Lipoprotein glomerulopathy: a rare cause of steroid-resistant nephrotic syndrome in a child

Lipoprotein glomerulopathy (LPG) is a rare condition of renal lipidosis characterized by lipoprotein thrombi in glomeruli, an abnormal plasma lipoprotein profile, and a marked increase in serum apolipoprotein E (apo E) levels. It is a monogenic disorder with autosomal dominant inheritance and the average age of presentation is 32 years (4-69 years). It is rare in children. The presentation can be nephrotic syndrome, hematuria, or progressive renal failure. Here we report the first described case of LPG in an Indian 7.5-year-old boy who presented with steroid-resistant nephrotic syndrome with normal renal function. A renal biopsy was suggestive of lipoprotein glomerulopathy. The detection of a pathogenic variant in apo E, Kyoto type, by exome sequencing, confirmed the diagnosis of lipoprotein glomerulopathy. Complete response was achieved with Angiotensin-converting Enzyme inhibitor and fenofibrates.

Structural Changes in Silicon Rubber Peritoneal Dialysis Catheters in Patients using Mupirocin at the Exit Site

Structural damage to polyurethane PD (peritoneal dialysis) catheters in patients using mupirocin ointment is widely appreciated, but damage to silicon rubber PD catheters is less well described. Ten catheters (6.6%) out of 152 were found to have structural alterations such as opacification, ballooning, thinning, and rupture. The duration of PD in these 10 patients ranged from 23 months to 80 months (mean duration 51.1 months). The frequency of mupirocin application varied from daily (2 cases) to 2-3 times per week (7 cases). In eight catheters opacification occurred at the exit site whereas one catheter showed opacification midway between the exit site and the titanium adaptor. One catheter showed opacification, ballooning, and thinning at the exit site ruptured in the form of two slit-like openings. In conclusion, various structural changes such as opacification, ballooning or thinning were seen in 6.6% of silicon rubber PD catheters in patients using mupirocin at the exit site. Although the mechanism remains elusive, mupirocin or the antiseptic solution alone or in combination may be contributory. We believe that this is an under-reported complication and encourage other health care givers to incorporate a search for such changes during clinic visits.

RMS Pictorial Scale (RMS-PS): an innovative scale for the assessment of child's dental anxiety

BACKGROUND

Dental anxiety assessment for young children is as important as performing their treatment. Appropriate knowledge of patient's anxiety boosts confidence and will help us to review potential management options specific to every child.

AIM

This study aimed to validate (RMS) Pictorial Scale (RMS-PS) and to compare it with Venham Picture Test (VPT) and Facial image scale (FIS) in measuring dental anxiety for young children during their first dental visit.

MATERIALS AND METHODS

A total of 102 healthy children aged between 4 and 14 years during their first dental visit were randomly selected for the study. Childs anxiety level was measured using three different scales namely (i) RMS-PS (ii) VPT, and (iii) FIS.

STATISTICAL ANALYSIS

Student t test was used to compare the scores obtained from all the three scales. Pearson correlation test was used to obtain correlation among the scales used in the study.

RESULTS

A strong correlation (0·76) was found between the VPT and RMS-PS, and a moderate correlation (0.5) was found between RMS-PS and FIS, indicating good validity for the RMS-PS.

CONCLUSIONS

The findings of this study suggest that the RMS-PS can be a newer and easiest means for the assessment of dental anxiety for young children in a clinical context.

Methionine down-regulates TLR4/MyD88/NF-κB signalling in osteoclast precursors to reduce bone loss during osteoporosis

BACKGROUND AND PURPOSE

Studies have demonstrated that a moderate intake of amino acids is associated with development of bone health. Methionine, a sulphur-containing essential amino acid, has been largely implicated for improving cartilage formation, however its physiological significance on bone integrity and functionality have not been elucidated. We investigated whether methionine can prevent osteoporotic bone loss.

EXPERIMENTAL APPROACH

The anti-resorptive effect of methionine, (250 mg kg(-1) body wt administered in drinking water for 10 weeks), was evaluated in ovariectomized (OVX) rats by monitoring changes in bone turnover, formation of osteoclasts from blood-derived mononuclear cells and changes in the synthesis of pro-osteoclastogenic cytokines.

