67Ga-9N3 uptake by xenografts of human melanotic melanoma in mice. Tumour uptake of the inert, neutral complex 67Ga-9N3 and the tumour:blood concentration ratio (1,4,7,triazacyclononane-1,4,7, triacetic acid) were measured in mice bearing xenografts of the human melanotic melanoma HX118. Between 1 and 4 h after the injection the tumour:blood ratio increased from 3.5 to 21 and the concentration of 67Ga-9N3 in the tumour decreased from 0.43 to 0.13% g-1. During the first 24 h the concentration of 67Ga-9N3 in the tumour exceeded that in all other tissues except the liver and kidneys. The tumour:blood ratio and tissue distribution of 67Ga-9N3 at 4 h were compared with those of four other complexes. The results indicated that of the five complexes 67Ga-9N3 would be the most suitable for tumour imaging at early times after administration. Imaging would not be restricted to gamma emitting 67Ga as there is also the possibility of using the 9N3 ligand to bind 111In for single photon emission computed tomography (SPECT), 68Ga for positron emission tomography (PET) or even stable Ga for direct in vivo nuclear magnetic resonance (NMR) detection.


A file format for the exchange of nuclear medicine image data: a specification of Interfile version 3.3. Working Group 1 of the European project COST-B2 on quality assurance of nuclear medicine software has been concerned with the development of an appropriate mechanism for the transfer of nuclear medicine image data files between computer systems from different vendors. To this end a protocol based upon Report No. 10 of the American Association of Physicists in Medicine (AAPM) [1] was adopted. A previous publication [2] gave a specification (V3.2) for an intermediate file format with a list of key-value pairs for the header data associated with nuclear medicine image data files. This paper presents a revised specification for the intermediate file format and associated keys, now called V3.3, which has evolved from the experience in using the earlier version. It is hoped that the modifications proposed will improve the definition and usability of the file format as given in the earlier version.


Quantitative estimation of human uterine artery blood flow and pelvic blood flow redistribution in pregnancy. To determine the contributions of uterine artery diameter and mean flow velocity to the increase in volumetric flow during human pregnancy. Volunteers (18 pregnant and six not pregnant) were studied using both a commercially available Doppler instrument with imaging ultrasound and an improved Doppler instrument with software that can determine instantaneous true mean blood flow velocity. Diameter and mean flow velocity measurements were combined to yield volumetric flows in the common iliac, external iliac, and uterine arteries during and after pregnancy. Compared with the nonpregnant state, uterine artery diameter doubled by week 21 (from 1.4 +/- 0.1 to 2.8 +/- 0.2 mm; P < .05), did not change between weeks 21 and 30 (2.9 +/- 0.1 mm), and increased between weeks 30 and 36 (to 3.4 +/- 0.2 mm). Uterine artery mean flow velocity rose progressively from nonpregnant values to attain at week 36 a velocity nearly eight times faster (8.4 +/- 2.2 versus 61.4 +/- 3.0 cm/second; P < .05). Unilateral uterine artery blood flow at week 36 was 312 +/- 22 mL/minute. Compared with nonpregnant values, common iliac artery flow increased and external iliac artery flow decreased during pregnancy, suggesting that redistribution of pelvic flow to favor the uterus contributed to the pregnancy-associated rise in uterus artery flow. Early in pregnancy, the increase in uterine artery blood flow was due in equal parts to changes in uterine artery diameter and mean flow velocity, whereas late in pregnancy, the rise was due mainly to faster mean flow velocity.


Maternal-fetal HLA-DR relationships and pregnancy-induced hypertension. Some studies have found an increased prevalence of pregnancy-induced hypertension among women sharing HLA antigens with their spouses or fetuses, thus supporting the hypothesis that maternal sensitization to fetal HLA alloantigens reduces the risk for pregnancy-induced hypertension. However, not all studies have confirmed these findings. No investigators have examined the four different types of maternal-fetal HLA relationships in their studies of pregnancy-induced hypertension. Our goal was to examine such associations to test further the HLA-allosensitization hypothesis. We conducted a cohort study of pregnancy-induced hypertension among 683 nulliparous women. Women and their neonates were typed for HLA-A, -B, -DR, and -DQ antigens using serologic techniques to establish maternal-fetal relationships. We found an increased prevalence of pregnancy-induced hypertension when the fetus, but not the mother, was potentially exposed to HLA-DR alloantigens (maternal allogenicity) compared with the other three conditions combined (P < .003). Controlling for confounding factors, the increased prevalence of pregnancy-induced hypertension persisted in situations of maternal HLA-DR allogenicity (P < .007). Based upon our observations and other immunologic studies of pregnancy-induced hypertensive and uncomplicated pregnancies, we conclude that a maternal humoral response against fetal anti-HLA-DR immunoglobulin (IgG) antibody may influence the development of pregnancy-induced hypertension. This could occur when an immunocompetent fetus is exposed to maternal HLA-DR alloantigens, maternal exposure to fetal HLA-DR alloantigens alloantigens, maternal exposure to fetal HLA-DR alloantigens is not possible, and fetal IgG antibody bears paternally inherited markers allogeneic to the mother.


Does closure of Camper fascia reduce the incidence of post-cesarean superficial wound disruption? To determine whether closure of Camper fascia prevents the development of superficial wound disruption after cesarean delivery. During a 1-year period, 438 women undergoing cesarean delivery were randomized into groups with and without approximation of Camper fascia with absorbable suture during closure of the abdominal incision. All women received routine postoperative care following our departmental guidelines. We reviewed charts after the puerperium to identify women with postoperative superficial wound disruption and to obtain demographic and delivery information for analysis. We found a significantly higher incidence of wound disruption in the group without the suture than in those in whom the tissue was approximated (P = .03). Four or more vaginal examinations and higher body mass index were also associated with a higher incidence of wound disruption (P = .05 and P = .04, respectively). Logistic regression correction for covariables that might influence the results of our main analysis revealed no effect of maternal age, parity, indications for cesarean delivery, duration of labor, duration of ruptured membranes, duration of surgery, use of internal monitoring, type of incision, use of antibiotic prophylaxis, surgeon's level of training, or maternal diabetes mellitus and/or hypertension. Approximation of Camper fascia with absorbable suture at closure of the abdominal incision during cesarean delivery appears to protect against postoperative superficial wound disruption and is therefore recommended.


Effect of time and storage temperature on amniotic fluid glucose concentration. To evaluate the effects of time and storage temperature on amniotic fluid (AF) glucose concentration. Amniocentesis was performed on 47 patients with preterm labor or preterm rupture of membranes at or before 34 weeks' estimated gestation and the AF was cultured for aerobic, anaerobic, Mycoplasma, and Ureaplasma organisms. Twenty-one samples were stored at 37C, 13 were kept at room temperature (22C), and 13 were frozen (-20C). Glucose concentration was measured at 0 and 12 hours on all AF samples and at 2, 4, and 6 hours on the unfrozen samples. No significant change in AF glucose concentration occurred over time at any storage temperature in the 35 samples with negative cultures. In 12 AF samples with positive cultures, a significant decrease from baseline was noted at 2 and 4 hours in those kept at 37C and 22C (P = .016). Glucose concentration was unchanged in frozen samples regardless of the culture results. The initial AF glucose concentration was significantly lower in samples with positive than in those with negative cultures (P < .0001). Amniotic fluid glucose concentration does not change over 12 hours in the absence of intra-amniotic infection.


Loop electrosurgical excision procedure of the transformation zone and colposcopically directed punch biopsy in the diagnosis of cervical lesions. To estimate the disagreement between the histologic reports at colposcopically directed punch biopsy of the cervix and subsequent loop excision of the transformation zone, and to assess the indications for loop excision in current practice. The histologic diagnoses from loop electrosurgical excision procedures and concurrent colposcopically directed punch biopsies were compared in 337 consecutive women undergoing loop excision in a 5-year period. Disagreement between punch biopsy and loop excision was recorded in 190 cases (56.4%). The undercall and overcall rates for punch biopsy were 14 and 42.4%, respectively. Undercall at punch biopsy occurred in 24 of 46 cases of cervical intraepithelial neoplasia (CIN) III and in one microinvasive cancer diagnosed at loop excision, and disagreement was within one grade of CIN in 16 cases. Loop electrosurgical excision allows further and more accurate histologic examination of the transformation zone and should be the standard assessment procedure in all cases of CIN II detected at punch biopsy and whenever cytology or colposcopy suggests the risk of punch biopsy undercall. Immediate treatment by local destruction should not be performed, to avoid underestimation of the severity of the lesion.


Chorionic villus sampling: experience with 3016 cases performed by a single operator. To describe our experience with 3016 first-trimester chorionic villus sampling (CVS) procedures, all performed by a single operator, to assess the influence of operator experience on the safety and efficacy of CVS. Transcervical or transabdominal CVS procedures were performed on 3016 patients between the gestational ages of 9-12 weeks. The sampling success rate, procedure complications, cytogenetic results, and pregnancy outcomes were tabulated and analyzed. Samples adequate for diagnosis were obtained in 99.7% of the cases. The mean (+/- standard deviation) number of insertions per procedure was 1.1 +/- 0.4. The percentage of procedures in which the sample was obtained with a single insertion increased from 51% in the first 100 cases to 96% in the last 2516 cases. There were 56 (1.94%) first- and second-trimester pregnancy losses among 2892 pregnancies intended to continue. This loss rate compares with published baseline risk figures for miscarriage of approximately 2-3%. No difference in pregnancy loss rate followed one or two catheter or needle insertions, but the need for three insertions was associated with a significantly increased loss rate (6.7 versus 1.9%; chi 2 = 4.35, P < .05). Operator experience plays a significant role in the safety and efficacy of CVS.


Prediction of the small for gestational age infant: which ultrasonic measurement is best? To determine the most appropriate ultrasonic measurement for the prediction of a small for gestational age (SGA) infant. A literature search of all English language journals over the last 15 years was undertaken. One hundred seventeen articles on the use of morphometric and Doppler ultrasonic measurements in the diagnosis of SGA were reviewed. Studies were included if antenatal and postnatal criteria for diagnosis were clearly defined and data for SGA and normal fetuses were reported, allowing the construction of a 2 x 2 table. Studies with the same criteria were grouped according to whether the population was high or low risk. The sensitivity, odds ratio (OR), and false-positive rate were calculated for each study; summary statistics were then calculated for each ultrasonic measurement provided the individual sensitivities, ORs, and false-positive rates were not significantly different (P > .01). In high-risk subjects, abdominal circumference below the tenth percentile had the highest common sensitivity, and estimated fetal weight below the tenth percentile had the highest common OR. In studies in which morphometric and Doppler ultrasonic measurements were compared in the same subjects, the Doppler ORs tended to be lower than the ORs for morphometric measurements. In low-risk subjects, much lower ORs were found for all ultrasonic measurements. The heterogeneous nature of the studies reviewed may have contributed to the different results within each group.


