Umbilical artery flow velocity waveforms and twin pregnancy outcome

Two hundred seventy-two twin pregnancies were studied by analysis of the fetal umbilical artery waveforms recorded using continuous-wave Doppler ultrasound. After the first 100 cases, a management strategy was adopted whereby all twin gestations would be studied between 28-32 weeks' gestation and the results made available to the referring obstetrician, thereby influencing clinical management. Perinatal mortality and morbidity, in pregnancies with both fetuses alive at 28 weeks' gestation, were compared between the patients studied in the first group of 100 and those studied after the Doppler examination was introduced as a clinical service. There was a decrease in perinatal mortality, both uncorrected (57.9 per 1000 to 17.9 per 1000; P less than .05) and corrected (42.1 per 1000 to 8.9 per 1000). Fetal deaths were reduced from six to one (P less than .05). This decrease in perinatal mortality was achieved without any appreciable change in the gestational age at delivery or mode of delivery between the two groups. There was a reduction in the number of infants requiring neonatal intensive care (from 38% to 24%; P less than .01).     

Reproductive problems and birth defects in survivors of Wilms' tumor and their relatives

In a retrospective cohort study of 47 Wilms' tumor survivors and their 77 sibling controls, female survivors had a fourfold excess risk (risk ratio, 4.1; 95% confidence interval, 1.7-10.1) for any adverse livebirth outcome, including birth defects, compared with their sibling controls. Wives of male survivors had no apparent excess risk for problem pregnancies. The families had a number of severe reproductive problems and major birth defects, such as primary amenorrhea in two survivors, bicornuate uterus in two survivors and one control, and mental retardation in one male survivor and a male control. The son of a female survivor died after bilateral Wilms' tumors. Birth defects in the offspring of female survivors are compatible either with intrauterine constraint, possibly due to radiation-induced fibrosis or with the complex of malformations associated with Wilms' tumor. Female survivors of Wilms' tumor appear to be at increased risk for a variety of reproductive problems, from sterility to fetal loss, early delivery, and birth defects in offspring. Furthermore, relatives of survivors of Wilms' tumor may be at risk of having associated birth defects, with clinically significant consequences.     

Diagnosis of 21-hydroxylase deficiency in newborn infants by GC-MS of urinary steroids

In a study using gas chromatography-mass spectrometry (GC-MS) on urine specimens from 16 normal infants and 16 infants with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (aged 1 day to 4 weeks), the major steroids recognized in all infants were: 16 alpha-hydroxy-dehydroepiandrosterone, 16 beta-hydroxy-dehydroepiandrosterone, 16-oxo-androstenediol, androstenetriol, 15 beta,17 alpha-dihydroxy-pregnenolone and 16 alpha-hydroxy-pregnenolone. Pregnanetriol was detectable in three normal infants (aged 3, 6 and 15 days) but the levels seen in 15 CAH patients were in a higher range. Pregnanetriolone, 5 beta-17-hydroxy-pregnanolone and 15 beta,17 alpha-dihydroxy-pregnanolone were present in the urine of 15 CAH patients, but were not detectable in any of the normal infants. The older the patient, the higher the level was of each of these four steroids. The results indicate that, even on day 1, patients with CAH due to 21-hydroxylase deficiency may be positively identified using GC-MS of urine specimens. This does not preclude the possibility that a minority of patients with CAH, most likely those with mild 21-hydroxylase deficiency, may not exhibit the characteristic GC-MS findings on day 1, as seen in one of the 16 CAH patients.     

