Evaluation of the self-assessment knowledge regarding cardiopulmonary resuscitation in medical students at the University of Belgrade

OBJECTIVE

Cardiopulmonary resuscitation (CPR) is a vital skill that can improve the outcome of patients with sudden cardiac arrest. To raise awareness about CPR some countries have introduced an obligatory First Aid Course (FAC), usually done parallelly to a driver's license (DL). While expected of doctors to know CPR, the curriculum of some medical schools does not seem to have enforced measures to improve that knowledge. The aim was to have students self-evaluate their current knowledge of CPR, comparing it before university and whether it improved during their studies.

SUBJECTS AND METHODS

A cross-sectional study was conducted in October 2020 using an anonymous questionnaire among students at the Faculty of Medicine in Belgrade (studies in English).

RESULTS

A total of 172 (66.7%) students possessed a DL, of which 39.8% felt they were ready, 45.8% felt neutral, and 14.4% felt unable to perform CPR. The total number of students that completed a FAC during their studies was 165. Analysis was performed on the ability assessment data after the first FAC during studies, comparing it to FAC for DL and assessments at the end of studies. No statistically significant difference was observed in the level of self-reported ability to perform CPR, while a statistically significant difference was found in ability assessments when comparing only the FAC for the DL, and the one after the first FAC during medical studies, with students feeling more prepared after the FAC for DL. Across the sample, 90.2% of the students wished they had more CPR training during their medical studies.

CONCLUSIONS

From this study, it may conclude that students wish and need more CPR training in their curriculum.

Strengths and weaknesses in the implementation of the IHR (2005) in low GNI countries

Background

The International Health Regulations (IHR) 2005 are an international legal instrument adopted by World Health Organization General Assembly to strengthen global health security and empower the countries to prevent and respond to public health threats.

Methods

This study was done within the Joint Action on Strengthened International Health Regulations and Preparedness in the EU (SHARP JA) with the aim to assess the strengths and weaknesses in preparedness and IHR implementation in order to develop and improve countries’ IHR capacities. Desk-based review and analysis of available data from the States Parties Annual Report tool (SPAR) from 2019 were done. Data (for 13 IHR capacities with 24 indicators) were analyzed for 15 countries participating in SHARP JA with gross national income (GNI) less than 90% of the EU average.

Results

The overall capacity for IHR implementation in low GNI countries is 69%, ranging from 33% in Bosnia and Herzegovina to 84% in Spain. The highest capacities are recognized in the area of Legislation and financing - 78%, IHR Coordination & NFP Functions - 77%, Food Safety - 76%, and Health service provision - 76%. The weak areas with the need for further improvement are recorded in the Points of entry (PoE) - 51%, Risk Communication - 52%, Chemical events - 60%, National health emergency framework - 65%, Surveillance - 66%, and Human Resources - 67%. The overall IHR capacity of low GNI countries is lower compared to the SHARP JA countries and the European average (76% and 73% respectively).

Conclusions

The results have shown the strongest and the weakest points of the IHR implementation in low GNI countries. This indicates the need for capacity building and further development in identified areas (Points of entry, Risk Communication, Chemical events, National health emergency framework, Surveillance, and Human Resources).

Key messages

• The assessment of the strengths and weaknesses in preparedness and IHR implementation is the key prerequisite for identifying countries’ needs for their capacity enhancement.

• Special attention should be given to the strengthening low GNI countries’ capacities.

Substance use prevention among migrant children in Serbia- challenges and opportunities

 

Among almost millions of children asylum seekers registered in the EU in 2015-2017, there were one-fifth unaccompanied children. These children are facing many challenges, including substance use while at the same time the recommendations for prevention are underdeveloped in many countries. To address the issue of substance use among migrant children in Serbia, the Institute of Public Health of Serbia with the support of the UNICEF and in cooperation with other partners developed recommendations for preventive activities in 2022 based on the migrant needs and country-specific situation. In the first phase of development, a desk review of current legislation and available relevant data was done. In the second phase, in order to gain in-depth view of the challenges and opportunities, workshops were conducted in two migrant centers with medical and other staff. Based on the findings and consultation process, feasible, evidence-based interventions were recommended. Several barriers to the implementation of evidence-based prevention activities in migrant centers were identified. To address the knowledge gap on the management of acute intoxication and the current referral system, guidelines were developed. The diversity of professional backgrounds of staff in migrant centers was identified as a barrier and recommendations for further training were made. There are several barriers that need further action and solutions such as short periods of stay in centers that hinder the provision of structured programs, language barriers, and ethical issues for minors, especially unaccompanied children. Prevention activities in migrant centers need to consider the specific needs of migrants, such as language barrier, capacities, and relevant knowledge of available staff and country-specific situations. The development of guidelines and a flowchart for a referral system for migrants at risk for substance abuse and dependence can be a useful tool for staff in migrant centers.

Key messages

• Substance use prevention among migrants should be evidence-based and in line with migrant needs and country-specific situations.

• Guidelines for prevention should be available to migrant centers’ staff.