Assessment of rapid identification tests for genital carriage of group B streptococci. The purpose of this study was to assess the relative value of reported methods for rapid identification of group B streptococcal colonization of the female genital tract. Trials of group B streptococcal identification techniques published in peer-reviewed journals were located using a computerized literature search and cited references from relevant articles or text chapters. Reports were included in the analysis if the methodology fulfilled the following criteria: 1) A reference culture method was used for comparison; 2) performance characteristics were presented or could be calculated; 3) the method could be performed in a standard laboratory on a 24-hour-a-day basis; and 4) results could be routinely available within 12 hours. Performance characteristics such as sensitivity, specificity, and predictive values for the various methods were evaluated and compared. Factors such as colonization rates and methods for identifying carriers were included in the overall assessment of test performance. The overall sensitivity of current methods for the rapid detection of group B streptococcal colonization is low. However, some rapid antigen detection tests are highly sensitive in identifying heavily colonized patients, and therefore may be useful for selecting high-risk patients for intrapartum antibiotic prophylaxis.


Rapid fetal lung maturity testing: commercial versus NBD-phosphatidylcholine assay. We compared the TDx Fetal Lung Maturity test and the fluorescence polarization method using 1-palmitoyl-2(6-[(7-nitro-2,1,3-benzoxadiazol-4- yl)amino]caproyl)phosphatidylcholine (NBD-phosphatidylcholine). Using 76 paired human amniotic fluid samples, the fluorescence polarization values of the two methods were found to have a strong nonlinear correlation (r2 = 0.946). Both assays can be completed in less than 1 hour, have excellent precision (between-day variation less than 2%), and indicate the amount of surfactant phospholipid relative to albumin. The FLM assay is calibrated with surfactant/albumin standards; therefore, the reported results (in mg/g) correlate inversely with polarization of NBD-phosphatidylcholine. Strong correlations were seen for both assays with the lecithin-sphingomyelin ratio and phosphatidylglycerol. The correlations indicate that the recommended reference range for FLM will have more false predictions of immaturity than the NBD-phosphatidylcholine assay.


A technique for laparoscopic pomeroy tubal ligation with endoloop sutures. A laparoscopic technique of Pomeroy tubal ligation using endoloop sutures was compared with the conventional technique of laparoscopic tubal ligation with Silastic rings. Fifty-three patients selected from a population undergoing tubal ligation were randomized to either the Pomeroy (N = 28) or ring (N = 25) group. Mean (+/- standard deviation) operative time for the Pomeroy group was 27.39 +/- 5.95 minutes, with a range of 18-40; for the ring group, the time was 23.11 +/- 11.53 minutes, with a range of 12-58. These times were not statistically different. Operative complication were encountered only in the ring group and included two lacerations of the mesosalpinx. There were no technical or method failures over a follow-up interval of 12-18 months. Specimens confirmed tubal histology in all cases in the Pomeroy group. Laparoscopic Pomeroy tubal ligation using endoloop sutures was easily performed, comparable to laparoscopic application of Silastic rings, and provided a surgical specimen to confirm tubal histology. This aspect may represent a medicolegal advantage of documentation not available with other laparoscopic techniques of tubal ligation.


Randomized comparison of laparoscopy-assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting. To compare outpatient laparoscopy-assisted vaginal hysterectomy with standard outpatient vaginal hysterectomy. Fifty-six women scheduled for vaginal hysterectomy were randomly assigned to undergo either a laparoscopy-assisted vaginal hysterectomy with endoscopic staples (N = 29) or a standard vaginal hysterectomy (N = 27). There were no differences between the study groups with regard to age, gravidity, parity, preoperative indications, and previous operations. Twenty-eight of 29 laparoscopy-assisted vaginal hysterectomies and all 27 vaginal hysterectomies were completed without incident. When indicated, unilateral or bilateral oophorectomies were completed. The mean operating time was significantly longer for laparoscopy-assisted vaginal hysterectomy (120.1 versus 64.7 minutes). Fifty-three of the 55 patients completing surgery were discharged home by 12 hours from the time of admission. Complications with laparoscopic hysterectomy were related to the technical aspects of laparoscopy. The incidence of febrile morbidity was similar in the groups. Although patients having laparoscopy-assisted hysterectomy required statistically significantly more pain medication and had lower postoperative hematocrit measurements, this did not make a clinical difference in the postoperative courses. The mean hospital charge for laparoscopy-assisted vaginal hysterectomy was $7905 and for vaginal hysterectomy $4891. Other than cost, laparoscopy-assisted vaginal hysterectomy and standard vaginal hysterectomy appear comparable in patients who could otherwise undergo a vaginal hysterectomy.


Appropriateness of hysterectomies performed for multiple preoperative indications. To correlate the listing of multiple preoperative indications for hysterectomy with the risk of non-confirmation of the preoperative diagnosis. Records of 171 women undergoing consecutive hysterectomies for all indications at a large teaching hospital were reviewed for preoperative indication(s), compliance with published preoperative validation criteria for cases in which tissue pathology was not expected, and histologic verification of the preoperative diagnosis for cases in which tissue pathology was expected. Rates of confirmation (histologic verification plus successful compliance with validation criteria) of the preoperative diagnosis were compared between subgroups of cases in which single indications were listed (N = 124) or multiple indications were listed (N = 47) preoperatively. The rate of confirmation of single indications (115 of 124 cases, 93%) was significantly higher than the rate of confirmation of even one indication in cases in which multiple indications were listed (28 of 47 cases, 60%, P < .0001; relative risk for non-confirmation of multiple indications = 1.55). Multiple indications were more likely to be listed when tissue pathology was not expected, representing 49% of validatable indications as compared with only 18% of histologically verifiable indications (P < .0001). Overall, the rate of compliance with validation criteria (70%) was significantly lower than the rate of histologic verification (90%) (P < .01). These data suggest that listing of multiple preoperative indications for hysterectomy is associated with both decreased appropriateness, as reflected in decreased compliance with generally accepted preoperative validation criteria, and decreased diagnostic accuracy, as reflected in lower rates of histologic verification.


The effect of bilateral pudendal blockade on the static urethral closure function in healthy females. To evaluate the effect of bilateral pudendal blockade on the urethral closure function in the resting state in healthy women. Synchronous measurements of pressure and cross-sectional area were recorded at the bladder neck, in the high-pressure zone, and in the distal urethra before and after the pudendal blockade in ten women. The blockade reduced the resting pressure significantly (P < .01) all along the urethra. The viscoelastic indices of elastance (reciprocal of compliance) and hysteresis (difference in pressure at a given degree of urethral dilation when this is increased and decreased stepwise) were significantly (P < .05) reduced. The striated muscles innervated by the pudendal nerve are of paramount importance for the closure function in the resting state all along the urethra. Urethral elastance and hysteresis seem to depend on activity in the surrounding striated muscle fibers.


Transvaginal sonographic findings in ambulatory patients with suspected pelvic inflammatory disease. To evaluate transvaginal sonographic findings in ambulatory patients with suspected pelvic inflammatory disease (PID). We studied 51 outpatients with a mean age of 26.8 years (range 16-52) who had a history of low abdominal pain, negative pregnancy test, and no gynecologic procedures performed during the last month. Endometrial biopsy was used for the histopathologic diagnosis. The presence of plasma cell endometritis was used as the criterion standard for the diagnosis of PID. Sonography was performed before biopsy in a blinded fashion without knowledge of the clinical findings and laboratory results except for the pregnancy test. Repeat pelvic and ultrasound examinations were performed 4 weeks after antimicrobial therapy. Endometrial biopsy revealed plasma cell endometritis in 13 cases (25%). Thickened fluid-filled tubes were seen in 11 of 13 patients (85%) with plasma cell endometritis and in none of those without. Other sonographic findings associated with plasma cell endometritis were polycystic-like ovaries and free pelvic fluid. A sonogram suggestive of PID, ie, thickened fluid-filled tube with or without free pelvic fluid, had a sensitivity of 85% and a specificity of 100% for the diagnosis of plasma cell endometritis. None of the patients with a normal sonogram or simple cyst had plasma cell endometritis. Repeat examination after 4 weeks showed that the sonographic findings had resolved in 60% of the patients who had had histologic evidence of infection. Transvaginal sonography can facilitate the outpatient management of patients with suspected PID.


Transvaginal ultrasound, color flow, and Doppler waveform of the postmenopausal adnexal mass. One thousand postmenopausal women were examined prospectively with transvaginal ultrasound. Seven hundred forty-three (74%) were asymptomatic and presented for screening. Data were analyzed to determine the accuracy of this new modality. Eighty-three women had surgery, and 29 malignant neoplasms were found. Color flow was identified in 27 of 29 malignant tumors and 35% of benign masses. A cutoff value of 0.41 for the Doppler resistance index in the feeder vessels had the best discriminatory value; sensitivity and specificity were 96 and 95%, respectively, for separating benign from malignant neoplasms. Positive and negative predictive values were 96 and 95%, respectively. Morphology alone had poor sensitivity, but when combined with Doppler indices, the sensitivity improved to 90% and the positive and negative predictive values were 90 and 96%, respectively. The results of this study suggest that in the postmenopausal ovary, transvaginal B-mode imaging, color flow, and Doppler indices satisfy criteria as tests that may be sensitive and specific enough for application in a screening program.