KEY RESULTS

Methionine improved bone density and significantly decreased the degree of osteoclast development from blood mononuclear cells in OVX rats, as indicated by decreased production of osteoclast markers tartarate resistant acid phosphatase b (TRAP5b) and MIP-1α. siRNA-mediated knockdown of myeloid differentiation primary response 88 [MyD88], a signalling molecule in the toll-like receptor (TLR) signalling cascade, abolished the synthesis of both TRAP5b and MIP-1α in developing osteoclasts. Methionine supplementation disrupted osteoclast development by inhibiting TLR-4/MyD88/NF-κB pathway.

CONCLUSIONS AND IMPLICATIONS

TLR-4/MyD88/NF-κB signalling pathway is integral for osteoclast development and this is down-regulated in osteoporotic system on methionine treatment. Methionine treatment could be beneficial for the treatment of postmenopausal osteoporosis.

Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix: a multicenter, randomized, double-blind, placebo-controlled trial

OBJECTIVES

Women with a sonographic short cervix in the mid-trimester are at increased risk for preterm delivery. This study was undertaken to determine the efficacy and safety of using micronized vaginal progesterone gel to reduce the risk of preterm birth and associated neonatal complications in women with a sonographic short cervix.

METHODS

This was a multicenter, randomized, double-blind, placebo-controlled trial that enrolled asymptomatic women with a singleton pregnancy and a sonographic short cervix (10-20 mm) at 19 + 0 to 23 + 6 weeks of gestation. Women were allocated randomly to receive vaginal progesterone gel or placebo daily starting from 20 to 23 + 6 weeks until 36 + 6 weeks, rupture of membranes or delivery, whichever occurred first. Randomization sequence was stratified by center and history of a previous preterm birth. The primary endpoint was preterm birth before 33 weeks of gestation. Analysis was by intention to treat.

RESULTS

Of 465 women randomized, seven were lost to follow-up and 458 (vaginal progesterone gel, n=235; placebo, n=223) were included in the analysis. Women allocated to receive vaginal progesterone had a lower rate of preterm birth before 33 weeks than did those allocated to placebo (8.9% (n=21) vs 16.1% (n=36); relative risk (RR), 0.55; 95% CI, 0.33-0.92; P=0.02). The effect remained significant after adjustment for covariables (adjusted RR, 0.52; 95% CI, 0.31-0.91; P=0.02). Vaginal progesterone was also associated with a significant reduction in the rate of preterm birth before 28 weeks (5.1% vs 10.3%; RR, 0.50; 95% CI, 0.25-0.97; P=0.04) and 35 weeks (14.5% vs 23.3%; RR, 0.62; 95% CI, 0.42-0.92; P=0.02), respiratory distress syndrome (3.0% vs 7.6%; RR, 0.39; 95% CI, 0.17-0.92; P=0.03), any neonatal morbidity or mortality event (7.7% vs 13.5%; RR, 0.57; 95% CI, 0.33-0.99; P=0.04) and birth weight < 1500 g (6.4% (15/234) vs 13.6% (30/220); RR, 0.47; 95% CI, 0.26-0.85; P=0.01). There were no differences in the incidence of treatment-related adverse events between the groups.

CONCLUSIONS

The administration of vaginal progesterone gel to women with a sonographic short cervix in the mid-trimester is associated with a 45% reduction in the rate of preterm birth before 33 weeks of gestation and with improved neonatal outcome.

The Effect of Transdermal Nitroglycerine on Intrathecal Fentanyl with Bupivacaine for Postoperative Analgesia following Gynaecological Surgery

