonary hyperplasia, which is of potential value when treating congenital diaphragmatic hernia.

Fetoscopic Nd:YAG Laser Coagulation for Twin-Twin Transfusion Syndrome in Cases of Anterior Placenta

Laser coagulation of anastomosing placental chorionic plate vessels was suggested as a treatment of severe twin-twin transfusion syndrome in midtrimester. An anteriorly located placenta may hamper access and visualization of the vessels involved. We treated six women with completely anterior placenta at 18 to 22 weeks' gestation. Through a 2- to 3-cm minilaparotomy the uterus was accessed after retraction of the viscera. A flexible cannula was inserted through the uterine fundus, and a 35-degree, 0.20-mm minifibroscope and 400-mm fiber were introduced. All vessels crossing the intertwining membrane were coagulated in a continuous mode and a maximum output of 45 W. All fetuses survived the operation. One fetus died in utero 6 weeks postoperatively from cardiac failure, and its receptor twin was born alive. All other pregnancies are either continuing, or the women delivered two healthy babies. Thus far, total fetal survival is 91.6%, compared with results with posterior-sided placentas. Neodymium:yttrium-aluminum-garnet laser coagulation is also possible in case of anterior placenta, but requires a minimal maternal incision and general anesthesia to allow safe cannula placement. A bent scope allows for a larger placental surface to be treated.

The effect of open and endoscopic fetal surgery on uteroplacental oxygen delivery in the sheep

Open fetal surgery predictably results in postoperative uterine contractions and often in premature labor, but its intraoperative effects on the uterus are not known. In 10 pregnant ewes (108 to 115 days' gestation), uterine artery flow, uterine venous oxygen saturation, arterial saturation, and uterine electromyography were recorded simultaneously (control). Six ewes underwent a stapled hysterotomy, and four underwent placement of three endoscopic surgery cannulas and amnioinfusion. Uterine contractions were present 52% of the time (range, 34% to 72%), and there was no significant difference between control, hysterotomy, and endoscopic access. Uterine artery blood flow and uteroplacental oxygen delivery at rest decreased (to 73% of control) after hysterotomy (P < .05), but not after endoscopy. Fetal + uteroplacental oxygen consumption did not differ significantly between the groups. In conclusion, (1) uteroplacental oxygen delivery after hysterotomy alone decreased to levels critical for adequate fetal oxygenation; (2) endoscopy did not alter uteroplacental oxygen delivery; and (3) during open fetal surgery, further oxygen demand/delivery mismatch is likely, by traction on uterine and umbilical vessels and fetal stress.

Caffeine counteracts the ergogenic action of muscle creatine loading

This study aimed to compare the effects of oral creatine (Cr) supplementation with creatine supplementation in combination with caffeine (Cr+C) on muscle phosphocreatine (PCr) level and performance in healthy male volunteers (n = 9). Before and after 6 days of placebo, Cr (0.5 g x kg-1 x day-1), or Cr (0.5 g x kg-1 x day-1) + C (5 mg x kg-1 x day-1) supplementation, 31P-nuclear magnetic resonance spectroscopy of the gastrocnemius muscle and a maximal intermittent exercise fatigue test of the knee extensors on an isokinetic dynamometer were performed. The exercise consisted of three consecutive maximal isometric contractions and three interval series of 90, 80, and 50 maximal voluntary contractions performed with a rest interval of 2 min between the series. Muscle ATP concentration remained constant over the three experimental conditions. Cr and Cr+C increased (P < 0.05) muscle PCr concentration by 4-6%. Dynamic torque production, however, was increased by 10-23% (P < 0.05) by Cr but was not changed by Cr+C. Torque improvement during Cr was most prominent immediately after the 2-min rest between the exercise bouts. The data show that Cr supplementation elevates muscle PCr concentration and markedly improves performance during intense intermittent exercise. This ergogenic effect, however, is completely eliminated by caffeine intake.

Significance of insulin for glucose metabolism in skeletal muscle during contractions

Glucose uptake rate in active skeletal muscles is markedly increased during exercise. This increase reflects a multifactorial process involving both local and systemic mechanisms that cooperate to stimulate glucose extraction and glucose delivery to the muscle cells. Increased glucose extraction is effected primarily via mechanisms exerted within the muscle cell related to the contractile activity per se. Yet contractions become a more potent stimulus of muscle glucose uptake as the plasma insulin level is increased. In addition, enhanced glucose delivery to muscle, which during exercise is essentially effected via increased blood flow, significantly contributes to stimulate glucose uptake. Again, however, increased glucose delivery appears to be a more potent stimulus of muscle glucose uptake as the circulating insulin level is increased. Furthermore, contractions and elevated flow prove to be additive stimuli of muscle glucose uptake at any plasma insulin level. In conclusion, the extent to which muscle glucose uptake is stimulated during exercise depends on various factors, including 1) the intensity of the contractile activity, 2) the magnitude of the exercise-associated increase in muscle blood flow, and 3) the circulating insulin level.