Drinking water quality as a risk factor for pupils’ health in rural schools in Serbia

Background

Access to safe drinking water in schools is essential for a good health, wellbeing, learning and dignity of pupils. The rural schools are most frequently connected to the rural water supply system or own water supply source, where the monitoring of drinking water quality is scarced. The study was conducted in the rural regions in Serbia in 2016, aiming at assessing drinking water quality and sanitary conditions of school water supply facilities.

Methods

In total 238 school facilities, including 108 in Šumadija and 130 in Pomoravlje District were investigated using laboratory testing of drinking water and sanitary inspection.

Results

Study revealed that 32% of analysed samples showed microbiological faecal contamination with bacteria E. coli, while 52% of samples showed physico-chemical non-compliance with the national standards, where higher nitrates were the most common cause. Overall non-compliance of drinking water from school rural water supply systems amounted to 66% of tested water samples. This study also showed the main technical shortcomings of school water supply facilities and distribution networks such as the lack of fencing of the water source, damaged or absence of drainage channels from the well concrete floor and poor construction characteristics of wells.

Conclusions

The results of this study, particularly presence of E. coli in drinking water may affect pupils’ health and is a consequence of poor sanitary conditions and maintenance of small rural drinking water supply systems and individual wells. It is necessary to provide continuous disinfection of water available in schools and to undertake measures for technical improvements in order to provide better sanitary protection of water sources and other water supply facilities in rural schools.

Key messages

• Drinking water quality in schools is vital for children public health.

• Raise awareness of local community on drinking water safety and enforce continuous monitoring of drinking water quality in small rural water supply systems in schools.

Predicting no-reflow phenomenon prior to primary percutaneous coronary intervention using a novel probability risk score derived from clinical and angiographic parameters

OBJECTIVE

We aimed to create a clinically usable probability risk score for prediction of no-reflow (NRF) phenomenon prior to primary percutaneous coronary intervention (PPCI).

PATIENTS AND METHODS

This single-center and retrospective study included 1254 patients with acute ST-segment elevation myocardial infarction (STEMI) who underwent PPCI. Patients were randomly assigned into two groups in the ratio 2:1, the derivation dataset (n=840) and validation dataset (n=414). Independent predictors of NRF were identified and combined to create a prediction model using univariate and multivariate regression analysis in the derivation dataset. The risk score was tested and validated by calculating area under the receiver operating characteristic (ROC) curves in the derivation and validation datasets, respectively.

RESULTS

Five significant, independent predictors of NRF were identified: age ≥ 65 years (odds ratio [OR]: 2.473, 95% confidence interval [CI]: 0.389-1.484, p < 0.01), heart rate ≥ 89 bpm (odds ratio [OR]: 1.622, 95% confidence interval [CI]: 0.024-0.945, p < 0.05), Killip class ≥ II (odds ratio [OR]: 1.914, 95% confidence interval [CI]: 0.024-1.306, p < 0.01), total ischemic time ≥ 268 min (odds ratio [OR]: 2.652, 95% confidence interval [CI]: 0.493-1.565, p < 0.01), and thrombus burden G≥4 (odds ratio [OR]: 8.351, 95% confidence interval [CI]: 0.344-15.901, p < 0.01). The risk score was created combining these predictors with assigned points. The overall score ranged from 0 to 17 points. The optimal cutoff value of the risk score was 11 points (area under curve [AUC]: 0.772, 95% confidence interval [CI]: 0.729-0.815, sensitivity 71.21%, specificity 70.34%, positive predictive value 30.92%, negative predictive value 92.91%, p < 0.001). The ROC curve for the validation group showed good discriminant power.

CONCLUSIONS

We developed a novel risk score based on five clinical and angiographic parameters, which might be a useful clinical tool for prediction of NRF in STEMI patients prior to PPCI with an acceptable accuracy.

Intercomparison of airborne multi-angle polarimeter observations from the Polarimeter Definition Experiment

In early 2013, three airborne polarimeters were flown on the high altitude NASA ER-2 aircraft in California for the Polarimeter Definition Experiment (PODEX). PODEX supported the pre-formulation NASA Aerosol-Cloud-Ecosystem (ACE) mission, which calls for an imaging polarimeter in polar orbit (among other instruments) for the remote sensing of aerosols, oceans, and clouds. Several polarimeter concepts exist as airborne prototypes, some of which were deployed during PODEX as a capabilities test. Two of those instruments to date have successfully produced Level 1 (georegistered, calibrated radiance and polarization) data from that campaign: the Airborne Multiangle Spectropolarimetric Imager (AirMSPI) and the Research Scanning Polarimeter (RSP). We compared georegistered observations of a variety of scene types by these instruments to test whether Level 1 products agreed within stated uncertainties. Initial comparisons found radiometric agreement, but polarimetric biases beyond measurement uncertainties. After subsequent updates to calibration, georegistration, and the measurement uncertainty models, observations from the instruments now largely agree within stated uncertainties. However, the 470 nm reflectance channels have a roughly +6% bias of AirMSPI relative to RSP, beyond expected measurement uncertainties. We also find that observations of dark (ocean) scenes, where polarimetric uncertainty is expected to be largest, do not agree within stated polarimetric uncertainties. Otherwise, AirMSPI and RSP observations are consistent within measurement uncertainty expectations, providing credibility for the subsequent creation of Level 2 (geophysical product) data from these instruments, and comparison thereof. The techniques used in this work can also form a methodological basis for other intercomparisons, for example, of the data gathered during the recent Aerosol Characterization from Polarimeter and Lidar (ACEPOL) field campaign, carried out in October and November of 2017 with four polarimeters (including AirMSPI and RSP).

