A new protocol for assessing action observation and imitation abilities in children with Developmental Coordination Disorder: A feasibility and reliability study.

AIMS: To develop a new protocol for the assessment of action observation (AO) abilities and imitation of meaningful and non-meaningful gestures, to examine its psychometric properties in children with DCD and typically developing (TD) children. BACKGROUND: For learning manual skills, AO and imitation are considered fundamental abilities. Knowledge about these modalities in children with DCD is scarce and an assessment protocol is lacking. METHOD: The protocol consists of 2 tests. The AO test consists of two assembly tasks. The imitation test includes 12 meaningful and 20 non-meaningful gestures. Items of both tests are rated on a 4-point scale. Twelve children with DCD (mean age 8y3m, SD, 1.30) and 11 TD children (mean age 8y2m, SD 1.52) were enrolled. For inter-rater reliability, intraclass correlation coefficients (ICC) were calculated for the total score, weighted kappa and percentage agreement for single items. Known group validity was assessed by comparison of DCD and TD group (Wilcoxon rank sum test). For construct validity, the mABC-2 test was used. The protocol was adapted and confirmed by an intra and inter-rater reliability study (new sample of 11 DCD children, mean age 7y5m, SD 1.37). RESULTS: Excellent ICCs were reported for intra and inter-rater reliability for the final protocol. A significant difference between DCD and TD group was found for AO abilities (p < .01), for nonmeaningful gestures (p < .001). A significant correlation was reported between the AO test and the mABC-2 test (r = 56;p ≤0.0001). No significant correlations were revealed for the imitation tests. DISCUSSION AND CONCLUSION: The results support the psychometric properties of this protocol. When fully validated, it may contribute to map the deficits in AO abilities and imitation, to evaluate treatment effects of imitation and AO interventions.

Venous thrombosis and congenital absence of inferior vena cava in a patient with menorrhagia and pelvic pain.

BACKGROUND: Agenesis of the inferior vena cava (IVC) is an uncommon congenital vascular malformation. We report a case in a teenage female recently started on oral contraception. CASE: Because of menorrhagia, the patient had begun an oral contraceptive pill (OCP) 1(1/2) months prior to presentation. She initially presented with pelvic and lower back pain, and imaging showed a pelvic deep venous thrombosis (DVT) and an interrupted IVC. Anticoagulation was started, the OCP was discontinued, and a discussion occurred regarding the treatment options for her menorrhagia following her recent diagnosis. SUMMARY AND CONCLUSION: The case presented shows the rare occurrence of the congenital absence of an IVC with pelvic thrombosis in a young female with a history of menorrhagia and new onset of pelvic pain. The evaluation of this case report leads to a comprehensive review in the treatment choice for menorrhagia with the preceding history of a thrombotic event.

Protein expression of phospholipase C in pregnant and nonpregnant rat uterine tissue.

OBJECTIVE: The phosphatidylinositol signaling pathway appears to play a significant role in the intracellular events leading to agonist-stimulated phasic myometrial contractions. The studies described in this report were performed to characterize phospholipase C isoform expression at the protein level and to confirm histologic localization of these proteins within the myometrial smooth muscle layers of the uterus. METHODS: For these studies, uterine tissue was obtained from timed- pregnant and spontaneously cycling adult female Sprague-Dawley rats. After isolation of myometrial cell membranes and cytosolic proteins, Western blots were performed by using phospholipase C isoform-specific antibodies. Tissue cross-sections of near-term pregnant rat uterus were used with the phospholipase C isoform-specific antibodies for immunohistochemical studies. RESULTS: The Western blot studies confirmed expression of the phospholipase C-beta3, -gamma1, -gamma2, and -delta1 proteins in both the membrane and cytosolic fractions of rat myometrium; in contrast, only trace amounts of the phospholipase C-beta1 protein was observed in this tissue. The immunohistochemical studies demonstrated localization of the phospholipase C-beta3, -gamma1, -gamma2, -delta1 and to a lesser degree phospholipase C-beta1 isoforms within the longitudinal and circular smooth muscle layers of the near-term pregnant rat uterus. CONCLUSION: These studies have confirmed the simultaneous expression of several phospholipase C proteins within the smooth muscle cells of the pregnant and nonpregnant rat uterus, thereby providing support for the possible redundant role of these signal transduction enzymes during the generation of cytosolic calcium oscillations and phasic myometrial contractions.

Comparison of a novel norgestimate/ethinyl estradiol oral contraceptive (Ortho Tri-Cyclen Lo) with the oral contraceptive Loestrin Fe 1/20.