A critical evaluation of transvaginal Doppler studies, transvaginal sonography, magnetic resonance imaging, and CA 125 in detecting ovarian cancer. To evaluate whether transvaginal Doppler ultrasound is more valid than transvaginal sonography, magnetic resonance imaging (MRI), and CA 125 in differentiating malignant from benign ovarian tumors. Sixty-three patients with ovarian tumors (36 benign and 27 malignant) were studied with transvaginal Doppler ultrasound before surgery. Blood flow velocity waveforms arising from intratumoral and/or tumor surface arteries were assessed by calculating the resistance index. Transvaginal B-mode sonography and MRI imaging examinations were also conducted. Serum CA 125 levels were measured. There was a significant difference between the resistance index value (0.692 +/- 0.188) in benign tumors and the value (0.503 +/- 0.107) in malignant tumors (P < .05). When 0.72 (mean of the malignant tumor resistance index values + 2 standard deviations) was considered as the cutoff value of the resistance index, the sensitivity and specificity of the resistance index in detecting malignant ovarian tumors were 92.6 and 52.8%, respectively. These values did not differ significantly from those with transvaginal sonography diagnosis (sensitivity 85.2%, specificity 69.4%). The resistance index sensitivity was significantly higher than those with MRI diagnosis (66.7%) and CA 125 levels (59.3%) (P < .05); however, the resistance index specificity was significantly lower than those with MRI diagnosis (97.1%) and CA 125 levels (91.7%) (P < .05). Our results suggest that transvaginal Doppler ultrasound does not provide more useful diagnostic information than transvaginal sonography, MRI, and CA 125 for the differentiation of malignant from benign ovarian tumors.


Comparison of clinical versus surgical staging systems in vulvar cancer. To compare prognostic information from the new surgical staging system of the International Federation of Gynecology and Obstetrics (FIGO) with the old clinical staging system for vulvar cancer. One hundred six women with previously untreated squamous cell carcinoma of the vulva who underwent radical vulvectomies and inguinal lymph node dissections at the University of Oklahoma from 1971-1990 were considered eligible for this study. A retrospective chart review was conducted to assign surgical stage. The clinical and pathologic factors analyzed for survival included the clinical and surgical stage of disease, nodal status, tumor size, and lesion location. Overall 5-year survival was 64%. Forty-three patients had inguinal and femoral node metastasis with a 5-year survival of 38%, versus 87% for patients without nodal metastasis (P < .00001). An increased number of positive groin lymph nodes was associated with a poorer prognosis. Thirty-one patients had tumors of 2 cm or less in maximum diameter with no recurrences, versus 52% 5-year survival in the remaining patients (P < .001). Perineal involvement was identified in 24 patients, but did not significantly influence survival. Overall, the new classification system revised by FIGO for vulvar cancer staging places patients into more accurate risk categories.


Surgical treatment of unexpected invasive cervical cancer found at total hysterectomy. To determine the proper management of patients found to have invasive cancer of the cervix on pathologic examination of a uterus removed for benign indications. We report 18 patients undergoing hysterectomy who were found to have cervical cancer with invasion deeper than 3 mm and/or lymph-vascular space involvement. None had gross residual tumor following simple hysterectomy. All patients underwent a second operation. Seventeen women underwent a radical parametrectomy, upper vaginectomy, and pelvic lymphadenectomy; one had pelvic and periaortic lymphadenectomy alone because of bilateral grossly positive obturator nodes. Median follow-up was 72 months. One of the 15 women without residual disease or nodal involvement at second operation had pelvic recurrence 66 months after therapy. Three patients with disease identified at radical surgery underwent tailored postoperative pelvic radiation, and two of these had pelvic recurrence. The overall actuarial 5-year survival for the 18 patients was 89%. Operative morbidity was comparable to that of patients undergoing primary radical hysterectomy. This study confirms that patients with unexpected invasive cervical cancer found at total hysterectomy can undergo radical re-operation with low morbidity and excellent cure rates.


Adenocarcinoma in situ of the uterine cervix. To assess the diagnostic accuracy of cervical conization in women with adenocarcinoma in situ and to determine whether a select group of women could be managed by conization alone without hysterectomy. We retrospectively reviewed 40 cases of cervical adenocarcinoma in situ diagnosed on cervical conization. Cervical conization revealed adenocarcinoma in situ alone in 15 women. Twenty-five women had adenocarcinoma in situ coexisting with squamous dysplasia (23) or microinvasive squamous cell carcinoma (two). Twenty-two women underwent hysterectomy after cone biopsy. Adenocarcinoma in situ was detected in the hysterectomy specimen in one of 12 women with uninvolved cone margins, versus seven of ten women with involved margins (P = .006); two of these seven women also had foci of invasive adenocarcinoma in the hysterectomy specimen. Conization was the only treatment for 18 selected women with adenocarcinoma in situ and uninvolved margins; all were relapse-free after a median interval of 3 years (range 1.5-5). Women with cervical adenocarcinoma in situ diagnosed by conization who have positive margins are at high risk of residual adenocarcinoma in situ and moderate risk of occult invasive adenocarcinoma; expectant management is not warranted. However, a cone biopsy with uninvolved margins can reliably guide subsequent therapy. Selected young women who desire preservation of fertility and have uninvolved margins probably can be managed by conization alone, but further study is required to establish the safety of this approach.


Radical hysterectomy in obese women.

Radical hysterectomy in obese women. To determine whether there is a significant difference in treatment outcome and acute and chronic complications in obese compared with non-obese women having radical hysterectomy for early-stage cervical cancer. From 1970-1985, 320 women underwent a class III radical hysterectomy and pelvic lymphadenectomy for stage IB-IIA invasive cervical cancer at Duke University Medical Center. Forty-three of these women weighed at least 80 kg and had a body weight greater than 25% above their ideal predicted weight. These women were compared to 277 patients with normal weight for height. The median age, incidence of diabetes mellitus and hypertension, number of nodes removed at lymphadenectomy, disease-free survival, length of hospital stay, and serious surgical or medical complications were the same in the two groups. However, obese patients had a significantly higher estimated blood loss, greater incidence of transfusion, and longer operative times. Survival is not compromised and the incidence of serious complications is not increased in obese patients treated with radical hysterectomy, but the operative technique is more difficult, the procedure lasts longer, and the surgery is associated with greater blood loss.


Maternal and neonatal outcomes after oxytocin augmentation in patients undergoing a trial of labor after prior cesarean delivery. To study the safety of oxytocin augmentation in patients having abnormal labors after a prior cesarean delivery. We retrospectively analyzed a case series of women undergoing a trial of labor after a previous cesarean delivery from the University of California San Francisco perinatal data base. Women whose labors were augmented with oxytocin were compared to women with labor abnormalities managed without the use of oxytocin. A wide range of maternal and neonatal outcomes was compared. Only vertex singleton term deliveries were studied. From 1975-1990 there were 504 trials of labor, of which 185 (37%) had labor abnormalities; 62 of these 185 (34%) were augmented with oxytocin. Fifty-eight percent of the trials of labor ended in vaginal delivery. In patients since 1982, 73% delivered vaginally. Forty-six (74%) of augmented patients delivered vaginally. There were no maternal deaths, uterine ruptures, or hysterectomies. Estimated blood loss was slightly greater among augmented patients after controlling for mode of delivery (P < .05), but only by 50-100 mL on average. There was no difference in the need for maternal transfusion. Fetal trauma and fetal scalp blood sampling occurred more frequently (P < .05) in the augmented labors, but only in the subgroup delivered by cesarean. No increased risk was demonstrated by a comparison between patients receiving oxytocin and epidural anesthesia and patients with labor abnormalities receiving neither. Retrospective analysis supports the use of oxytocin and epidural anesthesia to augment abnormal trials of labor after prior cesarean.


Labor induction in women at term with mifepristone (RU 486): a double-blind, randomized, placebo-controlled study. To determine the efficacy and safety of mifepristone as an induction agent for the initiation of labor or as a cervical ripening agent in women at term. Our study group contained 120 women at term (after 37.5 weeks' amenorrhea) who had clear clinical indications for labor induction. They were randomized to receive either 200 mg of mifepristone or placebo on days 1 and 2 of a 4-day observation period, with labor induction planned for day 4. Eight patients, three treated with mifepristone and five receiving placebo, had to be excluded from the survey because they required cesareans for medical reasons (fetal distress or maternal complications) less than 12 hours after taking the first tablet. Forty-one subjects entered spontaneous labor, 31 treated with mifepristone and ten in the control group (P < .001). Forty-five needed cervical maturation with prostaglandins on day 4, 13 of whom had received mifepristone and 32 of whom had been given placebo (P < .001). Thirteen women treated with mifepristone and 13 who had taken placebo had mature cervices sufficient for classic labor induction with oxytocin and amniotomy. Patients who delivered vaginally needed a much lower amount of oxytocin when mifepristone had been given, and the mean time interval between day 1 of the survey and the onset of labor was also significantly shorter in this group. Although more studies are needed, we have found mifepristone to be a safe, efficient, and suitable induction agent for initiation of labor in women at term.


Psychosocial correlates of drug and heavy alcohol use among pregnant women at risk for drug use. To investigate the roles of life stress, depression, and social support in the use of drugs and alcohol among pregnant women at risk for substance use because they have a substance-using partner. This is a secondary analysis of data collected for a study of the impact of health behaviors and psychosocial characteristics on the newborns of 1226 pregnant women. Participants were interviewed during pregnancy and postpartum using a questionnaire that included instruments such as the Life Experiences Survey, the Center for Epidemiologic Studies Depression Scale, and the Norbeck Social Support Questionnaire. Drug use by women was determined by self-report and urine toxicology screens. Drug use by partners was based on maternal report. Five hundred seventy-three women reported that they had a substance-using partner. These women were nearly five times more likely (odds ratio 4.87, 95% confidence interval 3.76-6.30) to be substance users compared with women who did not report substance use by a partner. Of these women, substance users reported more negative life events on average in the past year than did non-users (19.3 versus 15.8; P = .01). There was no difference in mean Center for Epidemiologic Studies Depression Scale scores (19.7 versus 18.7; P = .26) or in mean social support scores (78.2 versus 72.4; P = .14) between users and non-users. Women with substance-using partners have an increased likelihood of being users themselves. Among women with substance-using partners, substance use by a pregnant women is associated with more negative life events but not with depression symptomatology scores or social support scores.