Knowledge about cervical cancer, Pap test, and barriers to women's participation in screening in Belgrade, Serbia

INTRODUCTION

Cervical cancer (CC) is a serious public health concern in Serbia, due to opportunistic screening still being in force, which led to twice higher than the average incidence rate of cervical cancer in Europe. Despite the fact that early detection and treatment services of CC are available at no additional cost, majority of women use inadequate screening services in Serbia.

OBJECTIVE

This study aimed to examine the link between the knowledge about CC and Papanicolaou (Pap) test and perception of barriers to women's participation in CC screening.

MATERIALS AND METHODS

The study included 300 women aged 21 to 69, with a place of residence in the city of Belgrade (Serbia), who were attending for their medical examination to the University Clinic of Gynecology and Obstetrics - "Narodni front", from June through December 2014. A survey instrument to collect data was an adapted questionnaire for the assessment of knowledge about and barriers to CC and Pap test. Patients were divided into three groups: a study group consisted of women attending irregularly (over three years), women who never participated in screening, and a control group that included women regularly participating in screening.

RESULTS

Women regularly participating in screening (52.7%) had adequate knowledge about CC and Pap test, while women who irregularly (79.4%) or never participated (71.9%) did not have any adequate knowledge. There was a significant statistical difference between the CC and Pap test awareness in a group of respondents who regularly participated in comparison to respondents who irregularly or never participated in screening (x²= 27.772, p = 0.000). Regarding knowledge about human papillomavirus (HPV), 80% of women did not know that Pap test cannot be used for detection of HPV, as well as that abnormal Pap test result may be due to HPV (61.7%). Majority of women (93.7%) had poor knowledge about Pap test role in CC early detection and considered Pap test to be used to diagnose CC. The authors found a significant statistical correlation between participation of women in screening and barriers. Women who were irregular or never participated, had barriers such as: lack of time (F = 9.51; p = 0,000), difficult access to Healthcare facilities (F = 11.29; p = 0.000), lack of knowledge about the Pap test procedure (F = 21.27,p = 0.000), discomfort (F = 9.36; p = 0.000), and anxiety of Pap test results (F = 3.35; p = 0.036). Women who regularly participated did not have prejudice when choosing a gynecologist, unlike the other two groups that preferred a female gynecologist (F = 3.61; p = 0.028).

CONCLUSION

This study showed that the level of knowledge about CC and Pap test in women is an important factor associated with regular participation in screening. It is necessary to take educational measures in order to raise awareness of women regarding risk factors, as well as to overcome fear and shame, with the ultimate aim to reduce frequency and mortality rate caused by CC in Serbia.

Clinical implementation of cardiac resynchronization therapy-regional disparities across selected ESC member countries

Background

The present analysis aimed to estimate the penetration of cardiac resynchronization therapy (CRT) on the basis of the prevalence and incidence of eligible patients in selected European countries and in Israel.

Methods and Results

The following countries were considered: Italy, Slovakia, Greece, Israel, Slovenia, Serbia, the Czech Republic, Poland, Romania, Hungary, Ukraine, and the Russian Federation. CRT penetration was defined as the number of patients treated with CRT (CRT patients) divided by the prevalence of patients eligible for CRT. The number of CRT patients was estimated as the sum of CRT implantations in the last 5 years, the European Heart Rhythm Association (EHRA) White Book being used as the source. The prevalence of CRT indications was derived from the literature by applying three epidemiologic models, a synthesis of which indicates that 10% of heart failure (HF) patients are candidates for CRT. HF prevalence was considered to range from 1% to 2% of the general population, resulting in an estimated range of prevalence of CRT indication between 1000 and 2000 patients per million inhabitants. Similarly, the annual incidence of CRT indication, representing the potential target population once CRT has fully penetrated, was estimated as between 100 and 200 individuals per million. The results showed the best CRT penetration in Italy (47–93%), while in some countries it was less than 5% (Romania, Russian Federation, and Ukraine).

Conclusion

CRT penetration differs markedly among the countries analyzed. The main barriers are the lack of reimbursement for the procedure and insufficient awareness of guidelines by the referring physicians.