Fentanyl is a short-acting synthetic opioid with spinal analgesic properties and dose-dependent side-effects. The analgesic effect of opioids is mediated in part through activation of inhibitory descending pain pathways involving nitric oxide (as a central neurotransmitter) through the NO-cGMP system. This NO-cGMP pathway plays an important role in spinal nociception. The aim of the study was to evaluate the effect of transdermal nitroglycerine on the analgesic action of intrathecal fentanyl in patients undergoing abdominal hysterectomy. Patients (n=120) were randomised into one of four groups. All received 3 ml bupivacaine 0.5% plus 0.5 ml of an intrathecal test drug. Twenty minutes after lumbar puncture, a transdermal patch of either nitroglycerine or placebo was applied. Group B received spinal bupivacaine plus saline 0.5 ml and a placebo patch. Group B-N received bupivacaine plus saline 0.5 ml and a nitroglycerine patch. Group F received bupivacaine plus fentanyl 25 μg and a placebo patch. Group F-N received bupivacaine plus fentanyl 25 μg and a nitroglycerine patch. The duration of effective analgesia was longer in group FN (363.53±34.09 min) compared from the other groups (P <0.001). The times to two-segment regression in group F-N and group F were 132.87±31.2 min and 126.40±26.81 min respectively. The visual analog scale pain score at the time of the first rescue analgesic was similar in all groups. We conclude that nitroglycerine does not result in postoperative analgesia but enhances the analgesic effect of intrathecal fentanyl.

Progesterone vaginal gel for the reduction of recurrent preterm birth: primary results from a randomized, double-blind, placebo-controlled trial

OBJECTIVE

Preterm birth is the leading cause of perinatal morbidity and mortality worldwide. Treatment of preterm labor with tocolysis has not been successful in improving infant outcome. The administration of progesterone and related compounds has been proposed as a strategy to prevent preterm birth. The objective of this trial was to determine whether prophylactic administration of vaginal progesterone reduces the risk of preterm birth in women with a history of spontaneous preterm birth.

METHODS

This randomized, double-blind, placebo- controlled, multinational trial enrolled and randomized 659 pregnant women with a history of spontaneous preterm birth. Between 18 + 0 and 22 + 6 weeks of gestation, patients were assigned randomly to once-daily treatment with either progesterone vaginal gel or placebo until either delivery, 37 weeks' gestation or development of preterm rupture of membranes. The primary outcome was preterm birth at </= 32 weeks of gestation. The trial was analyzed using an intent-to-treat strategy.

RESULTS

Baseline characteristics were similar in the two treatment groups. Progesterone did not decrease the frequency of preterm birth at </= 32 weeks. There was no difference between the groups with respect to the mean gestational age at delivery, infant morbidity or mortality or other maternal or neonatal outcome measures. Adverse events during the course of treatment were similar for the two groups.

CONCLUSION

Prophylactic treatment with vaginal progesterone did not reduce the frequency of recurrent preterm birth (</= 32 weeks) in women with a history of spontaneous preterm birth. The effect of progesterone administration in patients at high risk for preterm delivery as determined by methods other than history alone (e.g. sonographic cervical length) requires further investigation.

Vaginal progesterone is associated with a decrease in risk for early preterm birth and improved neonatal outcome in women with a short cervix: a secondary analysis from a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To investigate the efficacy of vaginal progesterone to prevent early preterm birth in women with sonographic evidence of a short cervical length in the midtrimester.

METHODS

This was a planned, but modified, secondary analysis of our multinational, multicenter, randomized, placebo-controlled trial, in which women were randomized between 18 + 0 and 22 + 6 weeks of gestation to receive daily treatment with 90 mg of vaginal progesterone gel or placebo. Cervical length was measured with transvaginal ultrasound at enrollment and at 28 weeks of gestation. Treatment continued until either delivery, 37 weeks of gestation or development of preterm rupture of membranes. Maternal and neonatal outcomes were evaluated for the subset of all randomized women with cervical length < 28 mm at enrollment. The primary outcome was preterm birth at </= 32 weeks.

RESULTS

A cervical length < 28 mm was identified in 46 randomized women: 19 of 313 who received progesterone and 27 of 307 who received the placebo. Baseline characteristics of the two groups were similar. In women with a cervical length < 28 mm, the rate of preterm birth at </= 32 weeks was significantly lower for those receiving progesterone than it was for those receiving the placebo (0% vs. 29.6%, P = 0.014). With progesterone, there were fewer admissions into the neonatal intensive care unit (NICU; 15.8% vs. 51.9%, P = 0.016) and shorter NICU stays (1.1 vs. 16.5 days, P = 0.013). There was also a trend toward a decreased rate of neonatal respiratory distress syndrome (5.3% vs. 29.6%, P = 0.060).

CONCLUSION

Vaginal progesterone may reduce the rate of early preterm birth and improve neonatal outcome in women with a short sonographic cervical length.