Crack cocaine: a risk factor for human immunodeficiency virus infection type 1 among inner-city parturients. To define the relationship between crack cocaine use and human immunodeficiency virus (HIV) infection while controlling for other HIV risk factors. We performed a case-control study among inner-city pregnant women who were followed at a large urban hospital in Atlanta, Georgia; 79 of the women were HIV-1-infected and 525 were seronegative. We identified the women from a prenatal population undergoing routine voluntary HIV-1 antibody screening. From July 1, 1989 to December 31, 1990, we screened 13,469 pregnant women; 80 (5.9 per 1000) were HIV-1-infected. One seropositive woman who did not complete a risk-behavior questionnaire was excluded from the study. Seropositivity was associated with a history of crack cocaine use (odds ratio 2.3, 95% confidence interval [CI] 1.1-4.8), intravenous drug use (odds ratio 14.5, 95% CI 4.5-46.3), and a history of sexually transmitted diseases (odds ratio 2.6, 95% CI 1.5-4.5). We found a significant interaction (P = .01) between a history of crack cocaine use and employment status: Unemployed women who used crack cocaine were 3.5 times more likely to be HIV-1-infected than were employed women who used crack cocaine. Crack cocaine use was found to be a risk factor associated with HIV-1 infection among pregnant women, particularly those who were unemployed. This finding suggests that the impact of crack cocaine use on HIV transmission may be related to economic factors and possibly to either trading sex for money to buy cocaine or trading sex for the drug.


Management and therapy of human immunodeficiency virus-infected pregnancies in maternal-fetal medicine fellowship training programs. To determine attitudes and practices of obstetricians in maternal-fetal medicine fellowship programs regarding the management of human immunodeficiency virus (HIV) infection and the use of zidovudine during pregnancy. We sent a questionnaire to the directors of all 78 approved maternal-fetal medicine fellowship programs. The responses, reflecting the consensus of the staffs of each program, were obtained and tabulated. Although their programs annually provide care for more than 2100 pregnant women infected with HIV, less than 25% of all maternal-fetal medicine fellowship directors reported that their patients participate in multicenter studies of HIV infection complicating pregnancy. Nearly two-thirds of the infected women are excluded from such multicenter studies. More than 70% of all program directors believe that zidovudine should be offered to symptomatic pregnant women infected with HIV; one-half question whether zidovudine poses short-term fetal risks. Nevertheless, nearly half of all HIV-infected pregnant women they manage are excluded from trials of zidovudine therapy during pregnancy. Many HIV-infected pregnant women who receive care in clinics of maternal-fetal medicine fellowship programs are excluded from multicenter studies. Consideration should be given to creating a national registry for this important, currently unreported, clinical resource.


The epidemiology of pregnancy complications and outcome in a Norwegian twin population. To measure the contribution of genetic factors to selected pregnancy complications, including miscarriage, twinning, hypertension-toxemia, and nausea-vomiting. Information on 22,241 pregnancies of 8675 female twins or spouses of male twins was obtained by questionnaire from members of the population-based Norwegian Twin Panel. Comparisons of observed tetrachoric correlations were used to assess the importance of genetic influences on the variables examined. Pregnancy history information was provided by both members of 830 monozygotic and 902 dizygotic female twin pairs and by the spouses of both members of 459 monozygotic and 464 dizygotic male twin pairs. The incidence of twin pregnancy in general, and of opposite-sexed twins in particular, found among dizygotic twin women was nearly twice that observed for any other group. Monozygotic female twin pairs were more concordant than dizygotic female twin pairs for the occurrence of miscarriage, nausea or vomiting during pregnancy, and hypertension or overt toxemia. A similar pattern of twin similarity was observed for the use of certain medications during pregnancy including vitamins, aspirin, and nausea medication. Maternal genetic factors make an important contribution to a predisposition for dizygotic twinning, contribute to the risk of miscarriage, and appear to determine, in part, whether a woman experiences nausea-vomiting or hypertension-toxemia during pregnancy. In addition, health-seeking behaviors of women during pregnancy, as reflected by the use of several classes of medication, appear to be influenced somewhat by genetic factors.


Color Doppler flow as an indicator of trophoblastic activity in tubal pregnancies detected by transvaginal ultrasound. To evaluate the potential benefits of transvaginal color Doppler in the diagnostic evaluation of tubal pregnancies. Fifty-two women with suspected tubal pregnancy were examined by transvaginal ultrasonography and color Doppler. Those with positive scans were referred for exploratory laparoscopy. The area of the tubal pregnancy was examined by color flow imaging and the resistance indexes (RIs) of the artery blood flows were calculated. The pulsatility indexes (PIs) of both uterine arteries were also measured and serum beta-hCG was quantitated. Tubal pregnancy was diagnosed by transvaginal ultrasonography in 38 of the patients. There were two false-negative and two false-positive results. Color flow in the trophoblastic tissue was detected in 50% of the tubal pregnancies, and the mean (+/- standard deviation) RI of the trophoblastic flows was 0.51 +/- 0.12. The RIs of the trophoblastic flows tended to decrease at higher beta-hCG levels, and 88.2% of the cases with detectable trophoblastic flow had beta-hCG above 800 mIU/mL. The average PI of the uterine arteries was 2.28 +/- 0.89. The PIs of the ipsilateral uterine arteries were significantly lower in the patients with trophoblastic flow than in those without it. By monitoring trophoblastic activity, color Doppler may differentiate between active and inactive disease and could assist in choosing the correct treatment.


[Importance of prognostic factors in the prognosis of cancer of the endometrium]. 126 stage I and II endometrial cancer patients were followed up for at least 5 years to evaluate the impact of surgical-pathological risk factors on the survival. Out of the prognostic variables evaluated the age and clinical stage failed to influence the 5-year survival rate. The effect on survival of factors such as low grade of differentiation and the depth of myometrial infiltration was however significant, (p < 0.01 and p < 0.001 respectively). The early local recurrence has also significant negative prognostic value (p < 0.05). This latter can be effectively prevented through the prehysterectomy suture of the external cervical os. On the basis of their findings authors suggest to consider the grade and the depth of myometrial invasion beside the clinical stage at the determination of the extension of the surgical procedure and at the decision on the administration of postoperative irradiation.


[Biochemical, clinical and genetic analysis of various aminoacidopathies (non-ketotic hyperglycemia, maple syrup urine disease, histidinemia, tyrosinemia)]. The genetical types were classified according to the clinical findings and biochemical results in cases of 13 newborn/children suffering from various aminoacidopathies. The genetical types were: 3 neonatal and 4 infantile types were found out of 7 non-ketotic disease (MSUD) patient was infantile type with 9.1 per cent keto acid decarboxylase activity in leukocyte homogenate. Among the 3 histidinemic patients 1 was severe neonatal type and 2 cases were chronic types. The 2 treated tyrosinemic children proved to be type III. (chronic with rickets).


[Quality control of radiographic imaging of the lumbar spine]. The qualitative control of the roentgenographic findings was performed independently by the assessment of five x-ray specialists on 40 two-directional lumbosacral roentgenograms. The findings were based on questioners including all details and a table of the internationally used "Radiological Diagnosis". In earlier publications the anatomical and structural changes were considered the risk factors of the waist. (Osteoporosis, changes in the position of the vertebral body, change in the shape of the spine, restriction of the intervertebral cleft and deformation of the small articulations). The views of the research workers were compared by means of statistical analysis. Compared with other authors the methods of these findings are in agreement with the international norms. These findings drew attention to the necessity of an objective assessment of the subjective findings.


[Andrologic significance of genital mycoplasma]. The authors investigated the effect of genital mycoplasma infection of fertility. The rate of silent mycoplasma infection was studied in asymptomatic andrological patients (655 persons) and in a control group of so called "chronic prostatitis" (1085) patients with clinical symptoms. In the asymptomatic andrological group the urethral smear was positive in 12.5% of cases, the ejaculate in 22.0% of cases. In the "chronic prostatitic" group mycoplasma infection was present in urethral smear in 34.8% of cases, and in the ejaculate in 37.0% of cases. The isolation showed that 29.2% of positive ejaculate samples contained M. hominis, and 70.8% of samples was infected by U. urealyticum. For investigating the effect of mycoplasma infection on the male fertilization capacity, infected and non infected andrological patients was compared by conventional andrological parameters and by modern functional tests like bovin mucus penetration test, hypoosmotic swelling test and swim up procedure. All the modern parameters and one of the conventional tests (sperm motility) showed a significant difference between the two groups.


[Yersinia-induced arthritis in patients with spondylitis ankylopoietica of 20-year duration]. The case of a 46 years old woman with spondylitis ankylopoetica is reported. Following diarrhoea a severe, asymmetric oligoarthritis developed with positive Yersinia enterocolitica serology. The acute oligoarthritis repressed after 2 month.


A.C. and D.C. motility of mammalian auditory sensory cells--a new concept in hearing physiology. Transduction of sound events results mechano-electrically in a.c. and d.c. movements of the auditory sensory cells based on de- and repolarization steps through the opening of apical and lateral K(+)--conductive ion channels. During transduction, apical ionic channels are thought to allow an influx of K+ resulting in a depolarization of the outer cell membrane. This is followed by a K(+)--efflux through basolateral K(+)--channels, inducing a re- or hyperpolarization phase. Different hypotheses expect the apical transduction channels to be located either in the cell membrane of the stereocilia and/or in the cell membrane of the cuticular plate (CP). Patch-clamp techniques revealed the presence of an unspecific CP-channel adjacent to the insertion of the stereocilia. In the basolateral cell membrane of outer hair cells (OHC) from the mammalian cochlea, the prevailing channel type, a rectifying high-conductance K(+)--channel, has been characterized as C-channel. After depolarization of the auditory sensory cells, however, the signal transfer divides at this point. The depolarization of inner hair cells (IHC) leads to the release of afferent transmitters for which glutamate is a good candidate. By contracts in OHCs the stimulation induces active mechanical responses of the sensory cells. Slow d.c. movements of the cylindrical hair cell body as well as of the cuticular plate with the sensory hairs are thought to control the operation point of the stereocilia. The mechanical characteristics of the cochlear partition during adaptation, TTS as well as the homeostasis of the basilar membrane location could be modulated by the OHCs. In particular, the slow d.c. movements may protect the vulnerable cochlear partition against high sound pressure levels. Rapid d.c. movements of which the underlying mechanisms is unknown, may interfere cycle-by-cycle with the travelling wave. Thus, near hearing threshold, they could drastically amplify and tune the travelling wave. This could explain otoacoustic emissions, the high sensitivity and the frequency selectivity of the ear at low sound pressures. Moreover, it cannot be excluded that the actomyosin skeleton significantly helps to amplify the travelling wave by intermittent stimulations of a resonance system.