Psychometric evaluation of the depression anxiety stress scales-21 (DASS-21) in a Serbian student sample

The purpose of the current research was to examine the psychometric properties of the Depression Anxiety Stress Scales-21 (DASS-21) in a student sample. In Study 1 (N = 1374), a confirmatory factor analysis was used to evaluate construct validity of the DASS- 21. The stability of the DASS-21 structure over time (5-month follow-up, N = 693) was investigated also in Study 1. In Study 2, associations with measures of depression, anxiety, stress, affect, life satisfaction and general distress were examined to assess the convergent validity of the DASS-21. The results suggested that the DASS-21 was reliable and valid measure of unpleasant emotional states. The model with optimal fit consisted of general factor of negative affect plus three specific factors of depression, anxiety and stress.

Do humor styles matter in the relationship between personality and subjective well-being?

The primary goal of this research was to examine the role of humor styles in the relationships between personality (extraversion and neuroticism) and two components of subjective well-being: life satisfaction and affective well-being. The sample consisted of 225 young adults, with mean age 23.61 years. Results indicated that the relationship between both extraversion and neuroticism and satisfaction with life could be partially explained by the mediating role of self-enhancing humor. Additionally, affiliative humor proved to be a partial mediator of the relationship between neuroticism and affective well-being. The findings of this research suggested that adaptive humor styles might be one of the mechanisms linking personality and subjective well-being.

First results from a dual photoelastic-modulator-based polarimetric camera

We report on the construction and calibration of a dual photoelastic-modulator (PEM)-based polarimetric camera operating at 660?nm. This camera is our first prototype for a multispectral system being developed for airborne and spaceborne remote sensing of atmospheric aerosols. The camera includes a dual-PEM assembly integrated into a three-element, low-polarization reflective telescope and provides both intensity and polarization imaging. A miniaturized focal-plane assembly consisting of spectral filters and patterned wire-grid polarizers provides wavelength and polarimetric selection. A custom push-broom detector array with specialized signal acquisition, readout, and processing electronics captures the radiometric and polarimetric information. Focal-plane polarizers at orientations of 0 degrees and -45 degrees yield the normalized Stokes parameters q=Q/I and u=U/I respectively, which are then coregistered to obtain degree of linear polarization (DOLP) and angle of linear polarization. Laboratory test data, calibration results, and outdoor imagery acquired with the camera are presented. The results show that, over a wide range of DOLP, our challenging objective of uncertainty within +/-0.005 has been achieved.

Functional compartmentalization following induction of long-term graft survival with pregraft donor-specific transfusion

Long-term survival is achieved in rat recipients by pre-graft donor-specific blood transfusion. We characterized the immune compartments in long-term survivors and analyzed them for capacity to transfer tolerance and protect against chronic rejection. Splenocytes and spleen T cells from treated recipients transferred long-term graft survival to 100% of secondary recipients. In contrast, blood transferred graft survival to only 50% of recipients whereas blood T cells had no effect. An unaltered TCR repertoire, an increase in suppressive CD4+CD25+ T cells, a decrease in antidonor T-cell proliferative response and normal perforin-granzyme levels were the hallmarks of the spleen T cells. Blood T cells were characterized by a strongly altered CD8+ repertoire, normal CD4+CD25+ T cell number with unchanged antidonor T-cell proliferative response, an activated T-cell phenotype and an increase in perforin-granzyme levels. However, following the transfer of blood or spleen cells into secondary recipients, all grafts displayed chronic rejection. These findings provide evidence that distinct compartments play critical roles in DST recipients. Regulatory cells do not accumulate in blood, which appears to be a reservoir for cytotoxic T cells. Spleen T cells, which display a regulatory-like profile and transfer graft survival, are not able to prevent chronic rejection.

Life-threatening postoperative blood loss in a Jehovah's Witness, treated with high-dose erythropoietin

Six hours after an uncomplicated extended resection of ovarian cancer, postoperative arterial bleeding led to life-threatening blood loss in a 44-yr-old Jehovah's Witness who refused blood transfusion. Haemoglobin (Hb) decreased from 2.5 g dl(-1) directly after the emergency laparotomy, followed by a 10 h immeasurable period (below detectable minimum value of the analyser), to a measurable minimum of 1.5 g dl(-1) after 20 h. Haematopoiesis was induced by high-dose i.v. erythropoietin therapy (600 IU kg(-1)) and continued on days 3, 6, 8, 10 and 13. Iron, folic acid and vitamins were given as supplements. The patient needed ventilatory assistance for 18 days and some inotropic support. Complications included increases in pancreatic enzymes and liver enzymes, jaundice and skin necrosis at the fingertips and toes. Myopathy led to transient tetraparesis. Haemoglobin rose from 1.5 to 3.4 g dl(-1) (day 10) and the patient was discharged from the intensive care unit with haemoglobin 6.5 g dl(-1) on day 24. She made a full recovery and is still free of cancer in remission.

[Rupture of a renal artery aneurysm during delivery]

INTRODUCTION

Renal artery aneurysms represent a rare entity with an incidence of 0.3 - 1.3% in angiographies. Rupture of such aneurysms are rare. During pregnancy there is an increased risk of rupture with a high mortality for mother and child. We report the first case of rupture of a left renal artery aneurysm during delivery with survival of mother and child.