This multicenter study compared the contraceptive efficacy, cycle control, and safety of a new triphasic norgestimate (180/215/250 microg)/ethinyl estradiol 25 microg regimen (Ortho Tri-Cyclen Lo) (n = 1,723) with that of norethindrone acetate 1 mg/ethinyl estradiol 20 microg (Loestrin Fe 1/20) (n = 1,171). Healthy women were treated for up to 13 cycles. Demographics were similar between regimens. Contraceptive efficacy was comparable for Ortho Tri-Cyclen Lo and Loestrin Fe 1/20. The overall and method failure probabilities of pregnancy through 13 cycles were 1.9% and 1.5%, respectively, with Ortho Tri-Cyclen Lo and 2.6% and 2.4%, respectively, with Loestrin Fe 1/20. Breakthrough bleeding and spotting was reported by a significantly lower percentage of participants in the Ortho Tri-Cyclen Lo group compared with the Loestrin Fe 1/20 group. At representative Cycles 1, 3, 6, 9, and 13, breakthrough bleeding and spotting rates were 16.3, 11.5, 10.3, 7.9, and 7.7%, respectively, in the Ortho Tri-Cyclen Lo group and 34.9, 22.9, 22.2, 15.9, and 13.1%, respectively, in the Loestrin Fe 1/20 group. Compliance and safety data were similar for the two regimens.

Estrogens and hormone replacement therapy: is there a role in the preservation of cognitive function?

Alzheimer's disease affects as many as 40% of Americans over the age of 80 and, as such, is a major public health issue. Interestingly, there is a two- to threefold greater prevalence in women than in men. It has been estimated that the prevalence of Alzheimer's disease will quadruple over the next half century. There have been implications of an effect of estrogen on neurological function for many years. As long as 50 years ago a study published in the gerontology literature suggested that the administration of i.m. estrogen in a nursing home population was associated with improvement in memory and a delay in progression of memory loss. Most recently there has been great interest in the effect of estrogen on both neurons and the CNS vasculature. A study evaluating verbal memory and abstract reasoning in over 700 women without dementia demonstrated that women who had used estrogen for as little as 1 year had significant improvements in baseline cognitive testing. The pathogenesis of Alzheimer's disease and neurodementia is better understood today but remains incompletely elucidated. It has been suggested that inflammation exists both within the neurovasculature and the stroma and that beta-amyloid creates an inflammatory reaction. In Alzheimer's patients there are abnormal deposits of proteins such as beta-amyloid, presenelin, and apolipoprotein E-4. Estrogen may act as a protectant against these inflammatory mediating proteins. While a recent trial demonstrated no impact of estrogen in patients diagnosed with mild to moderate Alzheimer's, other studies have suggested that estrogen use significantly delays disease onset. One study followed over 1,100 subjects who were free of disease at trial initiation over a period of 1 to 5 years. Even short-term use of estrogen imparted protection, although longer-term estrogen use was associated with greater protection. Unfortunately, most women are unaware of the potential beneficial effect of estrogen on cognitive function. Prospective studies are under way to try to delineate how estrogen impacts Alzheimer's disease.

Thoracic endometriosis syndrome resembling pulmonary embolism.

A 32-year-old infertility patient with a previous diagnosis of stage IV endometriosis experienced shortness of breath and chest pain. She was diagnosed with a pulmonary embolism by spiral volumetric computed tomography (SVCT) and anticoagulated during hospitalization, although no history of thrombosis was ever identified. She continued to have intermittent symptoms of chest pain, back pain, and shortness of breath for the next 1.5 months. Repeat SVCT revealed a large, right-sided pleural effusion with associated consolidation but no evidence of pulmonary embolism. To obtain a definitive diagnosis, a thoracoscopic pleural biopsy was performed and showed thoracic endometriosis involving the pleura. The patient desired to retain her fertility and opted for treatment with depot medroxyprogesterone. She has been asymptomatic for 2 years with this treatment. This case illustrates the importance of recognizing thoracic endometriosis syndrome and the difficulty diagnosing this condition considering its nonspecific features.

Erythropoietin, the biology of erythropoiesis and epoetin alfa. An overview.