[One stage reconstructive surgery of the hypopharynx from clinical material of the ENT Clinic Medical Academy in Cracow]. From April 1990 till September 1991 in ENT Clinic Medical Academy in Cracow 6 patients with well advanced laryngeal cancer involving hypopharynx were treated surgically. Total laryngectomy with partial or total hypopharyngectomy was performed and then the reconstruction of hypopharynx one stage procedure using pectoralis major myocutaneous flap was done. In all patients cosmetic and functional results were excellent.


[Evaluation of frequency of recurrence in malignant head and neck neoplasms in the years 1980-1990]. During the years 1980-1990 in the Otolaryngological Department of the Silesian Medical Academy in Katowice 452 patients with malignant neoplasms of the head and neck were treated. 154 (35%) patients treated by radiotherapy. 140 (30%) were operated, 133 (29%) were treated by both methods and 25 (6%) were treated symptomatically. 139 (30%) out of them have had the recurrencies after the treatment. The authors made the analysis of frequency of recurrencies in years 1980-86 in comparison with period 1987-90. The statistically significant increase of frequency of recurrencies in years 1987-1990 was found.


[Histologic grading of malignancy and prognosis in laryngeal neoplasms]. The semi-quantitative grading system for squamous cell carcinoma based on estimation of multiple histologic variables according to Jakobsson is presented. Selected histologic parameters have been also evaluated regarding their importance in predicting patient outcome. Features such as differentiation of the tumor cells, their nuclear polymorphism, number of mitoses and vascular invasion significantly correlated with clinical outcome. The structure of the tumor and cellular host response had no influence on survival. There was statistically significant relationship between the patient outcome and histologic grade of malignancy expressed by total point value. The incidence of cervical node and distant metastases was three times more frequent in the group of poorly differentiated tumors than in others. There was no correlation found between the localization of the tumor and the degree of cancer differentiation, but the supraglottic tumors poorly and moderately differentiated infiltrated towards the glottis more often then highly differentiated.


[Partial supra-cricoid reconstructive laryngectomy with CHP and CHEP: surgical technique and oncologic results]. The authors present a report on 62 cases of partial horizontal supracricoid reconstructive laryngectomy, including 28 cases of cricohyoidopexy (CHP) and 34 cases of cricohyoidoepiglottopexy (CHEP). The surgery was carried out in the years 1971 to 1989 in the ENT Clinic of Pomeranian Medical Academy in Szczecin. The indications, surgical technique and oncological results are presented. 78% patients survived after 3 years and 73% after 5 years without recurrence. The reasons of failure and the way of treatment are discussed.


[Interleukin-1 beta and TNF alpha in serum of patients with otosclerosis]. Levels of interleukin-1 beta and tumor necrosis factor--alfa were determined using immunoradiometric method in the serum of patients who have gone surgical treatment due to otosclerosis. Values of both cytokines were higher in the serum of patients as compared with the control group. As regards TNF-alfa these differences were statistically significant.


[Effect of equilibrium disorders in otosclerotic patients post stapedectomy on postoperative hearing improvement]. In this paper author described the significance of vestibular symptoms post stapedectomy in postoperative hearing improvement. Vertigo post stapedectomy was noted and spontaneous nystagmus, positional nystagmus and directional preponderance were examined. Postoperative hearing improvement in patients with and without vestibular symptoms was compared. Author maintained that recent symptoms of peripheral vestibular disfunction had made no difference in postoperative hearing improvement.


[An objective evaluation of retrocochlear structures in the auditory pathway by means of CNT (cochlear nerve tester)]. Indications for hearing implants in profoundly deaf patients have been presented. Auditory pathway status was evaluated by application of electrical stimulation of cochlear nerve. The electrical stimulus originated from Cochlear Nerve Tester. Obtained sound sensations might be revealed on ABR pattern.


Diagnostic value of transtympanic electrocochleography; case reports. The transtympanic electrocochleography is performed on more than 1000 patients with various hearing loss. The registration technique in brief as well as some interesting findings (endolymphatic hydrops, neural hearing loss due to multiple sclerosis, mitochondrial cytopathology) will be presented. The indications of the electrocochleography as an audiological topo-diagnostic tool will be discussed.


Auditory brainstem responses (ABR) in guinea pigs to loud tones noise: a preliminary study. It is well known that exposure to intense acoustic stimuli can induce permanent damage to the tissues of the inner ear. In this study the technique of ABR measurement and the experimental animal model of acoustic trauma were presented. In forty 3 months old guinea pigs the hearing threshold was assessed using the ABR technique (Amplaid mk 10 system). The hearing thresholds ranged from 40 to 50 dB-pe-SPL (mean 45.26 dB, sd. 4.73). The mean latencies of the four most prominent peaks in the ABR pattern were also measured. Fourteen of animals were then exposed to a 1 kHz pure tone at different duration and stimulus level. The ABR threshold was measured immediately after exposure and 20 to 30 days later. The exposure at 112 dB for 2h caused the threshold shift in all guinea pigs varying from 25 to 65 dB. After 3-4 weeks of recovery time in all animals hearing threshold improved, in some animals reaching the pre-exposure level. We conclude that the ABR technique allows to measure precisely and with high reproducibility the hearing level in guinea pigs and also allows to estimate the threshold shift after exposure to noise.


[Władysław Ołtuszewski--organizer of the first Polish phoniatrics institute (in it's 100 year anniversary)]. On the occasion of 100's anniversary of first phoniatrics' department foundation in Poland--"The Warsaw Institute of Speech Deviation", the activity of dr med. Władysław Ołtuszewski its organizer and the pioneer of Polish phoniatrics is described. The main topics of his activities are referred in his book "About speech and its disorders" (1906). Dr Ołtuszewski's achievements in the popularization of the knowledge about speech disorders were strongly pointed out. His lectures were given not only for medical societies but also for the pedagogic ones.


[Malignant tumors of the head and neck in children. Part I--review]. About 27% of malignant tumors in children is located in the head and neck. Besides primary solid tumors, lymph node metastases as well as signs of systemic diseases of the lymphatic tissue are often found in this region. The latter are the most common childhood malignancies. Among primary solid malignant tumors in this region neoplasms of the soft tissues are frequency found. Their prevalence comes next to the tumors of the central nervous system and the orbit. Rhabdomyosarcoma (RMS) represents 50% of cases in this group. Malignant neoplasms originating from epithelial and bone tissue occur rarely in children. The evolution of triple therapy, combining surgery with irradiation and chemotherapy has produced and improvement in prolonged survival rates in these children.


Interdisciplinary treatment of spina bifida children. In the Spina Bifida Centre, Niguarda Ca' Granda Hospital (Milan, Italy), from June 1985 to June 1990, 60 spina bifida children have been treated. The results of the rehabilitation programme (including orthopaedic, urological and psychosocial aspects) at the time of the survey were: (a) Neuromotor function: 72% of the patients achieved ambulation, 52% of these being less than 2 years of age, and 20% older than 2 years; 18% were too young for walking. Thus, considering the children's age, about 90% of the subjects achieved the standing position, and 89% achieved ambulation. (b) Bladder function: 83% of the children had a complete urological evaluation; 40% of those with a neuropathic bladder had a hyperreflex type, 54% areflexic, and 6% normoreflexic. Thirty-two percent of the patients had signs of 'high pressure' bladder function. Urinary continence was: 36% > or = 2 hours, 20% < 2 hours, 44% not detectable (age < 2 years). Forty percent of the subjects used intermittent catheterisation. (c) Psychosocial aspect: child adaptation to the disease and to the rehabilitation programme was good in 61% of the patients; family problems were identified in 70% of the patients; enrollment in preschool and school programmes was normal (or with specialist teaching) in about 74%; 33.3% of the subjects had disturbance of affect. The results clearly showed that the interdisciplinary approach favoured the social integration of these children.


Spinal cord injury: 10 and 15 years after. Researchers have only recently begun to study the problems and adaptations of persons who have lived with spinal cord injury (SCI) for many years. This descriptive study examined recent functional changes and perceptions regarding the quality of life in 43 SCI persons who were 10 or 15 years post injury; 31 percent of the 137 persons surveyed (by mail) responded. On a general rating of quality of life, neither level nor completeness of injury was a significant factor. Subjects who were in a preferred current living situation had a significantly better perceived quality of life (t = -3.2, p < .01); employment did not similarly affect quality of life ratings. There was no significant Spearman correlation between quality of life and the number of recent changes experienced in daily functioning (rs = .17); likewise, quality of life was not related to involvement in exercise or other recreational activities. The nature of the changes most often experienced, as well as factors that persons saw as helping to maintain their independence, are described.


Depressed serum high density lipoprotein cholesterol levels in veterans with spinal cord injury. Cardiovascular diseases are the most frequent cause of death among persons with spinal cord injury (SCI), and these diseases are reported to occur prematurely in the disabled compared to the able bodied population. The mechanism of accelerated coronary heart disease (CHD) in persons with SCI may be partially explicable on the basis of the lipoprotein profile. We performed fasting lipoprotein determinations on 100 veterans with SCI, 50 with paraplegia and 50 with quadriplegia, and 50 veteran controls. The mean age of the subjects with SCI was 47.8 +/- 1.4 years with a duration of injury of 16.3 +/- 1.2 years. The mean serum high-density lipoprotein (HDL) cholesterol was depressed in subjects with paraplegia or quadriplegia compared to controls (37 +/- 1 or 40 +/- 1 versus 48 +/- 2 mg/dL, p < 0.0001). Although serum total cholesterol was lower (p < 0.01) in subjects with SCI than in controls, there was no significant difference in mean serum low-density lipoprotein (LDL) cholesterol. Thirty-seven percent of subjects with SCI have serum HDL cholesterol levels less than 35 mg/dL with no significant difference in lipoprotein distribution between high and low cord lesions. Eighteen percent of individuals with SCI have an absolute elevation of LDL cholesterol (greater than 160 mg/dL). About 40% of those with SCI and LDL cholesterol levels between 130 and 160 mg/dL also have serum HDL cholesterol values below 35 mg/dL, all of whom would have their serum HDL cholesterol level undetected if lipoprotein profiles were performed according to present recommendations--that is, only if the serum total cholesterol is elevated.(ABSTRACT TRUNCATED AT 250 WORDS)


Suggested MRI criteria for surgical decompression in acute spinal cord injury. Preliminary observations. The effect of spinal cord compression identified with magnetic resonance imaging (MRI), on neurological prognosis, was retrospectively evaluated in 36 patients with acute spinal cord injury. Of the 21 patients without cord compression, 16 had potentially reversible injury (normal spinal cord or cord oedema), all having functional recovery. Of the 15 patients with cord compression, 3 had operative decompression. In the 12 patients who did not undergo surgery, the degree of recovery was directly related to the magnitude of spinal cord compression, only one of the patients with moderate or marked cord compression having useful motor function at follow up. In contrast, the 3 patients with surgical decompression had at least 2 grades of improvement, all having functional recovery. These findings raise the possibility that MRI may be used to identify a patient group who will benefit from surgical decompression. A numerical index is proposed to prospectively identify patients for surgical decompression, and further studies are underway to evaluate this.