Role of diltiazem in pregnant women with chronic renal disease

OBJECTIVE

To determine whether diltiazem therapy decreases proteinuria during pregnancy in women with chronic renal disease, resulting in decreased risk of pre-eclampsia, preterm delivery and intrauterine fetal growth restriction.

METHODS

We undertook retrospective data collection by chart review of pregnant women with chronic renal disease. Women treated with and without diltiazem were compared by independent t test analysis.

RESULTS

Seven women were eligible for inclusion in the study. Individual patient trends revealed decreased or attenuated increase in proteinuria across gestation with diltiazem therapy. Mean arterial pressure was also decreased in the therapy group compared to increased pressure in the third trimester in the group with no therapy. The incidence of fetal growth restriction and need for labor induction were lower in the diltiazem-treated group.

CONCLUSIONS

Diltiazem, a non-dihydropyridine calcium channel antagonist, decreases proteinuria and preserves renal structure and function and should be considered an alternative to angiotensin converting enzyme inhibitors in pregnancy in women with chronic renal disease.

Apoptosis associated with esophageal adenocarcinoma: influence of photodynamic therapy

Tumor cell death in vitro by photodynamic therapy (PDT) has been related to the induction of apoptosis. We measured and compared changes in apoptosis and caspase 3 activity, an effector of apoptosis, in normal and neoplastic esophageal tissues during PDT. Apoptosis index, caspase 3 cleavage activity, pro-caspase 3, p53, and bcl-2 levels were measured in normal and neoplastic tissues of patients with esophageal adenocarcinoma before, during, and after PDT with Photofrin. The apoptotic index was greater in carcinoma tissue compared to adjacent normal tissues. In concert, pro-caspase 3 immunoreactivity was absent and caspase 3-like cleavage activity was over 30-fold greater in carcinoma tissue compared to normal esophageal tissues. These parameters were unaffected by PDT. Variable changes in bcl-2 and p53 immunoreactivity were noted in normal and carcinoma tissues during PDT. Greater levels of apoptosis and caspase 3 activity are hallmarks of esophageal adenocarcinoma compared to normal esophageal tissue. These differences were unaffected by PDT. This may be due to the fact that tissues were obtained 72 h post-PDT therapy. Changes in these parameters may have occurred early after PDT therapy. An assessment of apoptosis and caspase 3 activity prior to 72 h post-PDT may provide further insight into the mechanism involved, although no sustained effects on these parameters by PDT were noted.

Three-dimensional ultrasonographic technology to assess and compare echodensity of fetal bowel, bone, and liver in the second trimester of pregnancy

Increased fetal bowel echogenicity in the second trimester is used as a marker for prenatal diagnosis of Down syndrome. The diagnosis of hyperechogenicity is subjective. We sought to quantify and correlate fetal bowel echogenicity with liver and bone in 47 normal fetuses, using three-dimensional ultrasonographic technique and objective measurement of gray scale distribution. No significant change was found in the organs' echogenicity between 15 and 24 weeks of gestation, the optimal time for detection of fetal chromosomal anomalies. A wide variability in bowel density was noted within the normal group, which could explain its poor sensitivity for the detection of Down syndrome. Bowel echodensity correlates better with liver density than with bone density. Thus, comparison of bowel to liver echogenicity, even with two-dimensional sonography, may prove to be a more effective clinical tool in the evaluation of fetal intra-abdominal echodensities.

Gestational diabetes mellitus: controversies and current opinions

The past few years have seen significant controversy over the diagnosis and management of gestational diabetes and its influence on perinatal outcomes. The debate over who to screen and how to screen continues to rage. Even when a diagnosis has been made, there is a lack of consensus regarding appropriate management protocols and glycemic targets. In this review, we will examine many of the controversial areas in gestational diabetes, using contemporary data to discuss these issues.