CASE REPORT

Due to arrest of labor during a home birth, the patient was admitted to the hospital, where an immediate forceps extraction on account of fetal asphyxia was performed. Immediately after delivery a hypovolemic shock developed. Ultrasound examination showed a huge subsplenic hematoma. Emergency laparotomy revealed a ruptured renal artery aneurysm. The renal artery was ligated on the assumption of a lower pole vessel. Despite hemodynamic stability a drop in hemoglobin occurred the following day. Angiography showed no perfusion of the left kidney. A left nephrectomy was performed without complications. The further course was uneventful. Mother and child survived.

CONCLUSIONS

Rupture of aneurysms of the splenic and renal artery during later stages of pregnancy, during delivery or after childbirth are possible etiologies in cases of unexplained shock and abdominal pain. An emergency angiography in such cases helps to reveal the underlying cause and renders possible a targeted operative approach.

Primary non-Hodgkin lymphoma of the breast. Is it possible to avoid mastectomy?

Primary lymphoma of the breast is a rare disease that has been estimated to represent from 0.05% to 0.53% of all malignant breast tumors and approximately 2.2% of all extranodal lymphomas. The aim of this study is to review all cases of primary lymphoma of the breast at the Institute of Oncology and Radiology of Serbia from 1984 to 1996 in order to determine the incidence, patterns of clinical presentation, radiological features, histopathology, mode of therapy and outcome of the disease. The criteria for inclusion in this retrospective study corresponded to a revision of the original criteria suggested by Wiseman and Liao. The clinical histories of ten patients with breast lymphomas were reviewed. Clinical follow-up was obtained through a review of the patients hospital chart or by direct contact with the patients. Ten cases of primary lymphoma of the breast have been identified during the 12-yr period, presenting 0.05% of all patients with malignant breast disease. All patients were female, median age at diagnosis 58 years (range 49-69), all presented with breast lumps (3 right, 7 left) of median size 5 cm (range 3.5-8 cm). Mammography and breast echography were unable to bring a suspicion of lymphoma. Histologically, 6 cases were diffuse large cell, 3 of which with features consistent with immunoblastic lymphoma; 2 were diffuse mixed cells and 2 had small lymphocytic morphology. In 4 out of 5 patients, in the clinical stage corresponding to the "operable breast cancer" category, the ex tempore histological analysis could not differentiate lymphoma from cancer, so that all of them had mastectomy with axillary dissection. Those corresponding to the "locally advanced breast cancer" category, escaped mastectomy and a classical biopsy was performed, anticipating eventual neoadjuvant procedures. Thus, four patients underwent radical mastectomy, 1 wide local excision and 5 diagnostic biopsies. Further treatment included chemotherapy for 8 patients. The projected probability of a 10-years survival was 0,60. The rarity of this disease, and uneven treatment modalities make prognosis of breast lymphoma difficult. It seems that cooperation between the surgeon and the pathologist is necessary in order to reach the correct diagnosis during ex tempore analysis. With the limitations of available diagnostic procedures, it appears that most patients with breast lymphoma, in the stage corresponding to the "operable breast cancer" category, will unnecessarily undergo mastectomy and axillary dissection as primary treatment approach.

Comparative pharmacological and functional analysis of the human dopamine D4.2 and D4.10 receptor variants

The human dopamine D4 receptor is a D2-like receptor which is a target for most common neuroleptics. Previous investigations have shown that this receptor displays a large polymorphic variation in the third intracellular loop involving a variable number of direct imperfect tandem repeats (VNTR) of 16 amino acids. The shortest and longest repeat variants reported to date contain two and 10 repeat units (D4.2 and D4.10). No major pharmacological differences have been reported for the most common variants of this receptor (D4.2, D4.4 and D4.7), although the D4.7 was reported by us to display a slightly lower potency for dopamine in functional assays. Direct pharmacological and functional comparison of the longest and shortest variants in this study suggest no major discrepancies in pharmacological or functional profile between both receptors. Both receptors display, on average, a 15-fold and 90-fold lower potency for epinephrine and norepinephrine, respectively, compared with dopamine. We observed small increases in functional potency and affinity for dopamine and quinpirole at the D4.10 receptor variant compared with the D4.2 receptor. Our data indicate that there is no direct relationship between the length of the polymorphism and changes in pharmacology or functional activity. These findings are a suitable caution against the arbitrary pooling of D4 receptor VNTR genotypes in genetic studies, based on length.

Pure red cell aplasia evolving through the hyperfibrotic myelodysplastic syndrome to the acute myeloid leukemia: some pathogenetic aspects

The authors report a 58-year-old female who originally presented with acquired pure red cell aplasia (PRCA). At diagnosis, the karyotype was normal, the serum erythropoietin level was highly elevated and no T-cell mediated inhibition of erythropoiesis was demonstrated in coculture studies. Conventional immunosuppressive therapy proved ineffective. A year later a diagnosis of hyperfibrotic myelodysplastic syndrome was assessed. The sequential bone marrow examinations in the course of the three years showed a progressive increase in bone marrow fibrosis, erythroid hyperplasia and dysmegakaryocytopoiesis, terminating in the acute myeloid leukemia. This sequence of the events included the appearance of del(5)(q13q33), four years after setting a diagnosis of PRCA. The authors suggest that the absence of both cytogenetic abnormality and the signs of dyshematopoiesis at the diagnosis of PRCA does not exclude ultimately a "clonal" category of the disease. Thus, repeated hematological and cytogenetical reevaluations are recommended.