Bacterial biofilm formation in the urinary bladder of spinal cord injured patients. Ten spinal cord injured patients aged 8 to 55 years (mean 32) were followed for up to 2 months after admission to a rehabilitation setting from an acute care hospital. Urinary fluid and bladder epithelial cells were collected weekly by intermittent catheterization and examined for bacterial colonization. Six patients had no history of urinary tract infection upon admission, likely due to the antimicrobial coverage given during acute care. All the patients subsequently became colonized with uropathogens at some time during the study period. Bacterial biofilms were found in 73% of the samples (73% Gram negative organisms, 27% Gram positive), with mean pathogenic adhesion counts of 29 organisms per bladder cell. In 16% of cases, bladder biofilms were found when urine culture was negative. Bacterial biofilms were also evident during antimicrobial therapy in 10 of 12 samples tested and urine cultures showed breakthrough infections in 50% of cases. Two asymptomatic patients were colonized with Klebsiella pneumoniae and Pseudomonas aeruginosa and were dismissed without requiring therapy. Clearly, bacterial biofilms can exist on bladder epithelia, without being detected in urine samples and without giving rise to symptoms. The extent to which they occur and damage the host remains to be determined, as does the answer to the question, should these patients be treated?


Results of the combined treatment of paediatric intraspinal tumours. In this article 98 patients with paediatric intraspinal tumours are presented. All were evaluated according to their ages, sex, signs and symptoms. The patients also had radiological and histopathological studies; and the results of surgical, physical medicine and rehabilitation and of radiotherapy are discussed and compared with the results of patients reported in the literature.


Lumbar spine dimensions in paraparetic patients: a 10 year follow up study. Lumbar spinal AP radiographs of 13 C3-T11 paraparetic patients taken at about a 10 year interval were compared. The height (H) and maximum width (W) of the interapophysolaminar spaces (IALS), the width of the vertebral bodies at their waist (V) and the relationship between them showed minimal change over the follow up period. The difference between the late and early mean IALS height values increased caudally but was statistically significant only below L5. Subjective evaluation of the consecutive x-ray films revealed few new degenerative abnormalities. It is concluded that the normal aging process, which includes horizontal spreading of the lumbar vertebral bodies and narrowing of the lumbar spinal canal, is not accelerated by paraparesis and may even be retarded by relative immobilization.


Postoperative wound infections following myocutaneous flap surgery in spinal injury patients. Severe pressure ulcers in patients with spinal cord injury are frequently treated by using musculocutaneous (m-c) flap surgery. There have been few studies of the use of perioperative antibiotics to prevent postoperative infection in this setting. We reviewed 74 m-c flap surgeries in 53 patients (41 male and 12 female) from October 1989 for one year. The sites involved were ischial (31), sacral (24), trochanteric (18), deltoid (2), olecranon (1) and posterior thigh (1). An antibiotic was usually administered perioperatively for 5 days. Patients were followed for a median of 30 (8-96) weeks. Postoperative infections occurred at a median of 12 (4-25) days in 6 of 74 (8%) surgeries. The organisms cultured from the 6 infected wounds were: Bacteroides sp. (4), Proteus mirabilis (2), E. coli (2), MRSA (2), and others (6--each isolated once). These results indicate that antibiotics did not prevent postoperative infection in approximately 8% of patients undergoing m-c surgery. The frequency of isolation of Bacteroides sp. from these infections suggests that anaerobic bacteria may persist in healing pressure ulcers and perioperative antibiotics might include coverage for anaerobic bacteria.


Incidence and risk factors in the appearance of heterotopic ossification in spinal cord injury. Heterotopic ossification (HO) is a frequent complication in patients with a spinal cord injury (SCI), although the aetiology is unknown. A study was undertaken of 654 SCI patients with traumatic aetiology, admitted for the first time to the Hospital Nacional de Paraplejicos, Toledo, during 1988 and 1989. Of the total number of patients, 85 (13%) were diagnosed HO and 569 without HO. The diagnosis was mainly achieved by x-ray studies and clinical signs. From the 569 patients with traumatic aetiology without HO, 44 were selected at random, as were 44 of the 85 patients with HO. The mean time lapse between the occurrence of the accident and admission for patients with HO was 40.79 days (typical deviation (TD) = 45.2), and for patients without HO was 32.84 (TD = 38) days, resulting in a value of F = 0.796 through analysis of variance, which is not a statistically significant variation between the 2 groups. In both groups we have taken account of the following variables: age at time of lesion, lesion level, type of lesion (complete or incomplete), spasticity, urinary tract complications, deep vein thrombosis, important associated injuries occurring at the moment of lesion, time elapsed before admission and the existence of pressure sores. In those SCI patients with HO the number of ossifications and their localisations were also verified. By use of the chi square test (X2) over all 9 variables which were studied, we found that 3 variables (complete spinal lesion, presence of pressure sores and spasticity) were significantly related to HO formation.(ABSTRACT TRUNCATED AT 250 WORDS)


Use of the biceps femoris following failed inferior gluteal flap transfer. Case report. Considering the high recurrence rate of pressure ulceration in paraplegic patients, flap procedures to reconstruct a defect should not be at the expense of another possible future flap. The posterior thigh fasciocutaneous flap is useful for the coverage of ischial and trochanteric pressure sores; the biceps femoris musculocutaneous flap is a useful choice for deep ischial defects. However, the cutaneous portions of these two flaps is nearly identical. The previous transfer of the biceps flap excludes the further use of the posterior thigh flap. In contrast, use of the posterior thigh flap still permits the employment of a biceps V-Y advancement flap. Even if the donor site of the previous posterior thigh flap must be skin-grafted, the graft will remain viable on its muscular bed and function as the cutaneous portion of the flap; thus stable coverage is provided, despite previous use of 'first line' flaps. We demonstrate how careful planning of the stages of flap procedures can allow the most economic use of donor areas in this difficult patient group.


Urinary lithiasis induced by sulfamethoxazole in a patient with tetraplegia. Case report. Bladder lithiasis is a frequent complication in paraplegics and tetraplegics. We report on a patient where treatment of a urinary infection with antibacterial sulfamides was the causative factor in the formation of bladder stones.


Duration of symptoms and outcome in bacterial meningitis: an analysis of causation and the implications of a delay in diagnosis. The prompt diagnosis and therapy of bacterial meningitis remain enduring clinical challenges, for no physician would knowingly delay appropriate therapy. However, whether a delay in the initiation of antimicrobials in fact causes a worse outcome is a separate and tangential question. In clinical medicine a treatment decision involves a bedside estimate of the risk and potential severity of illness balanced against the benefits and adverse effects of therapy. For severe infections, the inexorable damage of untreated disease is presumed, and antimicrobials properly are given without hesitation. In contrast the methodical weighing of evidence regarding the issue of causation is for the purpose of characterizing biologic phenomena. Although legal and medical implications may be contained in such an analysis, its relevance to any particular clinical case is only retrospective. To judge responsibly the strength of a causative link, all available scientific evidence must be analyzed by established criteria. Such as analysis suggests that any connection between a delay in the treatment of bacterial meningitis and outcome depends on the presenting clinical pattern. If the presentation is that of a nonspecific illness with general symptoms, then a short delay of < 3 to 5 days does not appear to alter the risk of sequelae or death. In the case of fulminant meningitis a delay in initiating therapy seems unconnected to outcome. Finally for patients with a history of clinically overt meningitis, an inappropriate delay in commencing therapy incrementally increases the risk of permanent injury.


Therapy of bacterial sepsis, meningitis and otitis media in infants and children: 1992 poll of directors of programs in pediatric infectious diseases. To determine current opinions among experts in pediatric infectious diseases for treatment of bacterial sepsis, meningitis and acute otitis media, we polled directors of training programs in January, 1992. Responses were received from 69 centers in the United States and Canada. For initial treatment of presumed bacterial meningitis, the third generation cephalosporins alone or combined with ampicillin have become drugs of choice in all age groups. Most infectious disease programs include dexamethasone in the management of presumed bacterial meningitis for children 2 months of age and older. Third generation cephalosporins are also drugs of choice for presumed sepsis: combined with ampicillin for infants 5 weeks of age; used alone for children 5 months and 12 years of age. Amoxicillin remains the preferred drug for initial treatment of acute otitis media. The combination of amoxicillin and clavulanic acid is favored in the setting of an increased proportion of beta-lactamase-producing bacterial pathogens. Comparison of these results with polls in 1987 and 1989 indicates a shift in recommendations of therapy of presumed bacterial sepsis and meningitis from ampicillin alone or combined with an aminoglycoside or chloramphenicol to use of a third generation cephalosporin alone or combined with ampicillin.


Missed opportunities for influenza vaccination among children with asthma. Influenza vaccination is recommended for children with moderate to severe asthma. However, most children with asthma are not vaccinated, in part because many do not make an office visit during the vaccination time period. We studied 247 urban children with asthma to determine the maximum number that could have been vaccinated during a medical visit to a clinic or emergency department. One hundred thirty-nine patients (56%) had at least one visit during the study period. Sixty-five patients (26%) received the influenza vaccination; 74 patients (30%) did not receive the vaccination despite being seen in the clinic or emergency department. One-half of the missed vaccination opportunities at the clinic occurred during nonacute visits. Influenza vaccination rates could be substantially improved by efforts to increase primary care visits during the vaccination time period and to minimize missed vaccination opportunities.