Dietary myo-inositol therapy in hyperglycemia-induced embryopathy

Dysmorphogenesis in diabetic mothers occurs more frequently than in the general population. This phenomenon is believed to be caused by the teratogenic effects of metabolic fuel mixtures with associated membrane injury and aberrations in the biochemical constituents. The present experiment was designed to determine: 1) if hyperglycemia-induced membrane injury is associated with intracellular and/or extracellular lipid disturbances; 2) if supplemental myo-inositol therapy prevents hyperglycemia-induced embryopathy; 3) if a correlation exists between dietary myo-inositol, serum and tissue levels of myo-inositol, and conceptus development; and 4) the cellular content of arachidonic acid following myo-inositol supplementation. Sixty-five female Sprague-Dawley rats were mated, and divided into three groups. One group was nondiabetic normal controls, and two groups had diabetes experimentally induced with streptozotocin. Of the diabetic groups, one received a normal diet, while the other received a myo-inositol-supplemented diet during the period of organogenesis. Blood samples were collected on days 0 and 12 of pregnancy. Embryos and yolk sacs were analyzed for myo-inositol and arachidonic acid levels, using mass spectrochromatography. Dietary myo-inositol supplementation of diabetic mothers resulted in a significant decrease in the incidence of neural tube defects when compared with diabetics not receiving supplements (9.5 vs. 20.4%; P < 0.05). This protective effect was incomplete, based on the incidence observed in the nondiabetic controls (9.5 vs. 3.8%; P < 0.05). The myo-inositol embryonic tissue levels in the diabetic group which had been fed a regular diet without supplementation were significantly lower than in the nondiabetic group. Dietary therapy successfully restored myo-inositol levels in the yolk sacs, as suggested by similar tissue levels in diabetics receiving myo-inositol supplementation and normal controls (18.7 +/- 1.3 vs. 19.1 +/- 2.0 ng/mg; P = ns). Dietary therapy, however, failed to restore myo-inositol levels in the embryos, suggesting hyperglycemia-induced faulty transport of nutrients from the yolk sac to the embryo. No correlation was noted between maternal blood levels of myo-inositol, with or without supplementation, and the clinical outcome. Tissue arachidonic acid levels were markedly reduced in the conceptuses of diabetic mothers with (0.4 +/- 0.1 micrograms/mg) or without (0.25 +/- 0.08 micrograms/mg) myo-inositol supplementation when compared to the nondiabetic controls (3.33 +/- 0.24 micrograms/mg). These data demonstrate that diabetes-induced embryopathy is associated with a deficiency state in both myo-inositol and arachidonic acid. The myo-inositol deficiency is not demonstrated at the serum level, but rather at the tissue level, suggesting a paracrine action. Dietary supplementation of myo-inositol is associated with an increase in tissue myo-inositol levels and a decrease in malformations. This therapy holds promise for use as a dietary prophylaxis against diabetic embryopathy.

The clinical usefulness of routine stacked multiplanar reconstruction in helical abdominal computed tomography

RATIONALE AND OBJECTIVES

The authors evaluate the usefulness of stacked multiplanar reconstructions in routine, thick-section abdominal computed tomography.

MATERIALS AND METHODS

Twenty-five routine, thick-section contrast abdominal CTs performed with equivalent technique were reformatted by multiplanar reconstructions in sagittal and coronal planes sequentially from side-to-side and front-to-back. The image sets were submitted, first axial images only followed by axial plus multiplanar reconstructions (MPRs), to 5 separate physician readers including 2 radiologists and 3 nonradiologists. These readers graded the visualization of a variety of normal and up to 5 pathologic lesions per patient on a scale of 1 to 5 (5 = best).

RESULTS

The addition of sagittal and coronal multiplanar reconstructions significantly improved the visualization of all normal anatomic structures (mean axial only, 3.8; mean axial plus MPR, 4.1; P < 0.0001). In addition, most pathologic lesions were statistically better visualized with the addition of multiplanar reconstructions (mean axial images only, 3.9; mean axial plus MPR, 4.1; P < 0.0001). All five readers found improved visualization in nearly every category with the addition of the multiplanar reconstructions. However, in only 7% of cases, did a reviewer find new diagnostic information with the addition of MPR images.

CONCLUSIONS

Stacked multiplanar reconstructions of routine, thick-section abdominal CT has clinical value in both the display of normal anatomic and pathologic lesions. Further studies, however, are required to confirm these findings before it is commonly used.

Prenatal diagnosis of the 22q11 deletion syndrome

A 27 weeks gestation fetus, evaluated because of polyhydramnios, was found by echocardiography to have an interrupted aortic arch type B. Because of the known association between this malformation and DiGeorge syndrome, an amniocentesis was performed. Fluorescence in situ hybridization revealed a 22q11 deletion. This is, to our knowledge, the first report of prenatal detection of a fetus with 22q11 deletion in the absence of a family history.