Erythropoietin, a glycoprotein hormone, is synthesized predominantly in the kidney and secreted by renal cortical interstitial cells in response to tissue hypoxia. Erythropoietin is the main regulator of the production of red blood cells. It functions in the recruitment and differentiation of erythroid progenitor cells and aids in their maintenance and survival. Erythropoietin also stimulates the synthesis of hemoglobin. In the last 15 years, the ready availability of recombinant human erythropoietin (r-HuEPO, epoetin alfa) has permitted the clinical investigation and application of this hormone to the treatment of anemia in various patient populations. Epoetin alfa has been shown to accelerate erythropoiesis and reduce allogeneic blood transfusion in major elective, noncardiac, nonvascular surgery and in certain anemic patients with chronic renal failure, nonmyeloid malignancies and human immunodeficiency virus infection. In addition to improving hematologic parameters, epoetin alfa therapy can enhance health-related quality of life in these patients. The success of epoetin alfa in treating anemia in other surgical populations suggests that it may be of benefit in treating the perioperative anemia that is highly prevalent in gynecologic surgery patients. Further investigation of the use of epoetin alfa in patients undergoing gynecologic surgery would increase awareness of its benefits for this patient population.

Breast cancer and HRT--what are the data?

Breast cancer remains one of women's greatest concerns. When asked regarding the likelihood of contracting a specific disease, most women believe their greatest risk of death is from breast cancer. Interestingly, we have gone from a time when estrogen was utilized as a treatment regimen in advanced breast cancer, to the current question of hormone replacement therapy increasing the risk of breast cancer. When one searches earlier data, it is noted that estrogen in several different forms, including ethinyl estradiol, as well as DES, was used as a therapeutic agent in the management of advanced breast cancer. Indeed, some of the original trials evaluating tamoxifen for adjunctive treatment of breast cancer used estrogen as the "gold-standard" treatment arm. Numerous publications have attempted to address the relationship between hormone replacement therapy and breast cancer. In the last quarter of a century, at least 50 epidemiological studies have been published, with some studies demonstrating slight increases in patients who used hormone replacement therapy for an extended time, while others demonstrated no evidence of a change in incidence. The "Nurses' Health Study" suggested that current users of hormone replacement therapy of 5 or more years' duration have a relative risk of greater than 1.4. While a well-performed and conceived trial, it suffers from limitations like all other studies. In the same time period, multiple additional studies have cast doubt on the likelihood of hormone replacement therapy markedly increasing the risk of breast cancer. When the multitude of studies is combined, the evidence seems to demonstrate that in ever-use of hormone replacement therapy the increase in relative risk is small. It is interesting that, in almost all studies published (even those demonstrating increases such as the "Nurses' Health Study") discontinuation of 2 to 5 years evaporates the increased risk. This seems biologically implausible, given the prior exposure. A recent study by Sellers et al evaluated over 41,000 patients in a prospective cohort. In this study, they closely evaluated patients who were at a higher risk of breast cancer based on a positive family history in first-degree relatives. Interestingly, they, like others, found that HRT was not associated with a significantly increased incidence of breast cancer, but did note a significantly reduced total mortality rate. When one evaluates the sum total data in the world literature regarding hormone replacement therapy and breast cancer, it is difficult to ascertain that any substantial clinical risk exists with the use of hormone replacement therapy and breast cancer. Multiple ongoing trials, including the Women's Health Initiative-a Prospective Protocol, will help to define better if any appreciable risk exists.

Constitutive androstane receptor expression in the rat cervix during gestation.

OBJECTIVE: To investigate expression of the constitutive androstane receptor (CAR) in the pregnant rat cervix. METHODS: Rat uterine tissue was obtained on gestational days 12, 16, 20, 21, and 22 (the day of parturition), and postpartum day 1. In addition, liver, lung, kidney, heart, and skeletal muscle tissue were obtained. Expression of the two known CAR isoforms was evaluated using reverse transcriptase-polymerase chain reaction. RESULTS: These studies confirmed CAR expression in the liver; however, CAR was not demonstrated in the myometrium or cervical tissue. CONCLUSIONS: The currently described CAR1 and CAR2 isoforms are not expressed in rat uterine tissue; therefore, they do not appear to participate in parturition in the pregnant rat.

Tissue-specific protein kinase C isoform expression in rat uterine tissue.

OBJECTIVE: Activation of the phosphatidylinositol signaling pathway plays a key role during the generation of agonist-stimulated phasic myometrial contractions. Protein kinase C (PKC), a component of this signaling pathway, has been previously shown to produce feedback inhibition of agonist-stimulated myometrial contractions. The studies described in this report were performed to survey the tissue-specific expression of several PKC isoforms in the rat uterus. METHODS: Uterine tissue was obtained from timed pregnant and normally cycling adult female Sprague-Dawley rats. Immunohistochemical studies were performed using the Vectastain ABC immunostaining technique and PKC isoform-specific polyclonal antibodies. Western blot studies were performed using myometrial tissue separated into cytosol and membrane fractions by differential centrifugation. RESULTS: These studies confirmed significant expression of the PKC-alpha, -beta 2, -delta, -eta, and -zeta isoforms in myometrium from pregnant and estrus rats, whereas only trace or no expression of the PKC-beta 1, -gamma, -epsilon, and -theta isoforms was observed. Expression of the PKC-alpha, -beta 2, and -eta isoforms decreased modestly during the latter days of gestation; in contrast, PKC-delta and -zeta remained stable during this period. The immunohistochemical studies confirmed expression of the PKC-alpha, -beta 2, -delta, -eta, and -zeta isoforms in both circular and longitudinal smooth-muscle layers of the near-term pregnant rat uterus. CONCLUSION: In summary, these studies have confirmed significant levels of expression of several isoforms of PKC in estrus and near-term pregnant rat uterine tissue, which was most prominent in the smooth-muscle cells of the myometrium.