No effect of glycogen level on glycogen metabolism during high intensity exercise

This study examined the effect of glycogen supercompensation on glycogen breakdown, muscle and blood lactate accumulation, blood-pH, and performance during short-term high-intensity exercise. Young healthy volunteers performed two supramaximal (125% of VO2max) exercise tests on a bicycle ergometer, either for 1 min 45 s (protocol 1; N = 18) or to exhaustion (protocol 2; N = 14). The exercise tests were preceded by either 5 d on a controlled normal (N) diet, or by 2 d of glycogen-depleting exercise accompanied by the normal diet followed by 3 d on a carbohydrate-rich (CHR) diet. In protocol 1, preexercise muscle glycogen concentrations were 364 +/- 23 and 568 +/- 35 mumol.g-1 d.w. in the N and CHR condition, respectively (P < 0.05). During the exertion, glycogen concentration in the M. quadriceps decreased to the same extent in both groups. Accordingly, the exercise-induced increases in muscle and blood-lactate, and the fall in blood-pH were similar during N and CHR. In protocol 2, time to exhaustion was identical for N and CHR. It is concluded that during short-term intense exercise during which muscle glycogen availability exceeds glycogen demand, rate of glycogen breakdown, lactate accumulation, and performance are regulated irrespective of the preexercise muscle glycogen level.

Apparently new "anophthalmia-plus" syndrome in sibs

The index patient of this report is a 17-week-gestation female fetus with bilateral anophthalmia, bilateral cleft lip/cleft palate, macrotia with bilateral lateral facial cleft, large open sacral neural tube defect, and uterus unicornis. Parents were normal and nonconsanguineous with an unremarkable family history. Their first child, a 4-year-old boy, is normal. The second child, a 2 1/2-year-old boy, has bilateral anophthalmia and an abnormal left ear with absent lobule as the sole additional anomaly. These 2 sibs seem to be the first examples of a new "anophthalmia-plus" syndrome apparently inherited as autosomal-recessive.

Intrauterine endoscopic creation of urinary tract obstruction in the fetal lamb: a model for fetal surgery

OBJECTIVE

Our purpose was to evaluate the feasibility of intrauterine endoscopic fetal surgery in a fetal lamb model by creating a urinary tract obstruction.

STUDY DESIGN

Lower urinary tract obstruction was created by ligation of the urethra and urachus in 21 fetal lambs, eight at 95 to 105 days' gestation (term 145 days) and 13 at 70 to 75 days. The endoscopic approach consisted of a 0-degree 5 mm telescope, three 5 mm cannulas, uterine distention by amnioinfusion, and adapted instrumentation. Intrauterine fetal monitoring included temperature and pulse oximetry registration.

RESULTS

In 20 cases the urachus could be identified and ligated inside the umbilical cord. The urethra was ligated in the anterior abdominal wall (n = 7) or obstructed at the level of the penis (n = 13). Mean fetal heart rate was 147 +/- 35 beats/min, and fetal temperature at the end of intervention was 38.14 degrees +/- 2.1 degrees C. The overall postoperative survival rate was 76%.

CONCLUSION

Urinary tract obstruction can be created endoscopically in the fetal lamb. This operation can serve as a model for endoscopic fetal surgery.

Important role of insulin and flow in stimulating glucose uptake in contracting skeletal muscle

The relative role of contractions, insulin, and increased supply of glucose and insulin, via an increase in blood flow, in stimulating glucose uptake in skeletal muscle during contractions was studied in isolated perfused rat hindlimbs. Hindlimbs were perfused with a standard perfusate medium containing 6 mmol/l glucose and four different insulin concentrations (0, 100, 500, and 20,000 microU/ml). Contractions were induced by supramaximal intermittent electrical stimulation of the sciatic nerve. Three different perfusion protocols were used: 1) muscles were stimulated to contract without concomitantly increasing perfusate flow; 2) flow was increased in the absence of electrical stimulation; and 3) muscles were stimulated to contract together with a flow increase. Both contractions and increased flow of perfusate, applied as separate stimuli, increased (P < 0.05) glucose uptake in the absence of insulin. Yet when submaximal insulin concentrations were added to the perfusate, the stimulatory action of both contractions and increased blood flow on muscle glucose uptake was augmented. The higher the submaximal insulin concentration, the greater the increment (P < 0.05). This effect, however, faded at supramaximal insulin concentration. Electrical stimulation associated with an increase in perfusion flow rate produced a greater (P < 0.05) rise in glucose uptake than did contractions alone. In fact, stimulation of muscle glucose uptake by contractions and increased flow proved to be additive at any insulin concentration. We conclude that contractions and increased blood flow act as additional stimuli to muscle glucose uptake at any insulin concentration.(ABSTRACT TRUNCATED AT 250 WORDS)

Infrared fetoscopy in the sheep

The strong light sources used in fetoscopy and embryoscopy may cause eye injuries to the fetus. To circumvent this potential hazard, we have successfully used an infrared light source and infrared video camera to perform 'night vision' fetoscopy in a fetal lamb model.

