Urgency of caesarean section: a new classification

A new classification for caesarean section was developed in a two-part study conducted at six hospitals. Initially, 90 anaesthetists and obstetricians graded ten clinical scenarios according to five different classification methods--visual analogue scale; suitable anaesthetic technique; maximum time to delivery; clinical definitions; and a 1-5 rating scale. Clinical definitions was the most consistent and useful, and this method was then applied prospectively to 407 caesarean sections at the same six hospitals. There was close agreement (86%) between anaesthetists and obstetricians for the five-point scale (weighted kappa 0.89), increasing to 90% if two categories were combined (weighted kappa 0.91). We suggest that the resultant four-grade classification system--(i) immediate threat to life of woman or fetus; (ii) maternal or fetal compromise which is not immediately life-threatening; (iii) needing early delivery but no maternal or fetal compromise; (iv) at a time to suit the patient and maternity team--should be adopted by multidisciplinary groups with an interest in maternity data collection.     

Downregulated expression of ADAM9 in anterior polar cataracts

PURPOSE: To determine whether ADAM (a disintegrin and metalloproteinase) is regulated in lens epithelial cells (LECs) of patients with anterior polar cataracts and by transforming growth factor (TGF)-beta 1 in cultured LECs. SETTING: Department of Ophthalmology and Visual Science, College of Medicine, The Catholic University of Korea, Seoul, Korea. METHODS: Lens epithelial cells attached to the anterior capsules of human cataractous lenses with nuclear and anterior subcapsular cataracts and noncataractous lenses were analyzed by reverse transcribed-polymerase chain reaction for the expression of ADAMs. The effect of TGF-beta 1 on ADAM gene expression was also tested in mouse lens epithelial explants and cultured LEC lines (alpha TN-4 and HLE B-3). RESULTS: Significantly reduced expression of mRNA for ADAM9 was observed in LECs from patients with anterior polar cataracts. The expression of mRNA for ADAM9 was downregulated by TGF-beta 1 in cultured human LECs. Treatment of cultured mouse LECs with TGF-beta 1 led to a reduction in ADAM1 mRNA. CONCLUSIONS: ADAMs are expressed and regulated in LECs. The downregulated expression of ADAM9 may serve as a marker for anterior polar cataracts in addition to previously known proteins, fibronectin, alpha-SMA, and beta ig-h3. The functions of this protein in lens pathology require further investigation.     

Effect of mixed hematopoietic chimerism on cardiac allograft survival in cynomolgus monkeys

BACKGROUND: We have previously reported the successful induction of mixed chimerism and long-term acceptance of renal allografts in MHC-mismatched nonhuman primates after nonmyeloablative conditioning and donor bone marrow transplantation. In this study, we extended our regimen to cardiac allotransplantation and compared the immunological responses of heart and kidney allograft recipients. METHODS: Five cynomolgus monkeys were conditioned with low-dose total body irradiation (1.5 Gy on days -6 and -5), supplemental thymic irradiation (7 Gy on day -1), antithymocyte globulin (50 mg/kg on days -2, -1, and 0), splenectomy (day 0), donor bone marrow transplantation (day 0), and a 4-week posttransplant course of cyclosporine. Heart allografts from MHC-mismatched donors were transplanted heterotopically on day 0. RESULTS: Two monkeys failed to develop multilineage chimerism and rejected their allografts soon after cyclosporine was stopped (postoperative days [PODs] 43 and 56). Three monkeys developed multilineage chimerism, which persisted 20 to 43 days posttransplant by flow cytometric analysis and to POD 124 by polymerase chain reaction analysis. Allograft survival in these recipients was prolonged to 138, 428, and 509 days, and in vitro mixed leukocyte reaction and cell-mediated lympholysis (CML) assays demonstrated donor-specific hyporesponsiveness. However, in contrast to kidney allograft recipients, long-term heart allograft recipients eventually developed humoral and cellular immunity against the donor and rejected the grafts. At the time of rejection, 1.3% to 9.5% of donor coronary arteries exhibited intimal proliferation. CONCLUSIONS: The induction of transient mixed hematopoietic chimerism leads to long-term heart allograft survival in MHC disparate monkeys without chronic immunosuppression. However, unlike kidney allografts, full tolerance to cardiac allografts was not achieved. Organ-specific modifications of the preparative regimen may be necessary to prevent the chronic cellular and humoral immune responses elicited by cardiac allografts.     

Stroke in ovarian hyperstimulation syndrome in early pregnancy treated with intra-arterial rt-PA

Ovarian hyperstimulation syndrome (OHSS) caused by fertility medications can predispose women to thrombosis. The authors present a case of a previously healthy woman who underwent in vitro fertilization and experienced a middle cerebral artery thrombosis that was subsequently lysed with intra-arterial recombinant tissue plasminogen activator (rt-PA). To the authors' knowledge, this is the first reported case of successful use of rt-PA to lyse a cerebral arterial thrombus resulting from severe OHSS. The patient made a near complete neurologic recovery and delivered a healthy infant at term, illustrating that intra-arterial thrombolysis can be used with relative safety even in very early pregnancy.     