Primary hormonal therapy for prostate cancer: experience with 135 consecutive PSA-ERA patients from a tertiary care military medical center

The use of prostate specific antigen (PSA) in the 1990s has brought on a stage migration of prostate cancer. Despite that, many men have still presented with metastatic prostate cancer in the past decade. The use of primary hormone therapy in the PSA era at a tertiary care Army Medical Center is studied in this paper. Charts were reviewed of 135 men who were diagnosed with metastatic prostate cancer and treated with hormone therapy as a primary treatment between 1989 and 1995. Statistical analysis was used to determine significant predictor variables on the time to disease progression. In univariate analysis clinical stage, pretreatment alkaline phosphatase and nadir PSA values were significant predictors of time to progression. Race and type of treatment were not. In multivariate analysis the relative risk of progression was 3.2 for patients with an alkaline phosphatase >252 and 16.5 for patients with a nadir >2.0. This study supports the argument that racial disparities in prostate cancer outcomes are due to access to care. Furthermore, the survival rate for patients with D-2 disease is better than in the pre PSA studies. Clinical stage, pretreatment alkaline phosphatase and PSA nadir can be used to predict response for those men presenting with metastatic prostate cancer.     

The influence of a bupivacaine and fentanyl epidural infusion after epidural fentanyl in patients allowed to ambulate in early labor

Epidural fentanyl after a lidocaine and epinephrine test dose provides adequate analgesia and allows for ambulation during early labor. This study was designed to determine the influence of an epidural infusion of bupivacaine plus fentanyl administered after initiation of epidural labor analgesia with fentanyl. Specifically, we evaluated whether there is an increase in motor block or an increased time to request for further analgesic medication. Fifty-one laboring primigravid women at <5 cm cervical dilation who requested epidural analgesia were enrolled. After a 3-mL epidural test dose of 1.5% lidocaine with epinephrine (5 microg/mL), patients received fentanyl 100 microg via the epidural catheter. They then randomly received either an infusion (10 mL/h) of 0.0625% bupivacaine with fentanyl (3 microg/mL) or an infusion of preservative-free saline. After the administration of the initial analgesic, pain scores and side effects were recorded for each patient at 10, 20, and 30 min, every 30 min thereafter, and at the time of request for additional analgesic medication, by an observer blinded to the technique used. There were no demographic differences between the two groups. The mean duration of analgesia (time from initial dose to request for additional analgesia) was increased in the group that received a continuous infusion of bupivacaine and fentanyl compared with the Saline group (198 +/- 86 vs 145 +/- 50 min; P < 0.009). Side effects were similar between the two groups. No patient in either group experienced any detectable motor block. Fourteen patients chose to ambulate in the Saline group, and 12 patients chose to ambulate in the Infusion group. In early laboring patients, a continuous infusion of 0.0625% bupivacaine infusion with fentanyl (3 microg/mL) prolonged the duration until top-up was required, after epidural fentanyl 100 microg after a lidocaine and epinephrine test dose, and did not cause any clinically detectable motor block. IMPLICATIONS: A 0.0625% bupivacaine and fentanyl (3 microg/mL) infusion, when added to epidural fentanyl (100 microg), prolongs the analgesic duration without increasing motor block in women in early labor.     

Growth hormone safety update from the National Cooperative Growth Study

We reviewed adverse event (AE) data in the National Cooperative Growth Study from start-up (1985) until January 1, 1999. Enrollment was 33,161. A total of 2,632 AE reports were received; 863 were serious events, with 156 deaths. The most common cause of death was recurrence of intracranial neoplasm. There were 20 reports of leukemia, and the standard morbidity ratio (SMR) was 0.73 (95% CI: 0.20-1.86) for the four cases without risk factors. There were 35 reports of extracranial nonleukemic malignancy, and the SMR was 0.44 (95% CI: 0.24-0.74) for the 14 cases without risk factors. The recurrence rate for all brain tumors present at baseline was 7.6%, and for craniopharyngiomas, 6.4%. There were 49 reports of intracranial hypertension (20 patients had papilledema), 68 reports of diabetes/hyperglycemia, 45 of slipped capital femoral epiphysis, 136 of scoliosis, and five of pancreatitis. There was no evidence of increased incidence of leukemia or extracranial nonleukemic malignancies among patients without prior risk factors. Intracranial hypertension does not necessarily occur early in growth hormone therapy. Other findings were consistent with past observations.