A model for fetal surgery through intrauterine endoscopy

Video-endoscopic technology may offer new hope for the future of fetal surgery. Ten time-dated pregnant ewes (95 to 105 days; term, 145 days) were used to develop a model of fetal surgery through intrauterine endoscopy. Special 5-mm ports were designed with short, flexible, balloon-tipped shafts. The cannulas were inserted through purse-stringed hysterostomies. Amnioinfusion of warmed physiological fluid (Hartmann) was used as the work medium. Fetal heart rate and oxygen saturation (pulse oximetry), temperature, and amniotic pressure were monitored continuously through endoscopically placed sensors. Surgical procedures included subcutaneous dissection of the abdominal wall and ligation of the urethra in the male fetus (n = 7), ligation of the urachus within the umbilical cord (n = 8), and endoscopy of the fetal esophagus and trachea (n = 6). Bloodless surgery was achieved with a novel coagulation device that allows bipolar cutting and coagulation in an electrolyte-rich fluid medium. The mean fetal operative time was 147 minutes (range, 130 to 195). The intraamniotic temperature was maintained between 38.0 +/- 0.9 degrees C and 41.7 +/- 1.7 degrees C throughout the procedure. Oxygen saturation ranged from 51 +/- 20% to 72 +/- 14%, and fetal heart rate from 120 to 140 beats per minute. In conclusion, intrauterine endoscopy in a fluid medium allows fully monitored surgical procedures, lasting more than 2 hours, to be performed on the fetal lamb.

Prenatal ultrasound diagnosis of rhizomelic chondrodysplasia punctata in a primigravida

Rhizomelic chondrodysplasia punctata (RCDP) is a sublethal autosomal recessive disorder characterized by skeletal dysplasia, microcephaly, mental retardation, congenital cataracts, joint contractures, skin changes, and failure to thrive. Prenatal ultrasound diagnosis has been reported during the second trimester of pregnancy. Prenatal diagnosis is also possible from the first trimester onwards by demonstration of peroxisomal dysfunction in cultured chorionic villous or amniotic fluid cells. In all cases reported hitherto, the prenatal diagnosis was established after the birth of a previous affected child. In contrast to these studies in pregnant multiparous women at risk for RCDP, we report on the first case of prenatal ultrasound diagnosis of RCDP at 19 weeks' gestation in a primigravida. In addition, a complex cardiac malformation associated with hypoplasia of the thymus (DiGeorge anomaly) is described.

Fetoscopy-guided fetal endoscopy in a sheep model

Video-endoscopic surgical treatment of the fetus may, in the future, become an alternative to open fetal operation. Six 95-day-old fetal lambs were examined through intrauterine endoscopy using amnioinfusion and specially designed balloon-tipped cannulas. The fetuses were monitored endoscopically for oxygen saturation, heart rate and temperature throughout the procedure. With a rigid 5 millimeter telescope and a flexible 3 millimeter endoscope, the respiratory and upper gastrointestinal tracts could be examined. No mucosal or other trauma was noted upon completion of the endoscopy; all lambs survived the procedure. While the applications of fetal endosurgery are likely to be similar to those of open fetal operation, fetal endoscopy (looking in the fetus) is a new entity for which clinical relevance (rather than mere feasibility) remains to be demonstrated. This technique, however, could become a valuable research tool to study fetal gastrointestinal and pulmonary physiologic factors in situ.

Hereditary renal adysplasia: new observations and hypotheses

Renal agenesis and dysplasia are frequently regarded by pathologists, even pediatric pathologists, as sporadic malformations. We report six fetal autopsy cases of hereditary renal adysplasia (HRA): two pairs of siblings, one case with paternal unilateral renal agenesis, and one case with an autosomal balanced 6p/19q translocation. The main purpose of this paper is to emphasize that nonsyndromal renal agenesis and dysplasia are pathogenetically related and often inherited as an autosomal dominant trait with incomplete penetrance and variable expression. A subsidiary purpose is to present a case of bilateral multicystic dysplasia with a balanced 6p/19q translocation. This observation further supports the assignment of one of the loci for HRA to chromosome 6p.