Dietary intake of myo-inositol and neural tube defects in offspring of diabetic rats

OBJECTIVE

Embryopathy in diabetic mothers occurs at a rate four to five times higher than that observed in the general population. The current investigation was undertaken to assess the use of dietary myo-inositol supplementation as a pharmacologic prophylaxis to obviate the teratogenic effects of hyperglycemia in an in vivo study.

STUDY DESIGN

Seventy Sprague-Dawley rats were mated and after conception were randomly divided into five groups: one group was nondiabetic normal controls and four groups had diabetes experimentally induced with streptozotocin. Of the diabetic groups, one received the usual diet, whereas the others received, respectively, 0.08, 0.16, and 0.5 mg/day supplemental myo-inositol orally.

RESULTS

With the myo-inositol supplementation (0.08 mg/day), the incidence of neural tube defects was significantly reduced from 20.4% to 9.5% (p < 0.01). The most effective dosage of myo-inositol was 0.08 mg/day. Increasing the dose of myo-inositol beyond that level did not significantly reduce the rate of neural tube defects. However, the resorption rate was increased to 29.8%.

CONCLUSION

These data demonstrate that myo-inositol supplementation reduces the incidence of diabetic embryopathy and may serve as a pharmacologic prophylaxis against diabetes-induced congenital malformations.

Evaluation of fetal and uterine hemodynamics during maternal cardiopulmonary bypass

BACKGROUND

About 4% of pregnant women have concomitant cardiac disease and a few of these do not respond to medical therapy and require surgical correction during pregnancy. We report a unique case describing fetal hemodynamics and uterine blood flow before, during, and after maternal cardiopulmonary bypass, and compare them to normal reference values in the second trimester.

CASE

A woman with severe aortic regurgitation underwent aortic valve replacement at 19 weeks' gestation. A nonpulsatile cardiac pump was used for cardiopulmonary bypass, maintaining the mean arterial pressure at 77-90 mmHg, with a peak flow rate of 3.5-4.0 L/minute/m2 and core temperature of 34-35C throughout surgery. Blood velocity waveforms were recorded by Doppler ultrasound at the level of maternal main uterine artery and fetal vessels. Pulsatility index (PI) values were calculated. Preoperatively, fetal hemodynamic characteristics were within normal limits. Preoperatively, uterine artery PI was 3.9 (normal 0.5-1.5 at 20 weeks). Intraoperatively, fetal bradycardia ensued after aortic clamping (120 to 75 beats per minute), with a rise in umbilical artery PI (1.7 to 7.1) and disappearance of diastolic flow. The middle cerebral artery PI decreased (2.0 to 0.92) and the PI increased in the descending aorta (2.22 to 3.55), inferior vena cava (2.7 to 9.3), and ductus venosus (0.6 to 1.7). During bypass, after aortic clamping, nonpulsatile uterine artery flow was noted. Postoperatively, the uterine artery PI improved, to 1.0. Two days later, hydrocephalus and hydrops were observed.

CONCLUSION

Despite high peak flow rates, normal mean arterial pressure, and normothermia, fetal outcome was dismal. Nonpulsatile cardiopulmonary bypass under normothermia may not be able to meet the demands of the fetoplacental circulation.

Endoscopic management of a bronchobiliary fistula

A bronchobiliary fistula is a rare entity that manifests as bilioptysis. We report a 73-year-old woman with a hepato-cellular carcinoma who developed a bronchobiliary fistula. Endoscopic biliary sphincterotomy and insertion of a prosthesis led to successful resolution of symptoms and restoration of normal bile flow. We review the pertinent literature and the basis for management.

Glucose monitoring and insulin therapy during pregnancy

Excellent blood glucose control is necessary to reduce the excess fetal morbidity and mortality associated with the diabetic pregnancy. This article outlines the roles of glucose monitoring and insulin therapy in intensive treatment regimens during gestation. The discussion includes recommended monitoring frequency, glycemic standards, types of insulin and mechanism of action, goals and timing of insulin therapy, as well as the complications of insulin therapy.