Value of C-reactive protein determination in the initial diagnostic evaluation of the febrile, neutropenic child with cancer. We studied prospectively the value of administration C-reactive protein (CRP) in the diagnostic evaluation of the child with cancer hospitalized for fever and neutropenia. During a 7-month period 74 patients with malignant disease had 122 hospital admissions because of fever and neutropenia. All patients had a serum CRP obtained 8 to 24 hours after the onset of fever as part of their initial evaluation. There was a borderline correlation between serum CRP concentration and temperature at admission (P = 0.06). Patients with fever without an identifiable source had significantly lower CRP concentrations compared with those having focal or microbiologically documented infection (34.9 +/- 6 vs. 70.2 +/- 12 mg/liter; P = 0.0005). Twelve patients had positive blood cultures, 5 of which were coagulase-negative staphylococci considered to be central venous catheter-related infection or colonization. CRP concentrations were significantly lower in these 5 patients compared with the 7 patients with septicemia caused by other organisms (21 +/- 9 vs. 113 +/- 23 mg/liter; P = 0.01). In distinguishing between septicemic and nonsepticemic children, serum CRP was found to have excellent sensitivity and negative predictive value at concentration limits of 20, 50 and 100 mg/liter. However, both specificity and positive predictive value were low at these respective levels, thus limiting the overall utility of serum CRP in the initial empiric management of the febrile, neutropenic child with cancer.


Prophylactic miconazole oral gel for the prevention of neonatal fungal rectal colonization and systemic infection. Prior rectal colonization with fungi may be an important risk factor for development of systemic fungal infection in the neonate. This placebo-controlled study evaluated the benefits of miconazole oral gel in the prevention of fungal rectal colonization and systemic infection in high risk neonates admitted to the Neonatal Intensive Care Unit. Repeated oral application of miconazole gel reduced the overall prevalence of postnatally acquired rectal colonization; a yeast was grown in 19.5% of the weekly rectal swabs in the miconazole-treated group compared with 36.2% in the control group (69 of 354 vs. 146 of 403, P < 0.0001). There was no reduction in the incidence of systemic fungal infection in the two groups although the overall incidence of the infection was low in both groups, at 2.0% vs. 2.6% (6 of 298 vs. 8 of 302, P not significant). No relationship was shown between prior rectal colonization and subsequent systemic fungal infections in either of the two groups. This study does not support the use of prophylactic miconazole oral gel for the prevention of neonatal systemic fungal infections.


Comparative efficacy of oral rifampin and topical chloramphenicol in eradicating conjunctival carriage of Haemophilus influenzae biogroup aegyptius. Brazilian Purpuric Fever Study Group. Persistent conjunctival carriage of the Haemophilus influenzae biogroup aegyptius (Hae) strain (BPF clone) responsible for Brazilian purpuric fever (BPF) has been documented. Topical chloramphenicol is routinely used to treat conjunctivitis in areas affected by BPF in Brazil. Although the BPF clone is susceptible to chloramphenicol, we observed a number of children treated with topical chloramphenicol for conjunctivitis who still developed BPF. During an investigation of an outbreak of BPF in Mato Grosso State, Brazil, we compared oral rifampin (20 mg/kg/day for 4 days) with topical chloramphenicol for eradication of conjunctival carriage of H. influenzae biogroup aegyptius among children with presumed BPF clone conjunctivitis. Conjunctival samples were taken for culture on the day treatment was initiated and a mean of 8 and 21 days later. At 8 days the eradication rates for oral rifampin and topical chloramphenicol were 100 and 44%, respectively (P = 0.003); at 21 days they were 100 and 50% (P = 0.01). Oral rifampin was more effective than topical chloramphenicol for eradication of the BPF clone and may be useful in prevention of BPF.


Immunogenicity of recombinant hepatitis B vaccine in urban black children from Ga-Rankuwa, Bophuthatswana, South Africa. Many areas in Southern Africa have a relatively high endemicity for hepatitis B for which the only effective medical measure is vaccination. The aim of this study was to evaluate the antibody response to a recombinant hepatitis B vaccine (Engerix B; Smith Kline-Beecham) in a black urban population, with the use of the recommended regimen and a low dose, short course. One hundred eleven children seronegative for hepatitis B virus (5 to 19 years old) were randomized to receive one of the two vaccination schedules (20 micrograms at zero, 1 and 6 months or 2 micrograms at zero, 1 and 2 months). Antibody to hepatitis B surface antigen was determined 6 to 8 weeks after the last dose by radioimmunoassay (Ausab; Abbott Laboratories). The recommended schedule gave a seroconversion rate of 100% with a geometric mean titer of 585.9 mIU/ml. The low dose, short course schedule produced a seroconversion rate of 63.8% and a geometric mean titer of 73.8 mIU/ml. In the 5- to 9-year-old individuals, however, 71.6% seroconverted (geometric mean titer 114.2 mIU/ml). For cost reasons further investigations on low dose regimens are indicated.


Diphtheria-tetanus toxoids-pertussis vaccination does not increase the risk of hospitalization with an infectious illness. The purpose of this study was to determine whether children hospitalized with a primary diagnosis of infection were more likely than matched controls to have had a diphtheria-tetanus toxoids-pertussis immunization in the 30 days before hospitalization of the case. Cases were less likely than controls to have received an immunization (P = 0.003). They were also less likely to have been breast-fed (P < 0.001) and to have had a well-child care clinic visit (P = 0.01). Cases were significantly more likely to be preterm (< 38 weeks gestation), low birth weight (< 2500 g) and attending day care than their matched nonhospitalized controls (P = 0.003, 0.03 and 0.002, respectively). This study demonstrates no association between receipt of diphtheria-tetanus toxoids-pertussis immunization and subsequent hospitalization for an infectious illness.


Gastric lavage is better than bronchoalveolar lavage for isolation of Mycobacterium tuberculosis in childhood pulmonary tuberculosis. We compared the sensitivity of gastric lavage (GL) with bronchoalveolar lavage (BAL) for isolating Mycobacterium tuberculosis (Mtb) from 20 children with a presumptive diagnosis of primary pulmonary tuberculosis. GL was performed on three consecutive mornings after an overnight fast. BAL was performed on the same day as the last GL. Specimens were submitted for smears and culture for Mtb. None of the acid-fast stained smears was positive. Cultures of BAL fluid on 2 patients (2 of 20 or 10%) were positive for Mtb. Cultures of the gastric aspirates from the same 2 patients were also positive for Mtb. Eight additional patients had positive GL cultures with negative BAL cultures, resulting in a total of 10 of 20 (50%) patients with positive GL cultures for Mtb. The results of our study indicate that GL done on three consecutive days is better than BAL for the bacteriologic diagnosis of childhood pulmonary tuberculosis.


[Quantitative analysis of pneumoconiosis in standard chest radiographs]. A computerized method to quantify and characterize interstitial diseases by using physical texture measures obtained from an analysis of the power spectrum of lung textures in digital chest radiographs was applied to Japanese standard radiographs of pneumoconiosis. Texture measures were determined from standard radiographs of silicosis, asbestosis, and other types of pneumoconiosis as well as chest radiographs of normal lungs. Our preliminary results indicated that the texture measures obtained from computer analysis corresponded closely with the standard categories of silicosis. However, there was no significant correlation between texture measures and the categories for asbestosis and other types of pneumoconiosis in terms of texture pattern. Japanese standard radiographs of pneumoconiosis are categorized according to the profusion of opacities, without reference to the size and shape of the opacities. Furthermore, in some films the size and shape of the opacities vary considerably within the same category. Therefore, it is considered that these characteristics of the standard films affected the results of our texture measures. It also considered that a large ROI and other texture measures are needed to characterize large opacities and mixed-shaped opacities of pneumoconiosis.


[Imaging diagnosis of lupus enteritis--especially about sonographic findings]. We evaluated 4 cases of lupus enteritis by US, abdominal X-ray and CT. On US examinations, in particular, we observed ascites and edematous thickening of the small intestine where Kerckring folds with submucosal edema resembled an accordion. After steroid treatment and consequent improvement of the disease, we noticed disappearance of the intestinal thickening and ascites on US examination, compatible with the diagnosis of lupus enteritis. Based on these results, US was useful for the diagnosis and follow-up of lupus enteritis.


[Assessment of a coaxial system accommodated to a 0.035 inch guide wire in superselective hepatic angiography and embolization]. A special coaxial catheter system accommodated to a 0.035 inch guide wire was recently developed. The four-part coaxial system is composed of a central 0.035 inch flexible guide wire, a 4-French inner catheter (straight, 90 cm in length), a 6-French outer catheter (fork-shaped, 60 cm in length), and a hemostatic valve. The 4 French inner catheter is large enough in diameter to allow a larger volume of contrast medium and greater amount of embolic material than the earlier coaxial system. Using this coaxial catheter system, we performed successful superselective hepatic arteriography and embolization in 44 patients with malignant hepatic tumors. Catheterization of the celiac and superior mesenteric arteries with the 6 French outer catheter was easy, and the angiogram obtained was very distinct. The 4 French inner catheter was easily and safely advanced into the segmental hepatic artery, and even common hepatic arteriography with this catheter provided clear images on conventional cut films. Therefore, in most cases, both angiography and embolization can be accomplished using this coaxial system alone.


[Intracranial MR imaging of achondroplasia]. Intracranial MR imaging was performed in five patients with achondroplasia. All patients had narrowing of the subarachnoid space at the level of the foramen magnum that was mainly due to protrusion of the posterior aspect. Three patients had compressive deformities of the brainstem and/or upper cervical spine. Among them, two patients had deformities of the pons. Relative upward displacement of the brainstem was seen in all patients. Hydrocephalus was seen in three patients.


[MR imaging of thyroid masses].

[MR imaging of thyroid masses]. Magnetic resonance (MR) imaging was performed in 35 patients with histologically proved thyroid masses. Gadopentetate dimeglumine was used in 25 of these cases. The thyroid tumors were analyzed by MR imaging as to shape, margin, pseudocapsulation, homogeneity, and enhanced pattern. Gd-DTPA was helpful in identifying pseudocapsules and showing the extent of the tumor. Papillary carcinoma tended to display unclear margins, heterogeneous intensity, and inhomogeneously enhanced patterns. In follicular adenoma, the tumor margin was smooth and pseudocapsules were clearly detected. Follicular adenoma was enhanced homogeneously, but it was difficult to distinguish follicular adenoma from follicular carcinoma by MR imaging. Adenomatous goiter was delineated as multiple nodules with smooth margins, but without pseudocapsules. These nodules were enhanced in various ways after Gd-DTPA administration.