Short- and long-term heterologous sensitization of adenylate cyclase by D4 dopamine receptors

The D4 dopamine receptor, a member of the D2-like dopamine receptor family, may be important in the etiology and treatment of schizophrenia. The present study was designed to examine the effects of dopamine agonist exposure on adenylate cyclase activity in HEK293 cells stably expressing recombinant-D4 receptors. Two hour pretreatment with dopamine receptor agonists resulted in heterologous sensitization of forskolin-stimulated cyclic AMP accumulation in intact cells expressing the D4.2, D4.4, or D4.7 dopamine receptor variant. The potency and efficacy of dopamine for sensitization of cyclic AMP accumulation was comparable at all D4 receptor variants. D4 dopamine receptor-mediated sensitization was blocked by the D4 antagonist, clozapine, and prevented by overnight pretreatment with pertussis toxin, implying a role for Gi/Go proteins in heterologous sensitization. Further, long-term (18 h) agonist exposure resulted in a greater degree of sensitization of forskolin-stimulated cyclic AMP accumulation in both intact cells and membrane preparations of cells expressing the D4 receptor, compared to 2 h agonist exposure, without altering the density of the receptors. In addition, long-term agonist exposure decreased the abundance of Gialpha without altering the abundance of Gsalpha, whereas short-term agonist treatment had no effect on the immunoreactivity of either G protein. In summary, long-term agonist-induced sensitization of adenylate cyclase by the D4 receptor may involve mechanisms that do not contribute to short-term sensitization.

A two-step reevaluation of high-dose amsacrine for advanced carcinoma of the upper aerodigestive tract: a pilot phase II study

Results of amsacrine studies in different solid tumors with a dose of 85 mg/m2/24 h x 1 quo 3 weeks have been, in general, disappointing. Although only a few patients with head and neck cancer have been included in broad phase II studies, several responses have been reported, but detailed data concerning responders are lacking. In the present study, amsacrine (Amsidil, Godecke-Parke Davis) was administered at an increased dose of 85 mg/m2/24 h x 3 (total dose per cycle 255 mg/m2) quo 3-4 weeks. 25 patients with advanced carcinoma of meso and hypopharynx were included in the first step of this phase II study (11/25 with histological grades I/II and 14/25 with histological grades III/IV; 10/25 pretreated with radical radiotherapy and 15/25 previously untreated), and 5 patients with undifferentiated carcinoma of the nasopharyngeal type (UCNT), all previously treated. 5/30 patients achieved a complete response (CR) and 5/30 a partial response (PR), the overall response rate being 10/30. Regarding the histology grade, only 1/11 patients with grade I/II carcinoma of meso and hypopharynx achieved a PR with no CR, but 5/14 with grade III/IV from the same group achieved a CR. Out of 10 pretreated patients only one achieved any response and none of the 5 patients with UCNT. Thus, in the second step of this study, high dose amsacrine was evaluated in the target group of previously untreated patients with advanced grade III/IV carcinoma of meso and hypopharynx. 20 patients were included in the second step and all were evaluable for activity. A CR was achieved for 6/20 patients and a PR for 7/20 patients (response rate 65%, 95% confidence interval 44%-86%). Hematological toxicity from both steps included grade IV granulocytopenia in 25/50 patients (50%, 95% confidence interval 36%-64%) and grade IV thrombocytopenia in 18/50 patients (36%, 95% confidence interval 23%-49%). High dose amsacrine seems to be a toxic, but very effective drug as first-line treatment for poorly differentiated carcinoma of meso and hypopharynx, and further studies seem warranted.

Solitary intracranial plasmacytomas

We present two cases of an unusal localised extramedullary plasmacytoma with a long survival period: a 42-year-old woman with left temporal and a 25-year-old woman with left parietal intracranial plasmacytoma. The tumor masses were totally removed in both patients and their histological, histochemical (PAS and methyl green pyronin positive granules) and immunohistochemical (positive light chains mostly lambda, and negative stains for GFAP, NSE and S-100 protein) properties showed that the tumor tissues consisted of monoclonal population of plasma cells. Our cases were diagnosed as solitary cerebral plasmacytomas since the presence-of underlying multiple myeloma has been ruled out by the clinical, laboratory, radiographic and immunological investigations. Postoperatively the patients were given 40 Gy to the whole cranium and additional 20 Gy focused on the tumor site. Complete remissions were achived 7.5 and 5.5 years, respectively.