Early prenatal diagnosis of bladder exstrophy: case report and review of the literature

Exstrophy of the urinary bladder is a rare congenital malformation. The first case of sonographic diagnosis, prior to viability, of bladder exstrophy without associated anomalies is presented. The diagnosis before viability allowed the parents to receive counseling on prognosis as well as possible options. This case is unique in that the bladder anomaly was an isolated defect, not associated with any other structural anomaly. The literature on the subject is also reviewed.

Maternal serum levels of alpha-fetoprotein and fetal fibronectin as markers of labor in the third trimester

Unexplained elevations of maternal serum alpha-fetoprotein (MSAFP) in the second trimester have been found to be associated with a two- to fourfold increase in the rate of preterm delivery, but the sensitivity is low. Therefore, we reasoned that MSAFP levels in the third trimester could prove to be a more useful biochemical marker to predict labor. The presence of placental and membrane-derived fetal fibronectin (FFN) in cervicovaginal secretions has recently been shown to predict preterm delivery with a sensitivity of 81.7% and specificity of 82.5%. We postulated that damage to membranes and microscopic breakdown of fetomaternal blood barrier during labor might result in release of AFP or FFN into maternal serum. Maternal serum alpha fetoprotein and fetal fibronectin levels were measured prospectively in 29 patients in active labor at term and in 25 controls undergoing elective cesarean section. Neither MSAFP nor serum FFN levels were associated with labor at term. We did, however, note significantly higher MSAFP levels in mothers bearing male fetuses versus female fetuses (p < 0.01). Since the current literature supports a sex difference in the MSAFP levels in the second trimester, this does not appear to change as gestation advances. Further studies are needed to determine if, in addition to maternal weight and race, MSAFP levels should be also adjusted for fetal sex diagnosed on sonography.

Palliative therapy for carcinoma of the esophagus

Despite improvements in medical and surgical care, the prognosis of patients with cancer of the esophagus has remained poor. The majority of patients are candidates for palliative rather than curative therapy. Surgery probably provides the most effective palliation of dysphagia, but it is associated with a high morbidity, and many patients are not candidates for surgery because of underlying medical problems. There are several endoscopic modalities for palliation. The choice of therapy depends on the location of the tumor, the presence or absence of a tracheo-esophageal fistula, and the projected prognosis for the patient. Expandable stents will probably become the treatment of choice for the inoperable patient because of ease of insertion and relative safety. Nevertheless, other endoscopic techniques will be a useful complement prior to stent insertion in order to debulk the tumor. With adequate palliation, attention can be given to treatment that may serve to prolong survival. Future trials on radiation therapy and chemotherapy are necessary so that we can improve survival without sacrificing the patient's quality of life. On the horizon is the administration of chemotherapy through such vehicles as tumor-specific photosensitizing agents, or intratumoral injection of cytotoxic agents.

Abdominal lymphangioma masquerading as a pancreatic cystic neoplasm

Lymphangiomas are congenital abnormalities of the lymphatics that occur predominantly in the head and neck, most often in children. We present an unusual case of a middle-aged man who had a large septated cystic lesion adherent to the pancreas that could not be differentiated from a pancreatic cystic neoplasm despite analysis by ultrasound, computed tomography, magnetic resonance imaging, or percutaneous needle aspiration. The correct diagnosis was established only via laparotomy and subsequent pathologic interpretation. Although lymphangiomas are rare, they should be included in the differential diagnosis of pancreatic cystic neoplasms.

Raf-1 protein expression in human breast cancer cells

BACKGROUND

The Raf-1 kinase, a 72-kDa cytoplasmic serine-threonine kinase, plays a central role as a second messenger in signal transduction. After ligand binding to a variety of transmembrane tyrosine kinase growth factor receptors including epidermal growth factor (EGF) receptor, the 72-kDa kinase is activated through phosphorylation to a 74-kDa phosphoprotein. The Raf-1 kinase is constitutively activated in many transformed cells either directly, by mutations within its amino-terminus regulatory region, or indirectly, due to overstimulation by autocrine growth factors or activated proximal oncogenes. The role of Raf-1 kinase in breast cancer has not been studied.