[CT-guided selective pneumomediastinography and its clinical evaluations]. CT diagnosis is playing a central role in the judgment of mediastinal invasion in esophageal and pulmonary cancers. Estimation of the mediastinal invasion is now based on the indirect findings such as presence of a fatty layer and angle of contact between the lesion and adjacent organs. An attempt to delineate directly the relation between the primary lesion and adjacent organs has been made by adopting new CT-guided selective pneumomediastinography (PMG CT). Twenty-three cases were studied with CT guided paravertebral route. Mediastinal invasion on PMG CT was judged by a condition of the air distribution to the adjacent organs. Assessment was made by the use of the findings whether the organs are separated by aeration or not and of presence or not of the "sulcus formation". The accuracy of judging mediastinal invasion has been improved from 41% by conventional CT to 85% by PMG CT based on the diagnostic criteria which adopted "sulcus formation". This method is useful clinically as a testing technique supplementing the conventional diagnostic imaging.


[Prevention and treatment of traveler's diarrhea]. Travelers' diarrhea (TD) affects 20-50 per cent of individuals going to developing countries in Asia, Africa, or Latin America. The etiology varies but is dominated by enterotoxigenic E. coli, found in 30-50 per cent. TD is usually a mild disease, self-limiting in 3-4 days, but 10 per cent of those afflicted have symptoms for one week or more. Prophylaxis of TD involves dietary restrictions and, in selected medical risk groups, antimicrobial drugs. The most important treatment of TD is oral rehydration and loperamide in mild to moderate, non-invasive illness. Antibiotics for self-treatment shall be restricted for medical risk groups and individuals travelling far from medical service.


[Prokinetic drugs].

[Prokinetic drugs]. Prokinetic drugs--preparations that stimulate gastro-intestinal motility--constitute a relatively new concept in medical therapy, chiefly represented by the products cisapride and metoclopramide. This review consists in an account of the physiological regulation of motility in the upper gastro-intestinal tract where prokinetic drugs are considered to exert their most significant effect, and the therapeutic effects demonstrable in treatment with these drugs.


[Bacterial adhesion to epithelial cells of the nasopharynx essential in the development of otitis media]. Otitis media develops when certain bacterial pathogens gain access to the middle ear cavity from the nasopharynx through the eustachian tube. Adhesion of bacteria, in particular Streptococcus pneumoniae and Haemophilus influenzae, to the non-ciliated epithelial cells of the nasopharynx, close to the opening of the eustachian tube, is significantly correlated to the otitis-prone condition in children. Otitis-prone children have significantly fewer bacteria in the nasopharynx coated with the immunoglobulin secretory IgA (SigA) then healthy children have. Adhesion and occurrence of middle ear pathogens in the nasopharynx decreases with advancing age. Epstein-Barr virus, causative agent of infectious mononucleosis, causes a remarkable increase in bacterial adhesion to epithelial cells.


[Psychosocial consequences of screening programs in children]. Owing to improved possibilities of early diagnosis, there has been increasing interest in screening children, particularly newborns. However, in the event of false-positive results or certain hereditary risk factors there is a danger of adverse psychosocial consequences, especially negative stigmatization (both of children and their families). Accordingly, except where neonatal screening may be essential for medical reasons, such screening programmes should preferably be scheduled for a later stage in life when the parents are less prone to anxiety about anything that might be interpreted as a threat to the well-being of their offspring.


[Problems of drug resistance in developing countries--use and abuse of anti-infective agents]. Widespread use and misuse of anti-infective agents have resulted in a problem of drug resistance linked to treatment of infectious diseases. In developing countries especially, the sale of such drugs is poorly controlled and the pharmaceutical industry is dumping obsolete products. Intensive marketing, lack of diagnostic facilities and receptive local cultural attitudes to new "wonder drugs" such as antibiotics, have resulted in dramatic unnecessary use of such. Therefore the ideal strategies for treatment of infectious diseases guided by microbiological diagnosis and resistance pattern are violated in most developing countries, leading to excessive use of anti-infective agents and development of resistance. This has serious consequences for the infections that cause most cases of infant mortality, namely malaria, diarrhoeas and infections of the respiratory tract. Improvements in this vicious circle of drug use and resistance can only be made by attacking several factors simultaneously. There is a need for general information, stricter legislation, essential drug lists, national drug policies, better knowledge of local resistance patterns, better diagnostic facilities, better knowledge about local beliefs about drugs and better communication to local health workers and the community.


Family medicine education in Canada.

Family medicine education in Canada. Within the sphere of health and welfare, Canada has more in common with the Scandinavian countries than with the United States. This article describes and discusses the unique role of the College of Family Physicians of Canada and the education and training for family medicine, both on the undergraduate and postgraduate levels in Canada. The development of the Master of Clinical Science in Family Medicine degree programme at the University of Western Ontario is considered to be an important vehicle for strengthening academic family medicine in Canada. The amalgamation of current knowledge not only from clinical sciences and educational research, but also from the social sciences, is seen as fundamental to the continued improvement of this discipline.


Molecular abnormalities responsible for thrombosis. Genetic aspects. The association between congenital deficiencies and recurrent thrombosis strongly suggests that antithrombin III, protein C and protein S play a major role in inhibiting thrombin formation in vivo. Genetic analysis using DNA fragment amplification by polymerase chain reaction and direct gene sequencing has led to the identification of many novel mutations in qualitative and quantitative deficiencies. Elucidation of the molecular basis of these deficiencies is critical to our understanding of natural antithrombotic mechanisms. It not only provides information on the structural features governing protein function, but also permits a better classification, based on genomic abnormalities of hereditary deficiencies responsible for mild to severe phenotypes and may prove of further value to define the most pertinent plasma assays for routine diagnosis.


Air filtration and prevention of aspergillary pneumopathies. Preliminary comparative study of two mobile units for bacteriological air purification with recycling. Two mobile units for air filtration with recycling designed to reduce the aerobiocontamination of hospital rooms were tested. Their efficacity was evaluated by measurement of particle retention and by quantitative determination of the reduction of aerobiocontamination in rooms occupied by patients. Results show a significant improvement in the aerobiocontamination of test rooms as compared to control rooms. It is thus reasonable to suppose that these systems may provide a practical solution to the problems posed by hospitalization in ordinary rooms of patients subjected to aplasive chemotherapy. A randomized clinical trial is in progress.


Evaluation of a new haematology analyser for whole blood count and full differential (NE-8000). We evaluated the fully automated haematology analyser TOA Sysmex NE-8000 over a three-month period according to the ICSH protocol using as reference techniques a Coulter STKR counter and microscope examination for WBC differential and cell morphology. The NE-8000 employs aperture impedance to perform cell counts, with a sheath fluid to focus cells hydrodynamically prior to counting and sizing. WBC are differentiated into five populations. A combination of aperture impedance, radio frequency measurement and differential cell shrinkage is used, eosinophil and basophil percentages being established in two separate channels and subtracted from the total granulocyte count in order to give the value for neutrophils. Analysis of 1060 samples processed by the closed sampling automode demonstrated satisfactory counting performance. Among the WBC differentials obtained from 100 samples, neutrophil, eosinophil and lymphocyte results correlated well with those from microscopic examination of blood smears performed according to the NCCLS standard H20 T protocol. Differences observed in the percentages of basophils were of no biomedical significance. A comparative study for monocytes showed poor correlation for values below 5% and above 10%, best results being obtained in the intermediate range 5-10%. The NE-8000 also demonstrated good reliability for detection of abnormal cells.


Use of the new Coulter MAXM for leucocyte differentials. The Coulter MAXM is an automated instrument designed to give a complete haematological profile including cell counts and WBC differential (DIFF). The WBC DIFF is determined by tridimensional flow cytometry on the basis of cell volume, light scattering and conductivity (VCS technology). Evaluation of the MAXM DIFF was performed by comparison with microscopic examination of blood smear. A total of 467 samples were studied by the MAXM and reference techniques, according to a standard protocol employed in our laboratory to define the criteria for smear examination. Good correlation was obtained between the two methods in non-flagged samples and those flagged only with an isolated "Imm Gran" message. In a group of 407 non-haematological and 60 haematological patients, there were 12 (2.6%) false positive and 5 (1.1%) false negative reports, all in non-haematological cases and the five false negative results corresponding to no more than minor abnormalities. The Coulter MAXM was thus shown to be an excellent haematology analyser. This instrument was capable of detecting significant abnormalities of blood smears with a sensitivity of 97.9%, a specificity of 94.7% and a global efficiency of 96.3% in the samples examined in the present study.


Cell proliferation: analysis by flow cytometry. Cell proliferation can be efficiently analyzed by multiparameter flow cytometry. Different strategies may be used: As a primary approach, static analysis reveals the momentary distribution in a single sample between cell cycle phases, metabolic states, or differentiation lineages. Kinetic analysis uses sequential measurements of cell cycle traverse in synchronized cell populations or accumulation of cells blocked in a particular cell cycle phase. DNA replication analysis is based on the incorporation of the thymidine analogue bromodeoxyuridine. Cell production by mitosis as well as cell loss by cell death can be estimated. Cell production may be assessed by measurement of mitotic rate or S-phase influx. Cycling/non-cycling status may be indicated by proliferation associated antigens. Specific cell clones in experimentally mixed populations can be discriminated using reporter genes. Flow cytometric multiparameter analysis has the potential of revealing and quantitating the heterogeneity with respect to stemlines, proliferation and differentiation. This is of increasing importance in the study of human cancers, as a possible basis for therapeutic decision making.


Bone marrow enrichment technique for detection and characterization of scarce abnormal cells. A frequent problem encountered in analysis of bone marrow aspirates is the small number of suspect cells in the material. We present a method for concentration of the cells in bone marrow aspirates which yields smears suitable for immunocytochemical techniques. Bone marrow sampling is performed in two steps: a first aspirate is used to prepare conventional smears and a second aspirate is submitted to two-step centrifugation to separate and collect the nucleated cells without use of a separation medium. Sufficient material is obtained to prepare a large number of films, thus allowing immunocytochemical investigation with a wide panel of monoclonal antibodies. The proportions of the different cell types are similar to those observed in conventional smears and cell morphology is unaltered. This enrichment procedure improves the accuracy of routine cytological bone marrow examination, may be easily applied in laboratories performing bone marrow studies and in our hands has proved of value for the detection and characterization of both malignant blood diseases and bone marrow dissemination of carcinoma.