Multifocal plasmacytoma of hand and foot bones

Simultaneous occurrence of localized plasmacytomas of both hands and feet has not been reported so far. Here we report a 40-year old female patient, who had at presentation pain and deformity. Of hands and feet, with numerous cystic lytic lesions of phalangeal, metacarpal and metatarsal bones, detected by X-rays. The biopsy of the affected bone showed moderately differentiated plasmacytoma of lambda light chain type (lambda-LC). Serum and urine biochemical analysis revealed the existence of lambda LC monoclonal component. The patient was treated by local radiotherapy and subsequent systemic chemotherapy, which consisted of 3 cycles of the M-2 protocol and 7 cycles of melphalan-prednisone. Five years after the diagnosis, the absence of plasmacytoma was confirmed by puncture biopsy of the left hand phalanx. Monoclonal protein in serum and urine was not detected.

Cryptic initiation at the human D4 receptor reveals a functional role for the amino terminus

It was found that deletion of the initiator methionine of the D4 receptor results in the use of a cryptic initiation site in the putative first transmembrane region. We made use of this observation to investigate the role of the amino terminus of the D4 receptor. In vitro transcription and translation of D4.4 and a D4.4 deleted for the initiation codon (D4.4 delta NH2) resulted in the formation of protein products with a molecular mass of about 44 and 40.5 kDa, respectively. The molecular mass of 40.5 kDa suggests initiation in the putative first transmembrane region. Transient expression of various deletion mutants indicated that this receptor form can be expressed at up to 70% of the D4.4 control levels and provided support for the existence for an alternative translation initiation site in the first transmembrane domain, most likely at nucleotide +112 (the initiator methionine codon is designated as +1). The D4.4 delta NH2 mutant was stably expressed in CHO cells. Pharmacological analysis demonstrated no major differences in antagonist binding with the regular D4.4 receptor, while dopamine and quinpirole binding affinities were about 5-fold decreased. The half-maximal level (EC50) for blocking forskolin-stimulated cAMP levels by dopamine was about 10-fold lower as compared to D4.4. Furthermore, the functional efficacy is decreased by about 40%. These data suggest that the amino-terminal domain is not essential for proper expression, but does interfere with the functional activity of the receptor, possibly through stabilization of the active state. To our knowledge this is the first demonstration that the amino terminus of a dopamine receptor is involved in signal transduction.

Modulation of intracellular cyclic AMP levels by different human dopamine D4 receptor variants

To investigate whether polymorphic forms of the human dopamine D4 receptor have different functional characteristics, we have stably expressed cDNAs of the D4.2, D4.4, and D4.7 isoforms in several cell lines. Chinese hamster ovary CHO-K1 cell lines expressing D4 receptor variants displayed pharmacological profiles that were in close agreement with previous data from transiently expressed D4 receptors in COS-7 cells. Dopamine stimulation of the D4 receptors resulted in a concentration-dependent inhibition of the forskolin-stimulated cyclic AMP (cAMP) levels. The potency of dopamine to inhibit cAMP formation was about twofold reduced for D4.7 (EC50 of approximately 37 nM) compared with the D4.2 and D4.4 variants (EC50 of approximately 16 nM). Antagonists block the dopamine-mediated inhibition of cAMP formation with a rank order of potency of emonapride > haloperidol = clozapine >> raclopride. There was no obvious correlation between the efficacy of inhibition of forskolin-stimulated cAMP levels and the D4 subtypes. Dopamine could completely reverse prostaglandin E2-stimulated cAMP levels for all three D4 receptor variants. Deletion of the repeat sequence does not affect functional activity of the receptor. The data presented indicate that the polymorphic repeat sequence causes only small changes in the ability of the D4 receptor to block cAMP production in CHO cells.

[The MRI in pre- and postnatal diagnosis of congenital sacrococcygeal teratoma]

INTRODUCTION

The main tasks of imaging methods on the evaluation of relatively rare and potentially malignant connatal sacrococcygeal teratomas (SCT) are to depict the extent, structure and relationship to surrounding systems.

METHODS

Two cases with SCT were studied with pre- and postnatal MRI and findings were compared with the ultrasound and clinical data.

RESULTS

Before delivery, MRI permits depiction of the size and structure of teratomas and the integrity of the serum. After delivery, evaluation of the rectum, urinary tract and levator muscles is important to facilitate surgical reconstruction.

Dopamine D4 receptor repeat: analysis of different native and mutant forms of the human and rat genes