METHODS

To investigate the role of Raf-1 kinase expression and its activation in breast cancer, we studied three human breast cancer cell lines expressing varying amounts of EGF receptor to determine the level of Raf-1 protein and the proportion expressed in the higher molecular weight form. Effects of serum starvation and stimulation with EGF on the Raf-1 protein were studied in T47D, BT474, and MDA-MB231 cells by precipitation of cell lysates with an anti-Raf-1 antibody followed by immunoblotting. [3H]Thymidine incorporation by these cells after EGF stimulation was also determined as a measure of DNA synthesis.

RESULTS

In all three breast cancer cell lines studied, the Raf-1 protein was identified in a 70- and a 74-kDa form. The level of Raf-1 was similar in all three cell lines and appeared unrelated to EGF receptor expression on the cell surface. The majority of the protein was found in the 74-kDa form even after serum starvation. A minor shift from the lower to higher molecular weight form of Raf-1 was apparent in cells treated with EGF, and increased [3H] thymidine incorporation could be demonstrated in two of the cell lines after EGF stimulation.

CONCLUSION

Baseline expression of the 74-kDa or activated form of the Raf-1 kinase appeared to be elevated in the breast cancer cells studied, indicating constitutive activation. Further investigation into the role of Raf-1 protein in the pathogenesis of breast cancer is indicated.

Ursodiol for hepatobiliary disorders

PURPOSE

To explain the rationale supporting the use of ursodiol (ursodeoxycholic acid) for the treatment of patients with cholesterol gallstones and chronic liver diseases and to describe the results obtained in clinical trials.

DATA SOURCES

Personal databases of the authors and MEDLINE were used to identify relevant English-language articles.

STUDY SELECTION

Randomized controlled trials evaluating ursodiol for the treatment of patients with cholesterol gallstones and chronic liver diseases were emphasized.

DATA SYNTHESIS

Ursodiol is at least as effective as chenodiol (chenodeoxycholic acid) for the dissolution of cholesterol gallstones and is associated with fewer adverse effects. Ursodiol desaturates bile, solubilizing cholesterol from the stone surface. The diameter of the largest stone is the most important determinant of successful dissolution. Dissolution with ursodiol is effective for approximately 30% to 50% of stones smaller than 20 mm in diameter, with the best results for small, buoyant stones. A meta-analysis of randomized trials with ursodiol found that the dissolution rate was 37% for patients treated with ursodiol at doses of more than 7 mg/kg per day or of more than 500 mg/d for at least 6 months. Maintenance therapy is effective for prevention of gallstone recurrence. Ursodiol also improves biochemical markers of cholestasis and inflammation when used to treat cholestatic liver diseases. By displacing potentially hepatotoxic bile salts, it appears to interrupt the cycle of cholestatic injury. It may also exert hepatoprotective membrane-stabilizing or immunomodulatory effects (or both). Improvements in laboratory variables are limited to the treatment period, with relapses after withdrawal of therapy. Pruritus may be markedly relieved in individual patients treated with ursodiol.

CONCLUSIONS

Ursodiol is a safe and effective therapy for the treatment of patients with cholesterol gallstones. Although treatment with ursodiol leads to improvement in biochemical markers for cholestatic liver diseases, whether it alters the natural history of these disorders is the subject of ongoing trials.

In vivo effects of nonionic and ionic contrast media on beta-thromboglobulin and fibrinopeptide levels

Nonionic contrast media are suggested to cause increased thromboembolism (in vivo), platelet aggregation and procoagulant effect (in vitro) as compared with ionic contrast media. To study these effects in vivo, 30 consecutive patients undergoing routine angiography were prospectively randomized to three groups of 10 patients each. Group A received diatrizoate (ionic, high osmolality), Group B ioxaglate (ionic, low osmolality) and Group C iohexol (nonionic, low osmolality). In vivo platelet alpha-granule release and fibrin-1 formation were measured by radioimmunoassay of beta-thromboglobulin and fibrinopeptide A in peripheral venous samples. Levels were estimated at three stages during the procedure: before and after left ventriculography and after coronary angiography. No differences were noted (p = NS) when the ratios of beta-thromboglobulin and fibrinopeptide A were compared among the three groups. These data suggest that the newer nonionic contrast media do not demonstrate enhanced systemic platelet activation or fibrin formation as compared with standard ionic contrast media. However, larger randomized clinical studies are necessary to conclusively establish the suggested thromboembolic potential of nonionic contrast media.