Phosphatidylinositol-specific phospholipase C isoform expression in pregnant and nonpregnant rat myometrial tissue.

OBJECTIVE: Activation of the phosphatidylinositol signaling pathway plays a significant role during the intracellular signal transduction events activated during agonist-stimulated phasic myometrial contractions. Phospholipase C is an essential molecular component of this signaling pathway. These studies sought to characterize the expression of phospholipase C isoform messenger ribonucleic acid in both pregnant and nonpregnant rat myometrium. STUDY DESIGN: Total cellular ribonucleic acid was isolated from myometrial tissue collected from Sprague-Dawley rats by use of the acidic guanidinium thiocyanate-phenol-chloroform extraction technique. After deoxyribonuclease treatment to ensure removal of genomic deoxyribonucleic acid, as well as resolution on formaldehyde-1% agarose horizontal slab gels to rule out degradation, the ribonucleic acid was used for semiquantitative competitive reverse transcriptase-polymerase chain reaction studies to evaluate the expression of five of the reported phospholipase C isoforms. These studies were performed with isoform-specific 20-mer primers and the inclusion of internal standard heterologous deoxyribonucleic acid sequences designed with ends homologous to the isoform-specific primers. The identity of the polymerase chain reaction products was confirmed with restriction endonuclease digestions and homology analysis of the sequenced polymerase chain reaction product deoxyribonucleic acid. RESULTS: These reverse transcriptase-polymerase chain reaction studies have confirmed expression of the phospholipase C-beta1a, phospholipase C-beta3, phospholipase C-gamma1, phospholipase C-beta2, and phospholipase C-delta1 isoforms in rat myometrial tissue. During pregnancy the levels of expression of the phospholipase C-beta3, phospholipase C-gamma1, and phospholipase C-delta1 isoforms were increased compared with the levels of expression in myometrium from nonpregnant rats. In myometrium from both pregnant and nonpregnant animals the phospholipase C-beta1 a isoform was expressed at the highest level, the phospholipase C-beta3, phospholipase C-gamma1, and phospholipase C-gamma2 isoforms at an intermediate level, and the phospholipase C-delta1 isoform was expressed at the lowest levels. CONCLUSIONS: These studies have confirmed at the messenger ribonucleic acid level significant expression of several isoforms of phospholipase C in both pregnant and nonpregnant myometrial tissue. These observations provide additional support for the hypothesis that the phosphatidylinositol signaling pathway plays an important role in uterine smooth muscle.

Anterior abdominal wall adhesions after laparotomy or laparoscopy.

STUDY OBJECTIVE: To determine the frequency of postoperative adhesions to the anterior abdominal wall peritoneum that could affect safe placement of the initial laparoscopic umbilical cannula at subsequent procedures. DESIGN: Prospective cohort study. SETTING: Reproductive endocrinology and infertility service of a tertiary care referral hospital. PATIENTS: Two hundred fifteen women, 124 with prior abdominal surgery and 91 with no prior surgery. INTERVENTIONS: Surgical histories were reviewed, abdominal skin scars noted, and extent of anterior abdominal wall adhesions prospectively recorded. Statistical analysis was performed with the chi2 test. MEASUREMENTS AND MAIN RESULTS: No anterior abdominal wall adhesions were present in 91 patients with no previous surgery or 45 patients with previous laparoscopy (12 had more than 1 laparoscopy; p <0.001 vs laparotomy). Seventeen (59%) of 29 patients with a midline vertical incision had anterior wall adhesions (p <0.05 vs suprapubic transverse incision). Eleven (28%) of 39 with a suprapubic transverse incision had anterior wall adhesions (p <0.001 vs no surgery or laparoscopy). Ninety-six percent of adhesions involved omentum and 29% included bowel. CONCLUSION: Prior laparotomy, whether through a midline vertical or suprapubic transverse incision, significantly increased the frequency of anterior abdominal wall adhesions, and these adhesions may complicate the placement of the laparoscopic cannula through the umbilicus.