Recent molecular characterization of the human D4 gene has revealed the existence of various polymorphic forms of this receptor. These variations are found in the putative third cytoplasmic loop region and encode a variable number of repeats of 16 amino acids in length. In the present study we have compared the pharmacological binding profiles of seven different polymorphic variants of the human D4 receptor, the rat D4 receptor, and two different human D4 receptor mutants that were deleted in the repeat sequence. For this purpose we cloned the rat D4 receptor gene and compared its gene structure and its pharmacological binding profile with those of the D4.4 and D4.7 genes. The rat and human D4 genes display a high degree of sequence similarity, especially in the coding regions. An Alu repeat sequence was identified in the first intron of the human D4 gene but is not present in the rat D4 gene. Furthermore, using the polymerase chain reaction we cloned 3-, 5-, 6-, and 9-fold repeat sequences. These cloned repeat sequences were used for the reconstruction of full length cDNAs encoding D4.3, D4.5, D4.6, and D4.9, respectively. These novel forms of the human D4 receptor, as well as the previously cloned D4.2, D4.4, and D4.7 forms, were transiently expressed in COS-7 cells. All of the different forms of the human and rat D4 receptors and repeat deletion mutants displayed similar binding profiles for all ligands tested, although small differences were observed. The affinity for dopamine could be decreased by guanosine-5'-(beta, gamma-imido)triphosphate with the different forms of the D4 receptor, including the two receptor mutants that were deleted in the repeat sequence. These data suggest that the polymorphic repeat sequence has little influence on D4 binding profiles and might not be essential for G protein interaction.

First-trimester alpha-fetoprotein screening for Down syndrome

Screening for Down syndrome and other chromosomal aneuploidies by biochemical parameters in maternal serum is well established for the second trimester. With screening as late as 16 weeks of gestation, the option of chorionic villus sampling (CVS) unfortunately is lost. In our study population, the maternal serum alpha-fetoprotein (MSAFP) concentration was determined in 2471 women in the first trimester immediately prior to CVS. Although in this sample MSAFP tended to be lower in Down syndrome (DS) pregnancies than in pregnancies with a chromosomally normal fetus, at this early gestational age neither a fixed cut-off level of 0.5 multiples of the normal median (MOM) nor one of 0.6 MOM was suitable for identifying pregnancies at higher risk for DS. This also applied to trisomy 18, although on average MSAFP in trisomy 18 pregnancies was lower than in normal and DS pregnancies.

Blood flow velocity in the fetal abdominal aorta and in the umbilical artery in uncomplicated pregnancies

The blood flow velocity waveform (BFWV) in fetal vessels depends on the stroke volume and the frequency of the fetal heart, the compliance of the vessel and the peripheral resistance of the fetal vascular bed. The objective of the present study was to establish the change of the BFVW throughout gestation and whether the change of the resistance indices are related to the peak flow velocity and/or the end-diastolic flow velocity. The BFVW of the fetal abdominal aorta and of the umbilical artery at 27th-30th week and at 37th-40th week of gestation were analysed in fifteen patients with uncomplicated pregnancies and subsequent normal outcome. The measurement was performed with a pulsed duplex scanner (Kranzbühler). The Doppler beam had a fixed angle of 50 degrees to the fetal vessel in all cases. The peak flow velocity in the fetal aorta remained constant from the 27th-30th week to the 37th-40th week of gestation: 1418 +/- 248 Hz vs. 1448 +/- 269 Hz. The end-diastolic flow, however, showed a significant increase during the respective periods: from 270 +/- 59 Hz to 325 +/- 69 Hz. The peak flow velocity in the umbilical artery was about 25% below that of the fetal aorta: 1028 +/- 149 Hz (27th-30th week) and 1106 +/- 196 Hz (37th-40th week). The end-diastolic flow, however, increased by about 41%: 292 +/- 86 Hz vs. 412 +/- 83 Hz demonstrating a tremendous change of the compliance and the peripheral resistance in the umbilical vascular system. These alterations are also exhibited by the resistance indices. The resistance indices S/D, PI and RI of both vessels were related to the EDF of the abdominal aorta and the umbilical artery at the respective gestational age. It demonstrated that the EDF is of major influence on the calculated resistance indices. The blood flow in the aorta and the umbilical artery was 135(+/- 18) ml/kg/min and 143 (+/- 21) ml/kg/min, respectively. In conclusion, the BFVW for fetal surveillance should be measured under a constant angle in the fetal abdominal aorta. It gives a good information concerning the peripheral resistance and compliance in the respective vascular areas. The EDFV has its lowest value at 200 Hz in the fetal aorta and in the umbilical artery under physiological conditions.

Multiple dopamine D4 receptor variants in the human population

The dopamine D4 receptor structurally and pharmacologically resembles the dopamine D2 and D3 receptors. Clozapine, an atypical antipsychotic that is relatively free of the adverse effects of drug-induced parkinsonism and tardive dyskinesia, binds to the D4 receptor with an affinity 10 times higher than to the D2 and D3 receptors. This may explain clozapine's atypical properties. Here we report the existence of at least three polymorphic variations in the coding sequence of the human D4 receptor. A 48-base-pair sequence in the putative third cytoplasmic loop of this receptor exists either as a direct-repeat sequence (D4.2), as a fourfold repeat (D4.4) or as a sevenfold repeat (D4.7). Two more variant alleles were detected in humans. Expression of the complementary DNA for the three cloned receptor variants showed different properties for the long form (D4.7) and the shorter forms (D4.2, D4.4) with respect to clozapine and spiperone binding. To our knowledge, this is the first report of a receptor in the catecholamine receptor family that displays polymorphic variation in the human population. Such variation among humans may underlie individual differences in susceptibility to neuropsychiatric disease and in responsiveness to antipsychotic medication.