Chemotherapy with or without radiotherapy in patients with locoregionally recurrent nasopharyngeal carcinoma

BACKGROUND: Treatment of locoregionally recurrent nasopharyngeal carcinoma (NPC) is challenging because of prior radiotherapy, morbidities from disease recurrence, and limited therapeutic options available. METHODS: A retrospective study of patients with locoregionally recurrent NPC. RESULT: Between March 1994 and December 1999, there were 42 patients; most were Chinese (98%) men (81%) with undifferentiated NPC (86%). A repeat course of radiotherapy was feasible in 20 patients and given concurrently with cisplatin followed by adjuvant cisplatin/5-fluorouracil (PF) (group 1). The remaining 22 (group 2) received palliative chemotherapy (PF) with a response rate of 50%. Significant morbidities resulted from cranial nerve palsies. The 2-year progression-free survival of patients in group 1 was expectedly better (58% vs 38%). Six (14%) developed systemic metastases at 12 months (median) from first recurrence. CONCLUSION: Concurrent chemoradiotherapy for locoregional recurrent NPC seems promising. The morbidity experienced resulted from locoregional disease with few progressing to develop systemic involvement.     

Meaning of Health-related Quality of Life among Children and Adolescents in an Asian Country: A Focus Group Approach

Aims: We aimed to evaluate the extent to which HRQoL instruments developed based on the Western notion of health is applicable to Asian children and adolescents by assessing their conceptualization of QoL. A secondary objective is to evaluate the necessity of developing age- or gender-specific HRQoL instruments. Methods: We explored the meaning of general and health-related QoL through focus group discussions in Singapore, a multi-ethnic Asian society. Two investigators independently analysed the data. They extracted major and sub-themes related to both general and health-related QoL. The agreement between the analyses was compared and disagreement was resolved through discussion. Results: Thirty-two subjects (children: 50.0%, female: 50.0%) participated. There were few disagreements. Meanings of general and health-related QoL could be grouped under three broad themes: (1) physical, (2) psychological and (3) social health, consistent with the current definition of HRQoL. We found that Singaporean and Western children/adolescents share a remarkably similar notion of general and health-related QoL. Compared to adolescents, children were more likely to report positive emotions, be less mindful of others’ opinions and had less varied social activities. Conclusion: The results suggest that currently available instruments are potentially useful for Singaporean children/adolescents. We also found that age-specific HRQoL instruments are necessary.     

Intracranial hemorrhage after stenting and angioplasty of extracranial carotid stenosis

BACKGROUND AND PURPOSE: The transluminal angioplasty and stenting procedure has been recently advocated as a potential alternative to surgical endarterectomy for the treatment of severe extracranial carotid stenosis. This study assesses the incidence and significance of intracranial hemorrhage occurring after this procedure. METHODS: We retrospectively reviewed 104 carotid arteries (96 internal, two external, and six common) in 90 patients (63 male; mean age, 69.4 years; range, 48-88 years) who underwent primary stenting and angioplasty by use of Wallstents (103/104) at three centers between January 1996 and January 1999. Seventy-five (83%) patients were referred by neurosurgery departments. Seventy-one (68%) arteries were symptomatic; the mean stenosis percentage was 85% (range, 40-99%). RESULTS: Four intraparenchymal hemorrhages occurred, representing 4.4% of patients and 3.8% of vessels, after angioplasty and stent placement. The mean preoperative stenosis percentage was 95% (range, 90-99%). One hemorrhage occurred immediately after stent placement, whereas the three other hemorrhages occurred in a delayed fashion (mean, 2.8 days). The mean hematoma size was 4.8 cm (range, 2-8 cm). Three patients had associated subarachnoid or intraventricular bleeding; the fourth had associated subdural hemorrhage. Three hemorrhages were fatal; the fourth experienced two seizures only. No acute neurologic symptoms were present prior to hemorrhages, and there was no postprocedural hypertension in these patients. All had been receiving antiplatelet agents as well as intraprocedural IV heparin. CONCLUSION: Intracranial hemorrhage can occur after carotid angioplasty and stenting. We speculate that this represents cerebral hyperperfusion injury. The 3.8% incidence of cerebral hemorrhage observed is approximately sixfold greater than that reported post endarterectomy (0.6%) (95% CI, 0.2-8.7%). This is not statistically significant in this small study group. This trend may reflect patient selection, different anticoagulation protocols, and/or study population size. Additional data are needed to determine the safety and efficiency of carotid stenting as a treatment for carotid stenosis.     

Phase II trial of docetaxel in Asian patients with inoperable stage III non-small cell lung cancer

Docetaxel has a response rate of greater than 30% in first-line treatment of Western patients with advanced non-small cell lung cancer (NSCLC). The goal of this open-label. phase II study was to evaluate the activity and safety profile of docetaxel in Asian patients with inoperable untreated stage III NSCLC. Docetaxel was given at 100 mg/m2 as a 1-h infusion every 3 weeks. Prophylactic dexamethasone was given to reduce hypersensitivity reactions and edema. Thirty-five patients were enrolled in the study. The response rate was 34% (95% CI, 19%-50%) according to intent-to-treat analysis. No complete response was observed. Twenty-four patients (69%) had grade 3 or 4 neutropenia in cycle 1, and febrile neutropenia was seen in 12 patients. Six patients (17%) experienced mild fluid retention. Docetaxel is an active agent in first-line treatment of Asian patients with locally advanced NSCLC, with the main toxicity being neutropenia. Fluid retention was a minor problem in this study.