Risk of Anterior Abdominal Wall Adhesions Increases with Number and Type of Previous Laparotomy

Adhesions to the anterior abdominal wall after previous midline vertical laparotomy were found in 68% of patients undergoing laparoscopy (Childers et al: Gynecol Oncol 50:221, 1993). We reviewed the prevalence of anterior wall adhesions in patients with previous laparotomy incisions who underwent laparoscopy (>95% of patients) or laparotomy. The prevalence of omental and/or bowel adhesions to the anterior abdominal wall in proximity to the umbilicus were tallied and analyzed by incision site (midline vertical or suprapubic transverse) and number of previous laparotomies (one or more than one). The following table illustrates the number of patients in each category with anterior abdominal wall adhesions. While the prevalence of adhesions is increased with more than one previous laparotomy this did not reach statistical significance (Chi-square test). A midline vertical laparotomy does significantly increase the risk for anterior wall adhesions compared to a transverse incision (p<0.05). However, it should be noted that 28% of patients with a previous suprapubic transverse incision (Pfannenstiel or Maylard) had omental and/or bowel adhesions. In this series, one patient with two previous transverse incisions had an incidental enterotomy. We currently employ the technique of LUQ trocar placement in patients with previous midline and suprapubic transverse incisions.

Transvaginal intratubal insemination by tactile sensation: a preliminary report.

Transvaginal catheterization of the fallopian tube has gained increased popularity for transfer of embryos and gametes. Forty-five ITIs were performed on 32 patients using the novel approach of tubal transfer via tactile sensation. This group of patients had undergone an average of 5.2 IUIs before ITI. There were a total of 11 pregnancies, 6 occurring with hMG stimulation and 5 with CC-stimulated cycles (34% PR per patient). Three pregnancies ended with spontaneous abortion, and one patient developed acute salpingitis necessitating laparotomy. These data suggest ITI may be effective in assisted reproduction but, as other invasive procedures, is not without risk.

Salmonellal empyema in a heart transplant recipient.

We report Salmonellal empyema in a heart transplant recipient. The patient required decortication and prolonged antibiotic therapy for cure.

Spinal cord monitoring during posterior spinal instrumentation and fusion.

Two hundred seventy-five consecutive patients who were treated by posterior spinal instrumentation and fusion with iliac crest bone graft were intraoperatively monitored using cortical somatosensory-evoked potentials without a planned wake-up test. The monitoring was performed using a TECA TE-4 system that included an electromyograph, a nerve stimulator, and a digital averager. Intraoperatively, six patients (2%) demonstrated significant changes in evoked potentials, consisting of either marked increase in latency or a loss of wave form during instrumentation of the spine. The instrumentation was removed immediately and the evoked potentials returned to base-line tracing within 15-30 minutes in all six cases. Five patients who had instruments refitted to maintain a lesser amount of correction had no subsequent change in the evoked potentials. One patient had spinal fusion without instrumentation. Postoperatively, all patients are neurologically normal.

Failed distal ulna resections.

Twenty patients with complaints of pain and limitation of activities for more than 1 year after ulnar head resection (Darrach) were studied. Their ages ranged from 18 to 60 years (mean, 38 years). The initial indications for operation were posttraumatic derangement in 18 patients, radial growth anomaly in 1, and a lesion of the ulna in 1. Follow-up ranged from 29 to 135 months (mean, 61 months). The patients had an average of 2.2 additional operations, with up to seven procedures per patient. Radiographs were compared with those from an equal number of successful Darrach resections chosen randomly, and no significant differences were noted. All 20 patients continue to have difficulties despite several years of treatment. The Darrach resection can result in serious disability, especially in the younger patient and the patient with lax ligaments. Reoperation on these patients is rarely successful.

Thumb avulsion: results of replantation/revascularization.

During a 9-year period, 39 thumb avulsions required emergency replantation/revascularization at our institution. Amputation was complete in 28 (72%) cases and involved the dominant thumb in 31 (80%). Farm machinery was the source of injury in 33 (85%) cases. Follow-up ranged from 7 months to 6 years. Only 10 of the revascularization attempts (26%) were successful; the remaining attempts required amputation at the level of the injury. In two (18%) of the 11 partial amputations and in eight (29%) of the 28 complete amputations, revascularization was successful. In eight (31%) of the 26 thumbs in which vein grafts were used, revascularization was successful, while one of the other two successes involved a transfer of the radial digital artery of the index finger. In six of the ten successful revascularizations, nerve repair was attempted, but without further procedures, none of the six digits regained two-point discrimination of less than 1 cm.